Nitroglycerin for management of retained placenta

Abdel‐Aleem, Hany; Abdel-Aleem, Mahmoud A; Shaaban, Omar M.

doi:10.1002/14651858.cd007708.pub3

Cited by 11 publications

(9 citation statements)

References 27 publications

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“…CHAMPION, WOMAN) 22,34 and some case series related to PPH management are also included. 31,32 Algorithms were found in the FIGO 17 , RCOG 18 and SA-NCCEMD 35 publications; all are consistent with the PPH algorithm being presented.…”

Section: Search Resultssupporting

confidence: 66%

“…As previously described, international and national guidance documents 15,16,17,18,19,20,43 , RCTs on individual treatments 22,34 and case series were all used to construct this algorithm. Three articles on temporising management for women who need emergency referral which include Non-pneumatic Antishock Garment (NASG), uterine tourniquet and Balloon Tamponade (BT) were also referenced 24,29,31,32 , as well as the Algorithms for PPH devised by the South African Confidential Enquiry into Maternal Deaths.…”

Section: Four Case Scenarios For Third Stage Abnormalitiesmentioning

confidence: 99%

“…Hysterectomy is a life-saving procedure for intractable uterine atony, but the skill is unlikely to be available at district hospital level where non specialists supervise maternity. 27,28,35 In this situation, temporising methods (BT, Uterine tourniquet and NASG) 24,31,32 , advice from a specialist and referral to more specialised care are necessary.…”

Section: 35mentioning

confidence: 99%

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Algorithms for managing third stage abnormalities

Marcus¹,

Fawcus²

2020

Preprint

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The development of clear approaches to the assessment, resuscitation, treatment and monitoring of the four case scenarios are presented as algorithms, based on available evidence. They need to be field tested, and adapted for Artificial intelligence and different settings. Further research is needed around multimodal sequential care package of care for PPH, conservative surgical measures, resuscitation in LMICs, and the psychological impact of PPH on women.

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Section: Search Resultssupporting

confidence: 66%

Section: Four Case Scenarios For Third Stage Abnormalitiesmentioning

confidence: 99%

Section: 35mentioning

confidence: 99%

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Algorithms for managing third stage abnormalities

Marcus¹,

Fawcus²

2020

Preprint

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“…In placentae that are detached but trapped behind a myometrial contraction ring, GTN could potentially treat retained placenta simply by relaxing local uterine muscle constriction and, thereby, effecting placental release. 8 For adherent placenta, Farley et al 23 have suggested that nitric oxide-mediated contraction and relaxation of human chorionic villi along their longitudinal axis might serve as a GTN-mediated mechanism for placental separation. For placentae that are retained because of partial placenta accreta, currently available nitric oxide drugs (including GTN) are unlikely to effect release and surgical management is likely to remain the preferred method of treatment.…”

Section: Biological Plausibility Of Glyceryl Trinitrate For the Managmentioning

confidence: 99%

“…Non-surgical management options for retained placenta are limited and it is recognised that further research is required to examine medical management strategies for retained placenta. 1,8 Current management of manual removal of retained placenta poses a risk of bleeding and infection, and a new safer medical management that is more acceptable to women is urgently required.…”

Section: Aim and Overviewmentioning

confidence: 99%

Glyceryl trinitrate to reduce the need for manual removal of retained placenta following vaginal delivery: the GOT-IT RCT

Denison

Carruthers

Hudson

et al. 2019

Health Technol Assess

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Background Retained placenta is associated with postpartum haemorrhage and can lead to significant maternal morbidity if untreated. The only effective treatment is the surgical procedure of manual removal of placenta, which is costly, requires skilled staff, requires an operative environment and is unpleasant for women. Small studies suggest that glyceryl trinitrate may be an effective medical alternative. Objective To determine the clinical effectiveness and cost-effectiveness of sublingual glyceryl trinitrate spray compared with placebo in reducing the need for manual removal of placenta in women with retained placenta after vaginal delivery following the failure of current management. Design A group-sequential randomised double-blind placebo-controlled trial with a cost-effectiveness analysis. Setting There were 29 obstetric units in the UK involved in the study. Participants There were 1107 women (glyceryl trinitrate group, n = 543; placebo group, n = 564) randomised between October 2014 and July 2017. Interventions Glyceryl trinitrate spray was administered to 541 women in the intervention group, and a placebo was administered to 563 women in the control group. Main outcome measures Four primary outcomes were defined: (1) clinical – the need for manual removal of placenta, (2) safety – measured blood loss, (3) patient sided – satisfaction with treatment and side effects and (4) economic – cost-effectiveness of both treatments using the UK NHS perspective. Secondary clinical outcomes included a > 15% decrease in haemoglobin level, time from randomisation to delivery of placenta in theatre, the need for earlier manual removal of placenta than planned, increase in heart rate or decrease in blood pressure, requirement for blood transfusion, requirement for general anaesthesia, maternal pyrexia, and sustained uterine relaxation requiring additional uterotonics. Results No difference was observed between the glyceryl trinitrate group and the control group for the placenta remaining undelivered within 15 minutes of study treatment (93.3% vs. 92%; odds ratio 1.01, 95% confidence interval 0.98 to 1.04; p = 0.393). There was no difference in blood loss of > 1000 ml between the glyceryl trinitrate group and the control group (22.2% vs. 15.5%; odds ratio 1.14, 95% confidence interval 0.88 to 1.48; p = 0.314). Palpitations were more common in the glyceryl trinitrate group than in the control group after taking the study drug (9.8% vs. 4.0%; odds ratio 2.60, 95% confidence interval 1.40 to 4.84; p = 0.003). There was no difference in any other measures of patient satisfaction between the groups. There was no difference in costs to the health service between groups (mean difference £55.30, 95% confidence interval –£199.20 to £309.79). Secondary outcomes revealed that a fall in systolic or diastolic blood pressure, or an increase in heart rate, was more common in the glyceryl trinitrate group than in the control group (odds ratio 4.9, 95% confidence interval 3.7 to 6.4; p < 0.001). The need for a blood transfusion was also more common in the glyceryl trinitrate group than in the control group (odds ratio 1.53, 95% confidence interval 1.04 to 2.25; p = 0.033). Conclusions Glyceryl trinitrate spray did not increase the delivery of retained placenta within 15 minutes of administration when compared with the placebo, and was not cost-effective for medical management of retained placenta. More participants reported palpitations and required a blood transfusion in the glyceryl trinitrate group. Further research into alternative methods of medical management of retained placenta is required. Trial registration Current Controlled Trials ISRCTN88609453. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 70. See the NIHR Journals Library website for further project information.

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