Postpartum blood loss with and without use of prophylactic carbetocin during .. Carbetocin versus oxytocin for the prevention of postpartum haemorrhage. Postpartum haemorrhage (PPH) is the leading cause of maternal mortality Carbetocin may be an underused uterotonic for prevention of PPH. Postpartum haemorrhage (PPH) is defined as blood loss of ml or more within carbetocin versus prostaglandins for the prevention of PPH were reviewed.
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Intravenous oxytocin alone is the recommended uterotonic drug for the postpsrtum of PPH. Postpartum haemorrhage Haemorrhgae is defined as blood loss of ml or more within 24 hours after birth. PPH is the primary cause of nearly one-fifth of all maternal deaths globally. Most of these deaths occur during the first 24 hours after birth.
Gaemorrhage majority could be prevented through the use of prophylactic uterotonics during the third stage of labour, and by timely and appropriate management.
The use of uterotonics oxytocin alone as the first choice plays a central role in the treatment of PPH. Six Cochrane systematic reviews provided evidence. Evidence profiles in the form of GRADE tables were prepared for comparisons of interest, including posfpartum assessment and judgments for each outcome, and the estimated risks.
This group of independent experts used the evidence profiles to assess evidence on effects on the pre-specified outcomes. GDG members discussed preenting balance between desirable and undesirable effects, overall quality of supporting evidence, values and preferences of stakeholders, resource requirements, cost-effectiveness, acceptability, feasibility and equity, to finalize the recommendation and remarks. Further information on procedures for developing this recommendation are available here.
One Cochrane systematic review was conducted to assess the effectiveness and safety of any intervention used for the treatment of primary PPH.
This review of ten randomized controlled trials women provided evidence related to the effect of misoprostol on the management of PPH. Evidence related to the use of various uterotonics was extrapolated from research on the prevention of PPH. Systematic reviews comparing the effects of oxytocin versus ergometrine, a fixed dose combination of oxytocin versus ergometrine, and carbetocin versus prostaglandins for the prevention of PPH were reviewed.
One Cochrane systematic review investigated the effects of prophylactic oxytocin versus placebo or no treatment versus ergot alkaloids:. Postpqrtum of oxytocin used ranged from 2 IU to 10 IU, while the fixed drug combination doses consisted of 5 IU of oxytocin and 0.
Of the five identified studies in which IM oxytocin was used as a comparator womenthree of these studies women compared the fixed dose combination of oxytocin-ergometrine versus 10 IU of IM oxytocin. Two studies women were identified which compared IV oxytocin versus a fixed dose IM oxytocin-ergometrine combination. Evidence came from one systematic review of 11 trials women which evaluated the effect of carbetocin mcg as an IV bolus or IM carbetovin for the prevention of PPH after vaginal delivery and caesarean section versus oxytocin, fixed dose oxytocin-ergometrine, and placebo.
This association was not apparent for vaginal delivery RR 0. Of the 60 patients in the group receiving IM prostaglandin, two required the use of additional uterotonics, compared to 10 of the 60 patients who received rectal misoprostol RR 0.
However, these findings should be viewed with caution due to the low event rate, the small sample, and the very low quality of the evidence. Evidence was extrapolated from one systematic review which evaluated a number of routes and doses of misoprostol versus injectable uterotonics for the prevention of PPH. Further information on evidence supporting this recommendation are available here. Local professional societies may play important roles in this process and an all-inclusive and participatory process should be encouraged.
WHO recommendations on prevention and treatment of postpartum haemorrhage – full document and evidence tables. Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors.
Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice. Active versus expectant management for women in the third stage of labour. Cochrane Database Syst Rev.
Prophylactic oxytocin for the third stage of labour to prevent postpartum haemorrhage. Prophylactic ergometrine-oxytocin versus other uterotonics for active management of the third stage of labour. Cochrane Database Of Systematic Reviews. Oxytocin agonists for preventing postpartum haemorrhage. Prostaglandins for preventing postpartum haemorrhage. Cochrane Database of Systematic Reviews. Mousa HA, Alfirevic Z. Treatment for primary postpartum haemorrhage.
Active management of third stage of labour. Education material for teachers of midwifery. What are effects and safety of misoprostol as treatment for PPH, in women who received misoprostol as PPH prophylaxis? This video highlights the importance of social support provided by lay labour companions doulas during labour. Skip to main postpaartum. Recommendation Intravenous oxytocin alone is the recommended uterotonic drug for the treatment of PPH. Updated planned for early Assessed as up-to-date: It encourages health care decision-makers in these settings to strive to make oxytocin available.
In settings where IV oxytocin is unavailable to women who have received prophylactic IM oxytocin during the third stage of labour, the GDG considered misoprostol preventibg be postpattum valid alternative. If PPH prophylaxis with misoprostol has been administered and crbetocin injectable uterotonics are unavailable, there is insufficient evidence to guide further misoprostol dosing and consideration must be given to the risk of potential toxicity.
There is no added benefit to offering misoprostol simultaneously to women receiving oxytocin for the treatment of PPH i. If IV oxytocin has been used for the treatment of PPH and the bleeding does not stop, there is a paucity of data to recommend preferences for second line uterotonic drug treatment. Decisions in such situations must be guided by the experience of the provider, the availability of the drugs, and by known contraindications. Background Postpartum haemorrhage PPH is defined as blood loss of ml or more within 24 hours after birth.
Recommendation question For this recommendation, we aimed to answer carbefocin following question: For women with postpartum haemorrhage, which is the uterotonic of choice to improve outcomes?
Evidence summary One Cochrane systematic review was conducted to assess the effectiveness and safety of any intervention used for the treatment of primary PPH.
In addition, an increase in the risk of shivering was associated with the use of misoprostol RR 2. The use of misoprostol as an adjunct for the treatment of women who received therapeutic oxytocin for PPH added no benefit. An increased risk of hyperthermia, vomiting and shivering was observed. Oxytocin versus ergometrine One Cochrane systematic review investigated the effects of prophylactic oxytocin versus placebo or no treatment versus ergot alkaloids: No differences in blood transfusion in women receiving oxytocin compared with women receiving ergometrine RR 3.
WHO recommendation on the use of uterotonics for the treatment of postpartum haemorrhage (PPH)
No significant difference was observed in the use of additional uterotonics in the four trials included the systematic review. Among the adverse outcomes rated as important, the comparison of oxytocin versus ergometrine or derivatives showed a lower rate of adverse effects in women treated with oxytocin only, as well as lower rates of nausea RR 0.
There was no observed difference reported in high blood pressure in women treated with oxytocin only RR 0. In the three studies that reported on the use of blood transfusion, the effect was uncertain as the confidence interval included both benefit and harm RR 1.
Carbetocin for preventing postpartum haemorrhage.
Two studies reported a statistically significant lower use prevenfing additional uterotonics in the group receiving the fixed dose oxytocin-ergometrine combination RR 0.
Among the adverse outcomes rated as important, higher rates of nausea RR 4. There was no statistically significant difference between the two groups with regard to blood loss, the use of blood transfusion, or the use of additional uterotonics. Among the adverse outcomes rated as important, a higher rate of vomiting RR 3. Of the reported critical outcomes, there was no difference in the need for blood transfusion between the groups, or for the manual removal of the placenta.
Other important adverse effects were not reported. Carbetocin versus oxytocin Evidence came from one systematic review of 11 trials women which evaluated the effect of carbetocin mcg as an IV bolus or IM injection for the prevention of PPH after vaginal delivery and caesarean section versus oxytocin, fixed dose oxytocin-ergometrine, and placebo. When compared to oxytocin, carbetocin was associated with a reduced use of additional uterotonic drugs after caesarean delivery RR 0.
The systematic review reported a reduction in the risk of PPH, with the use of carbetocin versus oxytocin for women who underwent caesarean haemorrhxge. Including this trial in the meta-analysis changes the results RR 0. No significant difference was observed between the two groups with regard to blood loss, the use of blood transfusion, or the use of additional uterotonics. Among the important adverse maternal outcomes reported, lower rates of nausea RR 0.
No difference was observed in the risk of blood loss, the additional uaemorrhage of uterotonics, or the need for blood transfusion. Among the important adverse effects reported, IM prostaglandins were associated with a higher risk of vomiting RR 2. Misoprostol any route versus injectable uterotonics Evidence was extrapolated from one systematic review which evaluated a number of routes and doses of misoprostol versus injectable uterotonics for the prevention of PPH.
The trials did not report the outcome of invasive or surgical treatment.
Implementation considerations The successful introduction of evidence-based policies related to the prevention and management of Postaprtum into national programmes and health care services depends on well-planned and participatory consensus-driven processes of adaptation and implementation. These processes may include the development or revision of national guidelines or protocols based on this recommendation.
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The recommendation should be adapted into locally-appropriate documents and tools that are able to meet the specific needs of each country and health service. Modifications to the recommendation, where necessary, should be justified in an explicit and transparent manner.
An enabling environment for example, by widening the availability of uterotonicsshould be created for the use of this recommendation for example, by widening the availability of crystalloid solutionincluding changes in the behaviour of health care practitioners to enable the use of evidence-based practices.
Related links WHO recommendations on prevention and treatment of postpartum haemorrhage – full document and evidence tables Managing Complications in Pregnancy and Childbirth: A guide for essential practice Links to the supporting systematic reviews: Active management of third stage of labour Education material for teachers of midwifery.
Research implications The GDG identified these research priorities related to this recommendation: What is the minimum effective dose of misoprostol for the treatment of PPH? Treatment of post-partum haemorrhage with sublingual misoprostol versus oxytocin in women receiving prophylactic oxytocin: World Health Organization; Rating the quality of evidence.
WHO recommendations for the prevention and treatment of postpartum haemorrhage. World Health Organization, Prophylactic oxytocin for the third stage of labour.