Carbetocin versus oxytocin for prevention of postpartum hemorrhage after vaginal delivery in high risk women

The Role of Oxytocin versus Carbetocin in Prevention of Postpartum Hemorrhage in Cesarean Section: A Randomized Control Trial

BACKGROUND

Preventing postpartum haemorrhage (PPH) is a significant concern because of its effect on maternal morbidity and mortality. PPH is leading cause of maternal death in developing countries and also globally.

AIM

Evaluation of safety and efficacy of carbetocin versus oxytocin for PPH prevention in caesarean deliveries.

METHODS

Double blind randomised controlled trial carried for one year. 42 pregnant patients included in study, who underwent caesarean section and fulfilled inclusion criteria. Patients divided into two groups A and B with 21 in each group, with the help of computer generated random number, group A recieved 100 microgram of carbetocin through intravenous route and 1 ml of normal saline given intramuscularly as placebo, group B received 10 IU oxytocin through intramuscular route and 1 ml of normal saline is given intravascular.

RESULT

Mean age was 25.19 years±3.86 years and 24.76 years±3.93 in group A and group B respectively. Mean blood loss significantly reduced in carbetocin compared to oxytocin with significant p value 0.006, haemoglobin deficit was less in group A as we compare with group B having p value 0.052 whereas incidence of PPH in group A was 4.76 % and group B was 19.05% and had p value of 0.343, not significant. Effect of both medication on blood loss varies significantly across different BMI categories.

CONCLUSION

Observation shows equal efficacy and safety of both carbetocin and oxytocin in prevention of postpartum haemorrhage in caesarean section but carbetocin is considered as uterotonics of crucial importance due to heat stability in poor resource settings, therefore use of carbetocin could be better in comparison to oxytocin in PPH prevention.

Carbetocin versus Oxytocin with or without Tranexamic Acid for Prophylactic Prevention of Postpartum Hemorrhage after a Vaginal Delivery: A Randomized Clinical Trial

OBJECTIVE

Our study's primary objective was to examine the effects of four different prophylactic protocols on the prevention of postpartum hemorrhage following vaginal birth, including carbetocin only, oxytocin only, and a combination of carbetocin or oxytocin with tranexamic acid.

DESIGN

A multicentric randomized controlled trial.

PARTICIPANTS/MATERIALS, SETTING, AND METHODS

This multicentric center prospective randomized controlled trial was conducted at the Department of Obstetrics and Gynecology of Bezmialem University and Van Health Teaching and Research Hospital from August 2022 to January 2023. The collected data included age, gravidity, parity, gestational age at birth, duration of delivery stages, prepartum hemoglobin and hematocrit concentrations, changes in hemoglobin and hematocrit concentrations, intrapartum blood loss, estimated blood loss after 2 h of vaginal delivery, Apgar scores at 1 and 5 min, birth weight, and neonatal intensive care unit (NICU) admission. Intrapartum blood loss was objectively measured in milliliters using a postpartum drape with a calibrated bag. The amount of bleeding was measured by subtracting the empty weight of the pads placed under the patient in the patient's bed within 2 h after delivery. Group I: carbetocin 100 μg/mL (n = 75), group II: oxytocin 5 IU/mL (n = 75), group III: carbetocin and tranexamic acid 50 mg/mL (n = 75), group IV: oxytocin and tranexamic acid (n = 75).

RESULTS

The hemoglobin concentration decrease significantly differed between groups (1.03 ± 1.04, 1.3 ± 0.85, 1.4 ± 0.85, 1.41 ± 0.87, respectively; p < 0.001). Group 4 has the highest decrease in hemoglobin and hematocrit concentrations. When we investigated the subgroup differences, the decrease in hemoglobin concentration was significantly higher in group 2 than group 1 (1.30 ± 0.85 vs. 1.03 ± 1.04; p = 0.023), in group 2 than group 3 (1.3 ± 0.85 vs. 1.04 ± 0.9; p = 0.013), and in group 4 than group 3 (1.41 ± 0.87 vs. 1.04 ± 0.9; p < 0.001). The decrease in hematocrit level was significantly different between groups (3.07 ± 3.23, 3.55 ± 2.44, 2.13 ± 3.09, 4.25 ± 2.52; p < 0.001, respectively). No significant differences were observed in terms of mean blood loss between the four groups (277.19 ± 208.10, 294.13 ± 198.64, 274.33 ± 199.57, and 283.97 ± 178.11; p = 0.445, respectively). Furthermore, there was no significant difference between the groups in the rate of need for blood transfusion (1.3%, 5.4%, 4%, and 4%, respectively; p = 0.6).

LIMITATIONS

The most important limitation of the study is a relatively small number of participants.

CONCLUSION

In conclusion, our findings suggest that carbetocin may be more successful than oxytocin and oxytocin plus tranexamic acid regimens in terms of postpartum hemoglobin reduction, and there is no difference in terms of the need for blood transfusion when it is used for postpartum hemorrhage prophylaxis after vaginal delivery.

Effectiveness of prophylactic carbetocin versus oxytocin following vaginal delivery for preventing severe postpartum hemorrhage

OBJECTIVE

To compare the effectiveness of prophylactic carbetocin with prophylactic oxytocin for preventing severe postpartum hemorrhage (PPH) following vaginal delivery.

METHODS

This before and after cohort study took place between 2020 and 2021 in a university maternity hospital. In 2021, the protocol for PPH prevention immediately after vaginal delivery changed: intravenous oxytocin (5 IU) was replaced by intravenous carbetocin (100 μg). All patients with vaginal births were included, with two groups compared: patients who received prophylactic oxytocin in 2020 and those who received prophylactic carbetocin in 2021. The primary outcome was severe PPH, defined as one or more of the following: estimated blood loss ≥1500 mL, transfusion ≥4 units of red blood cells, Bakri balloon use, embolization, vascular ligation, hysterectomy, and maternal death.

RESULTS

Among 4832 women included, 2417 received oxytocin and 2415 received carbetocin. The rate of severe PPH was similar in both groups (0.5% vs. 0.6%, respectively; adjusted odds ratio, 0.8 [95% confidence interval, 0.4-1.8]). The rate of PPH ≥500 mL was lower in the carbetocin group (4% vs. 5.8%; P = 0.004).

CONCLUSION

Although prophylactic carbetocin was associated with a reduction in the rate of PPH ≥500 mL, carbetocin is no different to oxytocin in preventing severe PPH caused by atony after vaginal delivery.

Peripherally restricted oxytocin is sufficient to reduce food intake and motivation, while CNS entry is required for locomotor and taste avoidance effects

OBJECTIVES

Oxytocin (OT) has a well-established role in reproductive behaviours; however, it recently emerged as an important regulator of energy homeostasis. In addition to central nervous system (CNS), OT is found in the plasma and OT receptors (OT-R) are found in peripheral tissues relevant to energy balance regulation. Here, we aim to determine whether peripheral OT-R activation is sufficient to alter energy intake and expenditure.

METHODS AND RESULTS

We first show that systemic OT potently reduced food intake and food-motivated behaviour for a high-fat reward in male and female rats. As it is plausible that peripherally, intraperitoneally (IP) injected OT crosses the blood-brain barrier (BBB) to produce some of the metabolic effects within the CNS, we screened, with a novel fluorescently labelled-OT (fAF546-OT, Roxy), for the presence of IP-injected Roxy in CNS tissue relevant to feeding control and compared such with BBB-impermeable fluorescent OT-B₁₂ (fCy5-OT-B_12; BRoxy). While Roxy did penetrate the CNS, BRoxy did not. To evaluate the behavioural and thermoregulatory impact of exclusive activation of peripheral OT-R, we generated a novel BBB-impermeable OT (OT-B₁₂ ), with equipotent binding at OT-R in vitro. In vivo, IP-injected OT and OT-B₁₂ were equipotent at food intake suppression in rats of both sexes, suggesting that peripheral OT acts on peripheral OT-R to reduce feeding behaviour. Importantly, OT induced a potent conditioned taste avoidance, indistinguishable from that induced by LiCl, when applied peripherally. Remarkably, and in contrast to OT, OT-B₁₂ did not induce any conditioned taste avoidance. Limiting the CNS entry of OT also resulted in a dose-dependent reduction of emesis in male shrews. While both OT and OT-B₁₂ proved to have similar effects on body temperature, only OT resulted in home-cage locomotor depression.

CONCLUSIONS

Together our data indicate that limiting systemic OT CNS penetrance preserves the anorexic effects of the peptide and reduces the clinically undesired side effects of OT: emesis, taste avoidance and locomotor depression. Thus, therapeutic targeting of peripheral OT-R may be a viable strategy to achieve appetite suppression with better patient outcomes.

Effect of Carbetocin on Postpartum Hemorrhage after Vaginal Delivery: A Meta-Analysis

Background

The efficacy of oxytocin and carbetocin in preventing postpartum hemorrhage (PPH) in women with vaginal delivery has been controversial. This study is aimed at conducting a meta-analysis that compares the efficacy of carbetocin and oxytocin in the prevention of PPH among women with vaginal delivery.

Methods

Literature was retrieved from PubMed, Medline, Embase, CENTRAL, and CNKI databases. The randomized controlled trials (RCTs) that compare the efficacy of carbetocin and oxytocin to prevent PPH were searched. Data from the included literatures were extracted by two researchers, including author, title, publication date, study type, study number, the incidence of PPH, number of patients requiring additional uterotonics, and number of patients requiring blood transfusion. Jadad scale was used to evaluate the quality of the included RCTs. The Chi-square test was adopted for the heterogeneity test. A fixed-effect model was used for analysis if heterogeneity did not exist between literatures. If heterogeneity exists between literatures, a random-effect model was used for analysis. The source of heterogeneity was explored by subgroup analysis and sensitivity analysis.

Results

The incidence of PPH in the carbetocin group was lower than that in the oxytocin group (OR = 0.62, 95% CI (0.46, 0.84), Z = 3.14, P = 0.002). There was no heterogeneity among studies (χ² = 7.29, P = 0.12, I² = 45%) and no significant publication bias (P > 0.05). The proportion of women requiring additional uterotonics in the carbetocin group was lower than that in the oxytocin group (OR = 0.41, 95% CI (0.29, 0.56), Z = 5.34, P < 0.00001). There was no heterogeneity among studies (χ² = 0.82, P = 0.84, I² = 0%) and no significant publication bias (P > 0.05). There was no significant difference in the proportion of women needing blood transfusion between the carbetocin group and the oxytocin group (OR = 0.92, 95% CI (0.66, 1.29), Z = 0.46, P = 0.64). There was no heterogeneity among studies (χ² = 3.06, P = 0.55, I² = 0%) and no significant publication bias (P > 0.05).

Conclusion

Carbetocin is superior to oxytocin in preventing PPH among women with vaginal delivery and can be widely used in clinical practice.

Effectiveness and safety of carboxytocin versus oxytocin in preventing postpartum hemorrhage: A systematic review and meta-analysis

OBJECTIVE

This study compared the effectiveness and safety of carbetocin and oxytocin in preventing postpartum hemorrhage (PPH).

METHODS

A systematic literature search was performed on PubMed, Embase, and the Cochrane Library for relevant studies published up to February 2019. Next, two independent reviewers screened the studies according to the selection criteria as well as the strategies recommended by the Cochrane Collaboration. Data were then extracted and evaluated. All statistical analyses were performed using RevMan 5.1.

RESULTS

A total of 24 studies involving 37 383 patients were included for analysis. For cesarean section patients, carbetocin was superior to oxytocin in reduction of the need for additional uterine contraction (odds ratio [OR] = 0.48, 95% confidence interval [CI] [0.35, 0.65], p < 0.00001), PPH (OR = 0.70, 95% CI [0.51, 0.95], p = 0.02), blood loss (mean [MD] = -64.36, 95% CI [-107.78, -20.93], p = 0.004), and transfusion (OR = 0.59, 95% CI [0.42, 0.82], p = 0.002), and there was no significant difference in severe PPH (OR = 0.84, 95% CI [0.66, 1.090], p = 0.19). For vaginal delivery patients, carbetocin was superior to oxytocin in reduction of the need for additional uterine contractions (OR = 0.48, 95% CI [0.25, 0.93], p = 0.03), PPH (OR = 0.28, 95% CI [0.09, 0.91], p = 0.03), and blood loss (MD = -63.52, 95% CI [-113.43, -13.60], p = 0.01), and there were no significant differences in severe PPH (OR = 0.82, 95% CI [0.40, 1.69], p = 0.59) and transfusion (OR = 0.60, 95% CI [0.22, 1.61], p = 0.31). With regard to safety, for cesarean section patients, carbetocin was superior to oxytocin in reduction of the incidence of headache (OR = 0.72, [0.55, 0.95], p = 0.02), and there were no significant differences in nausea, vomiting, abdominal pain, flushing, tremors, itching, dizziness, and fever. For vaginal delivery patients, there were no significant differences in nausea, vomiting, headache, abdominal pain, flushing, tremors, itching, dizziness, and fever between the two drugs.

CONCLUSION

For patients undergoing cesarean section and vaginal delivery, carbetocin was superior to oxytocin in effectiveness and similar in safety. Therefore, carbetocin is expected to be an alternative uterine contraction agent for preventing PPH.

Carbetocin versus oxytocin following vaginal and Cesarean delivery: a before-after study

PURPOSE

A nationwide shortage of oxytocin in Canada resulted in a temporary switch from oxytocin to carbetocin for all postpartum women at our institution. This change offered a unique opportunity to conduct a pragmatic comparative assessment of the efficacy of carbetocin and oxytocin.

METHODS

In a retrospective before-after study, we reviewed the medical records from 641 women in the carbetocin group and 752 women in the oxytocin group . The standard carbetocin dosing was 100 µg iv following vaginal and intrapartum Cesarean delivery, while for elective Cesarean delivery it was 50 µg, with an additional 50 µg if required. The standard oxytocin dosing was 5 IU iv followed by 2.4 IU·hr^-1 for four to six hours after vaginal delivery, while for Cesarean delivery it was 1-3 IU iv, three minutes apart, up to 10 IU if required, followed by the same maintenance. In both modalities of delivery, if uterine tone was suboptimal, the maintenance dose of oxytocin could be increased to 4.8 IU·hr^-1. In both groups, additional uterotonics were used as required. The primary outcome was the need for additional uterotonics. Secondary outcomes included estimated and calculated blood loss, the occurrence of postpartum hemorrhage, and the need for blood transfusion.

RESULTS

The incidence of additional uterotonic use was not different between the carbetocin and oxytocin groups (12.0% vs 8.8%; P = 0.05; odds ratio, 1.39; 95% confidence interval, 0.97 to 2.00). The incidence of postpartum hemorrhage was higher in the carbetocin group than in the oxytocin group (10.3% vs 6.6%; P = 0.01). Blood transfusion was more common in the carbetocin group (1.4% vs 0.3%; P = 0.02).

CONCLUSION

There was no difference in the use of additional uterotonics when carbetocin or oxytocin were used in a cohort of women undergoing vaginal deliveries and both elective and emergency Cesarean deliveries.

Effect of carbetocin administration during the mid-period of parturition on farrowing duration, newborn piglet characteristics, colostrum yield and milk yield in hyperprolific sows

Control of the farrowing process is crucial to reduce the risk of post-parturient disorders in sows and newborn piglet mortality. Carbetocin is a long-acting oxytocin-like compound that has been introduced to domestic animal obstetrics. The aims of the present study were to evaluate the effects of carbetocin administration during the mid-period of parturition on farrowing duration as well as colostrum and milk production and its side effects on neonatal piglet characteristics in hyperprolific sows. The study included 89 Landrace x Yorkshire crossbred sows and 1534 piglets. Sows were randomly distributed into two groups: CONTROL (n = 46), where sows were allowed to farrow naturally, and TREATMENT (n = 43), where sows were administered 0.5 μg/kg carbetocin intramuscularly after the birth of the 7th piglet. In each litter, the piglets were classified into two groups according to birth order: 1-7 and ≥8. The colostrum yield of sows and the colostrum intake of each individual piglet were calculated. Litter weight gain of the piglets from 3 to 5 days of lactation was used to estimate milk yield. Farrowing duration tended to be reduced from 338.4 ± 35.2 min in the CONTROL group to 255.3 ± 36.4 min in the TREATMENT group (P = 0.105). However, the colostrum yield in the TREATMENT group was lower than that in the CONTROL group (3828 ± 149 and 3041 ± 158 g, respectively, P < 0.001). Nevertheless, milk yield during 3-5 days of lactation in the TREATMENT group did not differ significantly compared to that in the CONTROL group (7.53 ± 0.01 and 7.54 ± 0.01 kg/day, respectively, P = 0.643). The incidence of stillbirths in the TREATMENT group was not significantly different from that in the CONTROL group (8.3 and 7.4%, respectively, P = 0.944). However, the incidence of piglets born with umbilical cord rupture in the TREATMENT group with birth order ≥8 was higher than that in the CONTROL group in the same birth order (16.6 and 5.7%, P < 0.001). Across groups, colostrum intake of piglets born with birth order ≥8 was lower than that of piglets born in the birth orders 1-7 (187.4 ± 8.7 and 241.5 ± 9.0 g, P < 0.001). Interestingly, the colostrum intake of piglets with birth orders 1-7 in the TREATMENT group was also lower than that of piglets with the same birth order in the CONTROL group (214.9 ± 12.9 and 268.1 ± 12.5 g, respectively, P = 0.003). Colostrum intake was lowest in the piglets with birth order ≥8 in the TREATMENT group (159.6 ± 12.3, P < 0.001). Carbetocin administration after the birth of the 7th piglet reduced the birth interval of piglets but increased the incidence of piglets born with umbilical rupture and reduced colostrum intake. Therefore, colostrum supplementation and care of the newborn piglets immediately after birth are strongly recommended after carbetocin administration.

Side-effects of carbetocin to prevent postpartum hemorrhage: A systematic review and meta-analysis of randomized controlled trials

Postpartum hemorrhage (PPH) increases the risk of maternal death worldwide. Heat-stable carbetocin, a long-acting oxytocin analog, is a newer uterotonic agent. Clinicians do not fully understand its side-effects, particularly the unanticipated side-effects. The aim of this study is to investigate the side-effects of carbetocin to PPH. The Cochrane Library, Web of Science, PubMed, Elsevier ScienceDirect, Embase, and ClinicalTrials.gov were searched from the inception to September 2020. Randomized controlled trials (RCTs) that considered pregnant women who received carbetocin before delivery and provided at least one adverse event were included. Statistical analysis included random or fixed-effect meta-analyses using relative risk. Stratified analyses and sensitivity analyses were also performed. Begger's and Egger's test and funnel plots were used to assess the publication bias. Seventeen RCTs involving 32,702 women were included, and all these studies ranked as medium- to high-quality. Twenty-four side-effects were reported. The use of carbetocin had a lower risk of vomiting in intravenously (0.53, 0.30 to 0.93) and cesarean birth (0.51, 0.32 to 0.81) women, and had a slightly higher risk of diarrhea (8.00, 1.02 to 62.79) compared with oxytocin intervention. No significant difference was found among other side-effects. Evidence from our systematic review and meta-analysis of 17 RCTs suggested that the risk of vomiting decreased with carbetocin use in the prevention of PPH after delivery.

Carbetocin versus rectal misoprostol for management of third stage of labor among women with low risk of postpartum hemorrhage

OBJECTIVE

To compare effectiveness and safety of carbetocin and misoprostol for prevention of postpartum hemorrhage (PPH) among low-risk women.

METHODS

Randomized controlled trial among 150 pregnant women with low risk of PPH admitted for vaginal delivery at Kasr Al Ainy Hospital, Cairo, Egypt, between July 2018 and May 2019. Participants were assigned to two groups by a web-based randomization system ensuring allocation concealment. After neonatal delivery, the carbetocin group received one ampoule of carbetocin (100 μg/mL) intravenously and the misoprostol group received two rectal tablets of misoprostol (800 μg) for active management of the third stage. Blood pressure, blood loss, and hemoglobin levels were monitored. The primary outcome measure was need for additional uterotonic drugs.

RESULTS

The carbetocin group had significantly less blood loss (P<0.001), shorter third stage (P<0.001), and less need for additional uterotonics (P=0.013) or uterine massage (P=0.007). The two drugs were hemodynamically safe. Hemoglobin levels after delivery were comparable in the two groups (P=0.475). Adverse effects were more common in the misoprostol group (P<0.001).

CONCLUSION

Among low-risk women, carbetocin seems to be a better alternative to misoprostol for active management of the third stage of labor; it reduced blood loss and use of additional uterotonic drugs. CLINICALTRIALS.GOV: NCT03556852.

Carbetocin vs oxytocin for prevention of postpartum hemorrhage after vaginal delivery: A meta-analysis

OBJECTIVE

To evaluate the efficacy and safety of carbetocin for prevention of postpartum hemorrhage in women undergoing vaginal delivery compared with oxytocin.

METHODS

We conducted a systemic literature search in PubMed, the Cochrane Library, and Embase without language restrictions from inception of each of database to November 18th, 2018. Randomized controlled trials with outcome measure of blood loss ≥500 ml were eligible if they compared carbetocin with oxytocin to prevent postpartum hemorrhage during the third stage of labor in women undergoing vaginal delivery.

RESULTS

This meta-analysis of 5 randomized controlled trials (30,314 women) indicated that there was no significant difference between carbetocin and oxytocin in blood loss ≥500 ml in women undergoing vaginal delivery (relative risks (RRs), 0.52; 95% confidence intervals (CIs), 0.24 to 1.15; P = .11; I = 69%). Sensitivity analyses showed the same results. No significant differences were found in blood loss ≥1000 ml, use of additional uterotonic agents, blood transfusion, uterine massage, flushing, vomiting, abdominal pain, nausea, dizziness, headache, palpitation, itching, and shivering.

CONCLUSIONS

This meta-analysis showed that carbetocin was as effective and safe as oxytocin for prevention of postpartum hemorrhage in women undergoing vaginal delivery, and the choice of carbetocin for routine prophylaxis will depend on cost-effectiveness.

Uterotonic drugs to prevent postpartum haemorrhage: a network meta-analysis

BACKGROUND

Postpartum haemorrhage (PPH) is the leading cause of maternal mortality worldwide. Prophylactic uterotonic drugs can reduce blood loss and are routinely recommended. There are several uterotonic drugs for preventing PPH, but it is still debatable which drug or combination of drugs is the most effective.

OBJECTIVES

To identify the most effective and cost-effective uterotonic drug(s) to prevent PPH, and generate a ranking according to their effectiveness and side-effect profile.

METHODS

The Cochrane Pregnancy and Childbirth's Trials Register (1 June 2015), ClinicalTrials.gov and the World Health Organization (WHO)'s International Clinical Trials Registry Platform (ICTRP) were searched for unpublished trial reports (30 June 2015). In addition, reference lists of retrieved studies (updated October 2017) were searched for randomised trials evaluating uterotonic drugs for preventing PPH. The study estimated relative effects and rankings for preventing PPH, defined as blood loss of ≥ 500 ml and ≥ 1000 ml. Pairwise meta-analyses and network meta-analysis were performed to determine the relative effects and rankings of all available drugs and combinations thereof [ergometrine, misoprostol (Cytotec®; Pfizer Inc., New York, NY, USA), misoprostol plus oxytocin (Syntocinon®; Novartis International AG, Basel, Switzerland), carbetocin (Pabal®; Ferring Pharmaceuticals, Saint-Prex, Switzerland), ergometrine plus oxytocin (Syntometrine®; Alliance Pharma plc, Chippenham, UK), oxytocin, and a placebo or no treatment]. Primary outcomes were stratified according to the mode of birth, prior risk of PPH, health-care setting, drug dosage, regimen and route of drug administration. Sensitivity analyses were performed according to study quality and funding source, among others. A model-based economic evaluation compared the relative cost-effectiveness separately for vaginal births and caesareans with or without including side effects.

RESULTS

From 137 randomised trials and 87,466 women, ergometrine plus oxytocin, carbetocin and misoprostol plus oxytocin were found to reduce the risk of PPH blood loss of ≥ 500 ml compared with the standard drug, oxytocin [ergometrine plus oxytocin: risk ratio (RR) 0.69, 95% confidence interval (CI) 0.57 to 0.83; carbetocin: RR 0.72, 95% CI 0.52 to 1.00; misoprostol plus oxytocin: RR 0.73, 95% CI 0.6 to 0.9]. Each of these three strategies had 100% cumulative probability of being ranked first, second or third most effective. Oxytocin was ranked fourth, with an almost 0% cumulative probability of being ranked in the top three. Similar rankings were noted for the reduction of PPH blood loss of ≥ 1000 ml (ergometrine plus oxytocin: RR 0.77, 95% CI 0.61 to 0.95; carbetocin: RR 0.70, 95% CI 0.38 to 1.28; misoprostol plus oxytocin: RR 0.90, 95% CI 0.72 to 1.14), and most secondary outcomes. Ergometrine plus oxytocin and misoprostol plus oxytocin had the poorest ranking for side effects. Carbetocin had a favourable side-effect profile, which was similar to oxytocin. However, the analysis was restricted to high-quality studies, carbetocin lost its ranking and was comparable to oxytocin. The relative cost-effectiveness of the alternative strategies is inconclusive, and the results are affected by both the uncertainty and inconsistency in the data reported on adverse events. For vaginal delivery, when assuming no adverse events, ergometrine plus oxytocin is less costly and more effective than all strategies except carbetocin. The strategy of carbetocin is both more effective and more costly than all other strategies. When taking adverse events into consideration, all prevention strategies, except oxytocin, are more costly and less effective than carbetocin. For delivery by caesarean section, with and without adverse events, the relative cost-effectiveness is different, again because of the uncertainty in the available data.

LIMITATIONS

There was considerable uncertainty in findings within the planned subgroup analyses, and subgroup effects cannot be ruled out.

CONCLUSIONS

Ergometrine plus oxytocin, carbetocin and misoprostol plus oxytocin are more effective uterotonic drug strategies for preventing PPH than the current standard, oxytocin. Ergometrine plus oxytocin and misoprostol plus oxytocin cause significant side effects. Carbetocin has a favourable side-effect profile, which was similar to oxytocin. However, most carbetocin trials are small and of poor quality. There is a need for a large high-quality trial comparing carbetocin with oxytocin; such a trial is currently being conducted by the WHO. The relative cost-effectiveness is inconclusive, and results are affected by uncertainty and inconsistency in adverse events data.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42015020005; Cochrane Pregnancy and Childbirth Group (substudy) reference number 0871; PROSPERO-Cochrane (substudy) reference number CRD42015026568; and sponsor reference number ERN_13-1414 (University of Birmingham, Birmingham, UK).

FUNDING

Funding for this study was provided by the National Institute for Health Research Health Technology Assessment programme in a research award to the University of Birmingham and supported by the UK charity Ammalife (UK-registered charity 1120236). The funders of the study had no role in study design, data collection, data synthesis, interpretation or writing of the report.

Uterotonic agents for preventing postpartum haemorrhage: a network meta-analysis

BACKGROUND

Postpartum haemorrhage (PPH) is the leading cause of maternal mortality worldwide. Prophylactic uterotonic agents can prevent PPH, and are routinely recommended. The current World Health Organization (WHO) recommendation for preventing PPH is 10 IU (international units) of intramuscular or intravenous oxytocin. There are several uterotonic agents for preventing PPH but there is still uncertainty about which agent is most effective with the least side effects. This is an update of a Cochrane Review which was first published in April 2018 and was updated to incorporate results from a recent large WHO trial.

OBJECTIVES

To identify the most effective uterotonic agent(s) to prevent PPH with the least side effects, and generate a ranking according to their effectiveness and side-effect profile.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (24 May 2018), and reference lists of retrieved studies.

SELECTION CRITERIA

All randomised controlled trials or cluster-randomised trials comparing the effectiveness and side effects of uterotonic agents with other uterotonic agents, placebo or no treatment for preventing PPH were eligible for inclusion. Quasi-randomised trials were excluded. Randomised trials published only as abstracts were eligible if sufficient information could be retrieved.

DATA COLLECTION AND ANALYSIS

At least three review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We estimated the relative effects and rankings for preventing PPH ≥ 500 mL and PPH ≥ 1000 mL as primary outcomes. Secondary outcomes included blood loss and related outcomes, morbidity outcomes, maternal well-being and satisfaction and side effects. Primary outcomes were also reported for pre-specified subgroups, stratifying by mode of birth, prior risk of PPH, healthcare setting, dosage, regimen and route of administration. We performed pairwise meta-analyses and network meta-analysis to determine the relative effects and rankings of all available agents.

MAIN RESULTS

The network meta-analysis included 196 trials (135,559 women) involving seven uterotonic agents and placebo or no treatment, conducted across 53 countries (including high-, middle- and low-income countries). Most trials were performed in a hospital setting (187/196, 95.4%) with women undergoing a vaginal birth (71.5%, 140/196).Relative effects from the network meta-analysis suggested that all agents were effective for preventing PPH ≥ 500 mL when compared with placebo or no treatment. The three highest ranked uterotonic agents for prevention of PPH ≥ 500 mL were ergometrine plus oxytocin combination, misoprostol plus oxytocin combination and carbetocin. There is evidence that ergometrine plus oxytocin (RR 0.70, 95% CI 0.59 to 0.84, moderate certainty), carbetocin (RR 0.72, 95% CI 0.56 to 0.93, moderate certainty) and misoprostol plus oxytocin (RR 0.70, 95% CI 0.58 to 0.86, low certainty) may reduce PPH ≥ 500 mL compared with oxytocin. Low-certainty evidence suggests that misoprostol, injectable prostaglandins, and ergometrine may make little or no difference to this outcome compared with oxytocin.All agents except ergometrine and injectable prostaglandins were effective for preventing PPH ≥ 1000 mL when compared with placebo or no treatment. High-certainty evidence suggests that ergometrine plus oxytocin (RR 0.83, 95% CI 0.66 to 1.03) and misoprostol plus oxytocin (RR 0.88, 95% CI 0.70 to 1.11) make little or no difference in the outcome of PPH ≥ 1000 mL compared with oxytocin. Low-certainty evidence suggests that ergometrine may make little or no difference to this outcome compared with oxytocin meanwhile the evidence on carbetocin was of very low certainty. High-certainty evidence suggests that misoprostol is less effective in preventing PPH ≥ 1000 mL when compared with oxytocin (RR 1.19, 95% CI 1.01 to 1.42). Despite the comparable relative treatment effects between all uterotonics (except misoprostol) and oxytocin, ergometrine plus oxytocin, misoprostol plus oxytocin combinations and carbetocin were the highest ranked agents for PPH ≥ 1000 mL.Misoprostol plus oxytocin reduces the use of additional uterotonics (RR 0.56, 95% CI 0.42 to 0.73, high certainty) and probably also reduces the risk of blood transfusion (RR 0.51, 95% CI 0.37 to 0.70, moderate certainty) when compared with oxytocin. Carbetocin, injectable prostaglandins and ergometrine plus oxytocin may also reduce the use of additional uterotonics but the certainty of the evidence is low. No meaningful differences could be detected between all agents for maternal deaths or severe morbidity as these outcomes were rare in the included randomised trials where they were reported.The two combination regimens were associated with important side effects. When compared with oxytocin, misoprostol plus oxytocin combination increases the likelihood of vomiting (RR 2.11, 95% CI 1.39 to 3.18, high certainty) and fever (RR 3.14, 95% CI 2.20 to 4.49, moderate certainty). Ergometrine plus oxytocin increases the likelihood of vomiting (RR 2.93, 95% CI 2.08 to 4.13, moderate certainty) and may make little or no difference to the risk of hypertension, however absolute effects varied considerably and the certainty of the evidence was low for this outcome.Subgroup analyses did not reveal important subgroup differences by mode of birth (caesarean versus vaginal birth), setting (hospital versus community), risk of PPH (high versus low risk for PPH), dose of misoprostol (≥ 600 mcg versus < 600 mcg) and regimen of oxytocin (bolus versus bolus plus infusion versus infusion only).

AUTHORS' CONCLUSIONS

All agents were generally effective for preventing PPH when compared with placebo or no treatment. Ergometrine plus oxytocin combination, carbetocin, and misoprostol plus oxytocin combination may have some additional desirable effects compared with the current standard oxytocin. The two combination regimens, however, are associated with significant side effects. Carbetocin may be more effective than oxytocin for some outcomes without an increase in side effects.

Intravenous carbetocin versus intravenous oxytocin for preventing atonic postpartum hemorrhage after normal vaginal delivery in high-risk singleton pregnancies: a triple-blind randomized controlled trial

PURPOSE

To compare the effectiveness of intravenous carbetocin to that of intravenous oxytocin for prevention of atonic postpartum hemorrhage (PPH) after vaginal delivery in high-risk singleton pregnancies.

METHODS

This triple-blind randomized controlled trial included singleton pregnant women who delivered at Siriraj Hospital between August 2016 and January 2017 and who were 20 years or older, had a gestational age of at least 34 weeks, had a vaginal delivery, and had at least one risk factor for atonic postpartum hemorrhage. Immediately after vaginal delivery, participants were randomly assigned to receive either 5 U of oxytocin or 100 mcg of carbetocin intravenously. Postpartum blood loss was measured objectively in mL using a postpartum drape with a calibrated bag.

RESULTS

A total of 174 and 176 participants constituted the oxytocin and carbetocin groups, respectively. The baseline characteristics were comparable between the groups. The carbetocin group had less postpartum blood loss (146.7 ± 90.4 vs. 195.1 ± 146.2 mL; p < 0.01), a lower incidence of atonic PPH (0 vs. 6.3%; p < 0.01), less usage of additional uterotonic drugs (9.1 vs. 27.6%; p < 0.01), and a lower incidence of postpartum anemia (Hb ≤ 10 g/dL) (9.1 vs. 18.4%; p < 0.05) than the oxytocin group. No significant differences regarding side effects were evident between the groups.

CONCLUSIONS

Intravenous carbetocin is more effective than intravenous oxytocin for the prevention of atonic PPH among singleton pregnancies with at least one risk factor for PPH.

CLINICAL TRIAL REGISTRATION

TCTR20160715004.

Uterotonic agents for preventing postpartum haemorrhage: a network meta-analysis

BACKGROUND

Postpartum haemorrhage (PPH) is the leading cause of maternal mortality worldwide. Prophylactic uterotonic drugs can prevent PPH, and are routinely recommended. There are several uterotonic drugs for preventing PPH but it is still debatable which drug is best.

OBJECTIVES

To identify the most effective uterotonic drug(s) to prevent PPH, and generate a ranking according to their effectiveness and side-effect profile.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register (1 June 2015), ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) for unpublished trial reports (30 June 2015) and reference lists of retrieved studies.

SELECTION CRITERIA

All randomised controlled comparisons or cluster trials of effectiveness or side-effects of uterotonic drugs for preventing PPH.Quasi-randomised trials and cross-over trials are not eligible for inclusion in this review.

DATA COLLECTION AND ANALYSIS

At least three review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We estimated the relative effects and rankings for preventing PPH ≥ 500 mL and PPH ≥ 1000 mL as primary outcomes. We performed pairwise meta-analyses and network meta-analysis to determine the relative effects and rankings of all available drugs. We stratified our primary outcomes according to mode of birth, prior risk of PPH, healthcare setting, dosage, regimen and route of drug administration, to detect subgroup effects.The absolute risks in the oxytocin are based on meta-analyses of proportions from the studies included in this review and the risks in the intervention groups were based on the assumed risk in the oxytocin group and the relative effects of the interventions.

MAIN RESULTS

This network meta-analysis included 140 randomised trials with data from 88,947 women. There are two large ongoing studies. The trials were mostly carried out in hospital settings and recruited women who were predominantly more than 37 weeks of gestation having a vaginal birth. The majority of trials were assessed to have uncertain risk of bias due to poor reporting of study design. This primarily impacted on our confidence in comparisons involving carbetocin trials more than other uterotonics.The three most effective drugs for prevention of PPH ≥ 500 mL were ergometrine plus oxytocin combination, carbetocin, and misoprostol plus oxytocin combination. These three options were more effective at preventing PPH ≥ 500 mL compared with oxytocin, the drug currently recommended by the WHO (ergometrine plus oxytocin risk ratio (RR) 0.69 (95% confidence interval (CI) 0.57 to 0.83), moderate-quality evidence; carbetocin RR 0.72 (95% CI 0.52 to 1.00), very low-quality evidence; misoprostol plus oxytocin RR 0.73 (95% CI 0.60 to 0.90), moderate-quality evidence). Based on these results, about 10.5% women given oxytocin would experience a PPH of ≥ 500 mL compared with 7.2% given ergometrine plus oxytocin combination, 7.6% given carbetocin, and 7.7% given misoprostol plus oxytocin. Oxytocin was ranked fourth with close to 0% cumulative probability of being ranked in the top three for PPH ≥ 500 mL.The outcomes and rankings for the outcome of PPH ≥ 1000 mL were similar to those of PPH ≥ 500 mL. with the evidence for ergometrine plus oxytocin combination being more effective than oxytocin (RR 0.77 (95% CI 0.61 to 0.95), high-quality evidence) being more certain than that for carbetocin (RR 0.70 (95% CI 0.38 to 1.28), low-quality evidence), or misoprostol plus oxytocin combination (RR 0.90 (95% CI 0.72 to 1.14), moderate-quality evidence)There were no meaningful differences between all drugs for maternal deaths or severe morbidity as these outcomes were so rare in the included randomised trials.Two combination regimens had the poorest rankings for side-effects. Specifically, the ergometrine plus oxytocin combination had the higher risk for vomiting (RR 3.10 (95% CI 2.11 to 4.56), high-quality evidence; 1.9% versus 0.6%) and hypertension [RR 1.77 (95% CI 0.55 to 5.66), low-quality evidence; 1.2% versus 0.7%), while the misoprostol plus oxytocin combination had the higher risk for fever (RR 3.18 (95% CI 2.22 to 4.55), moderate-quality evidence; 11.4% versus 3.6%) when compared with oxytocin. Carbetocin had similar risk for side-effects compared with oxytocin although the quality evidence was very low for vomiting and for fever, and was low for hypertension.

AUTHORS' CONCLUSIONS

Ergometrine plus oxytocin combination, carbetocin, and misoprostol plus oxytocin combination were more effective for preventing PPH ≥ 500 mL than the current standard oxytocin. Ergometrine plus oxytocin combination was more effective for preventing PPH ≥ 1000 mL than oxytocin. Misoprostol plus oxytocin combination evidence is less consistent and may relate to different routes and doses of misoprostol used in the studies. Carbetocin had the most favourable side-effect profile amongst the top three options; however, most carbetocin trials were small and at high risk of bias.Amongst the 11 ongoing studies listed in this review there are two key studies that will inform a future update of this review. The first is a WHO-led multi-centre study comparing the effectiveness of a room temperature stable carbetocin versus oxytocin (administered intramuscularly) for preventing PPH in women having a vaginal birth. The trial includes around 30,000 women from 10 countries. The other is a UK-based trial recruiting more than 6000 women to a three-arm trial comparing carbetocin, oxytocin and ergometrine plus oxytocin combination. Both trials are expected to report in 2018.Consultation with our consumer group demonstrated the need for more research into PPH outcomes identified as priorities for women and their families, such as women's views regarding the drugs used, clinical signs of excessive blood loss, neonatal unit admissions and breastfeeding at discharge. To date, trials have rarely investigated these outcomes. Consumers also considered the side-effects of uterotonic drugs to be important but these were often not reported. A forthcoming set of core outcomes relating to PPH will identify outcomes to prioritise in trial reporting and will inform futures updates of this review. We urge all trialists to consider measuring these outcomes for each drug in all future randomised trials. Lastly, future evidence synthesis research could compare the effects of different dosages and routes of administration for the most effective drugs.

Carbetocin versus syntometrine for prevention of postpartum hemorrhage after cesarean section

OBJECTIVE

To compare effectiveness and tolerability of carbetocin versus syntometrine in prevention of postpartum hemorrhage (PPH) after cesarean section (CS).

METHODS

A double-blind randomized study conducted on 300 pregnant subjected randomly either to single 100 μg IV dose of carbetocin (150 women) or combination of 5 IU oxytocin and 0.2 mg ergometrine (150 women) after fetal extraction and before placental removal. Primary outcome parameter was the occurrence of PPH. Other parameters were hemoglobin and hematocrit changes, the need of additional oxytocic, hemodynamic changes and occurrence of side effects.

RESULTS

There was no significant difference between the two study groups regarding hemoglobin and hematocrit at start of CS and after 2 days of surgery and mean blood loss during the operation (p > 0.05). There was a highly significant difference between the two study groups regarding incidence of primary PPH (2.7% versus10%) and the need of additional oxytocic (3.3% versus17.3%). Women in oxytocin group showed a statistically significant lower systolic and diastolic blood pressure at 1, 5 and 30 min than women in carbetocin group. Women in carbetocin group experienced more metallic taste, flushing, headache, dizziness, dyspnea and itching, while women in oxytocin methergine group experienced more palpitations.

CONCLUSIONS

Carbetocin is a reasonable effective alternative to syntometrine in prevention of PPH after cesarean delivery.