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Wang LY, Wang J, Dong JH, Ping ZP, Chen XZ, Wei CN. The optimal oxytocin infusion rate for preventing uterine atony during cesarean delivery in elderly parturients with prior history of cesarean delivery. Front Pharmacol 2023; 14:1211693. [PMID: 37576820 PMCID: PMC10416618 DOI: 10.3389/fphar.2023.1211693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 07/17/2023] [Indexed: 08/15/2023] Open
Abstract
Background: An estimate of 90% effective dose (ED90) of oxytocin infusion has already been proved effective in non-laboring parturients. However, the requirements of oxytocin for elderly parturients with prior history of cesarean delivery (CD) may be higher. The aim of this study was to find the optimum oxytocin infusion rate for preventing uterine atony during CD in elderly parturients with prior history of CD. Method: We performed a randomized, double-blinded study in 120 healthy elderly parturients with prior history of CD scheduled for elective CD under combined spinal-epidural (CSE) anesthesia. Participants were treated with oxytocin infusion randomly at the rates of 0, 4, 8, 12, 16, or 20 IU h-1 after the delivery of infants. Following oxytocin administration, a blinded obstetrician evaluated the uterine tone (UT), verbally describing it using numerical scales (0-10: 0, no UT; 10, optimal UT) as either adequate or inadequate at the time intervals of 3, 6, and 9 min. Maternal adverse effects, requirements for additional uterotonic agents, delivery-placenta delivery time (PD), and estimated blood loss (EBL) were recorded. Results: The 50% effective dose (ED50) and 90% effective dose (ED90) of oxytocin infusion were 14.6 IU h-1 (95% confidence interval 12.0-18.4 IU h-1) and 27.7 IU h-1 (95% confidence interval 22.5-39.4 IU h-1), respectively. As the rate of infusion was increased in parturients, the rescue oxytocin dose and delivery-PD time were decreased. Parturients who received 0 IU h-1 oxytocin at 3, 6, and 9 min obtained lower UT scores than those who received 16 and 20 IU h-1 oxytocin (p < 0.05, respectively). No significant differences were observed among groups in EBL and maternal adverse effects. Conclusion: The infusion rate of oxytocin at 14.57 and 27.74 IU h-1 produces adequate UT in 50% and 90% of elderly parturients with prior history of CD, respectively. An oxytocin infusion rate of 27.7 IU h-1 is suggested to be the optimal dose for preventing uterine atony during CD in elderly parturients with prior history of cesarean delivery. Clinical Trial Registration: [https://www.chictr.org.cn/bin/project/edit?pid=62489], Identifier: [ChiCTR2000038891].
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Affiliation(s)
- Li Ying Wang
- Department of Anesthesia, Jiaxing University Affiliated Women and Children Hospital, Jiaxing, China
| | - Jin Wang
- Department of Anesthesia, Jiaxing University Affiliated Women and Children Hospital, Jiaxing, China
| | - Jin Hua Dong
- Department of Obstetrics, Jiaxing University Affiliated Women and Children Hospital, Jiaxing, China
| | - Ze Peng Ping
- Department of Obstetrics, Jiaxing University Affiliated Women and Children Hospital, Jiaxing, China
| | - Xin Zhong Chen
- Department of Anesthesia, Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chang Na Wei
- Department of Anesthesia, Jiaxing University Affiliated Women and Children Hospital, Jiaxing, China
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Davis PR, Sviggum HP, Arendt KW, Pompeian RJ, Kurian C, Torbenson VE, Hanson AC, Schulte PJ, Hamilton KD, Sharpe EE. Effect of an oxytocin protocol on secondary uterotonic use in patients undergoing Cesarean delivery. Can J Anaesth 2023; 70:1194-1201. [PMID: 37280454 PMCID: PMC10662968 DOI: 10.1007/s12630-023-02496-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 11/10/2022] [Accepted: 11/20/2022] [Indexed: 06/08/2023] Open
Abstract
PURPOSE Protocol-driven oxytocin regimens can reduce oxytocin administration compared with a nonprotocol free-flow continuous infusion. Our aim was to compare secondary uterotonic use between a modified "rule of threes" oxytocin protocol and a free-flow continuous oxytocin infusion after Cesarean delivery. METHODS We conducted a retrospective before-and-after study to compare patients who underwent Cesarean delivery between 1 January 2010 and 31 December 2013 (preprotocol) with patients who underwent Cesarean delivery between 1 January 2015 and 31 August 2017 (postprotocol). The preprotocol group received free-flow oxytocin administration and the postprotocol group received oxytocin according to a modified rule of threes algorithm. The primary outcome was secondary uterotonic use and the secondary outcomes included blood transfusion, hemoglobin value < 8 g·dL-1, and estimated blood loss. RESULTS In total, 4,010 Cesarean deliveries were performed in 3,637 patients (2,262 preprotocol and 1,748 postprotocol). The odds of receiving secondary uterotonic drugs were increased in the postprotocol group (odds ratio [OR], 1.33; 95% confidence interval [CI], 1.04 to 1.70; P = 0.02). Patients in the postprotocol group were less likely to receive a blood transfusion. Nevertheless, the two groups were similar for the composite end point of transfusion or hemoglobin < 8 g·dL-1 (OR, 0.86; 95% CI, 0.66 to 1.11; P = 0.25). The odds of an estimated blood loss greater than 1,000 mL were reduced in the postprotocol group (OR, 0.64; 95% CI, 0.50 to 0.84; P = 0.001). CONCLUSIONS Patients in the modified rule of threes oxytocin protocol group were more likely to receive a secondary uterotonic than those in the preprotocol group. Estimated blood loss and transfusion outcomes were similar.
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Affiliation(s)
- Paul R Davis
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Hans P Sviggum
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Katherine W Arendt
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Rochelle J Pompeian
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Christopher Kurian
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - Andrew C Hanson
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, USA
| | - Phillip J Schulte
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, USA
| | - Kimberly D Hamilton
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Emily E Sharpe
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
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Tantry TP, Karanth H, Anniyappa S, Shetty PK, Upadya M, Shenoy SP, Kadam D. Intravenous oxytocin regimens in patients undergoing cesarean delivery: a systematic review and network meta-analysis of cluster-based groups. J Anesth 2022; 37:278-293. [PMID: 36385197 DOI: 10.1007/s00540-022-03132-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 10/20/2022] [Indexed: 11/17/2022]
Abstract
Information on evaluations of different oxytocin regimens used to prevent post-partum hemorrhage during cesarean delivery is scarce, and there is a lack of statistically pooled results for comparative doses. In this review, we aimed to analyze the effectiveness of different oxytocin regimens used and rank them accordingly. We performed a meta-analysis of randomized controlled trials (RCTs) reporting the incidence of additional uterotonic (AUT) use or amount of blood loss during cesarean delivery, where different oxytocin regimens were compared. Cluster analysis was used to define different clusters of oxytocin therapy based on the identified variable regimens. During the frequentist network meta-analysis, all clusters were compared to bolus clusters of dose range 3-5 IU. Data from 33 RCTs (6741 patients) to 26 RCTs (5422 patients) were assessed for AUT use and blood loss, respectively. Pairwise meta-analysis revealed a significant reduction in the use of AUTs or blood loss was recorded for bolus-infusion combination regimens. The network meta-analysis found that combined bolus-infusion regimens of (i) 3-5 IU and 0.25-1 IU/min or (ii) 3-5 IU and < 0.25 IU/min had statistically significant results for lowest consumption of AUTs (Ranks 1 and 2, respectively); whereas with the latter's use, the lowest blood loss (Rank 2) was observed. In contrast, the dose range, > 5 IU regimen was associated with higher side effects (lowest rank). During cesarean delivery, a significant reduction in the use of AUTs or blood loss (Rank 2) was recorded for bolus-infusion combination regimens. High doses did not have enough evidence to draw meaningful conclusions.
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Affiliation(s)
- Thrivikrama Padur Tantry
- Department of Anaesthesiology, A J Institute of Medical Sciences and Research Centre, Kuntikana, Mangalore, 575004, India.
| | - Harish Karanth
- Department of Anaesthesiology, A J Institute of Medical Sciences and Research Centre, Kuntikana, Mangalore, 575004, India
| | - Saravana Anniyappa
- Department of Obstetrics and Gynecology, King Khalid University College of Medicine, Abha, Saudi Arabia
| | - Pramal K Shetty
- Department of Anaesthesiology, A J Institute of Medical Sciences and Research Centre, Kuntikana, Mangalore, 575004, India
| | - Madhusudan Upadya
- Department of Anaesthesiology, Kasturba Medical College, MAHE, Mangalore, 575001, India
| | - Sunil P Shenoy
- Department of Urology and Transplant Surgery, A J Institute of Medical Sciences and Research Centre, Kuntikana, Mangalore, 575004, India
| | - Dinesh Kadam
- Department of Plastic and Reconstructive Surgery, A J Institute of Medical Sciences and Research Centre, Kuntikana, Mangalore, 575004, India
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Abstract
PURPOSE OF REVIEW Postpartum hemorrhage (PPH) is the leading preventable cause of maternal morbidity and mortality worldwide. Uterine atony is identified as the underlying etiology in up to 80% of PPH. This serves as a contemporary review of the epidemiology, risk factors, pathophysiology, and treatment of uterine atony. RECENT FINDINGS Rates of postpartum hemorrhage continue to rise worldwide with the largest fraction attributed to uterine atony. A simple 0-10 numerical rating score for uterine tone was recently validated for use during cesarean delivery and may allow for more standardized assessment in clinical and research settings. The optimal prophylactic dose of oxytocin differs depending on the patient population, but less than 5 units and as low as a fraction of one unit is needed for PPH prevention, with an increased requirements within that range for cesarean birth, those on magnesium, and advanced maternal age. Carbetocin is an appropriate alternative to oxytocin. Misoprostol shows limited to no efficacy for uterine atony in recent studies. Several uncontrolled case studies demonstrate novel mechanical and surgical interventions for treating uterine atony. SUMMARY There is a critical, unmet need for contemporary, controlled studies to address the increasing threat of atonic PPH.
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Affiliation(s)
- Hayley E Miller
- Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University School of Medicine
| | - Jessica R Ansari
- Division of Obstetric Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford and Department of Anesthesiology, Stanford, Palo Alto, California, USA
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