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

Gallos, Ioannis D; Williams, Helen; Price, Malcom J; Merriel, Abi; Gee, Harold; Lissauer, David; Moorthy, Vidhya; Tunçalp, Özge; Gülmezoglu, A Metin; Deeks, Jonathan J; Hofmeyr, G Justus

doi:10.1002/14651858.cd011689

Cited by 32 publications

(53 citation statements)

References 24 publications

(6 reference statements)

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“…For every maternal death, a larger number suffer serious morbidity, including multi-organ failure and peripartum hysterectomy [2]. There is strong evidence, and widespread recommendation, for the routine administration of uterotonics to prevent postpartum haemorrhage at caesarean section [2][3][4].…”

Section: Introductionmentioning

confidence: 99%

Carbetocin at elective caesarean section: a sequential allocation trial to determine the minimum effective dose in obese women

et al. 2019

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Postpartum haemorrhage is a leading cause of maternal death during childbirth. There is an increasing incidence of atonic postpartum haemorrhage in developed countries, and maternal obesity has been proposed as a contributing factor. The dose-response relationship of carbetocin in obese women has not yet been determined. We conducted a double-blind, dose-finding study of carbetocin using a biased coin up-and-down design in women with a body mass index ≥ 40 kg.m À2 undergoing elective caesarean section. The determinant for a successful response was satisfactory uterine tone, with no intra-operative need for additional uterotonic drugs. Secondary outcomes included the use of additional uterotonic drugs postoperatively, estimated blood loss and adverse effects of carbetocin administration. Thirty women were recruited to the study. The median (IQR [range]) body mass index was 44.93 (41.5-55.2 [40-66.5]) kg.m À2 . The ED 90 of carbetocin was estimated as 62.9 (95%CI 57.0-68.7) lg using the truncated Dixon and Mood method, and 68 (95%CI 52-77) lg using the isotonic regression method. The estimated blood loss was 880 (621-1178 [75-2442]) ml. The overall rates of hypotension and hypertension after delivery were 40% and 6.7%, respectively, while nausea occurred in 26.7% of women. The ED 90 for carbetocin in obese women at elective caesarean section is lower than the dose of 100 lg currently recommended by the Society of Obstetricians and Gynaecologists of Canada, but is approximately four times higher than the previously demonstrated ED 90 of 14.8 lg in women with body mass index < 40 kg.m À2 .

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Section: Introductionmentioning

confidence: 99%

Carbetocin at elective caesarean section: a sequential allocation trial to determine the minimum effective dose in obese women

et al. 2019

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“…Other agents, such as Misoprostol and Carboprost, might offer a more cost-effective alternative 11. This is currently being investigated via a network meta-analysis to shed more light on the efficacy and cost-effectiveness of the various uterotonic agents 12. The use of surgical treatments was not common; this could be due to the limited number of massive PPH cases captured in our cohort.…”

Section: Discussionmentioning

confidence: 99%

Management of obstetric postpartum hemorrhage: a national service evaluation of current practice in the UK

Wattar¹,

Tamblyn²,

Smith³

et al. 2017

RMHP

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BackgroundPostpartum hemorrhage (PPH) continues to be one of the major causes of maternal mortality and morbidity in obstetrics. Variations in practice often lead to adverse maternity outcomes following PPH. Our objective was to assess the current practice in managing PPH in the UK.MethodsWe performed a national multicenter prospective service evaluation study over one calendar month and compared the current performance to national standards for managing PPH. We used a standardized data collection tool and collected data on patients’ demographics, incidence of PPH, estimated blood loss (EBL), prophylactic and treatment measures, onset of labor, and mode of delivery.ResultsWe collected data from 98 obstetric units, including 3663 cases of primary PPH. Fifty percent of cases were minor PPH (EBL 500–1000 mL, n=1900/3613, 52.6%) and the remaining were moderate PPH (EBL >1000 to <2000 mL, n=1424/3613, 39.4%) and severe PPH (EBL >2000 mL, n=289/3613, 8%). The majority of women received active management of the third stage of labor (3504/3613, 97%) most commonly with Syntometrine intramuscular (1479/3613, 40.9%). More than half required one additional uterotonic agent (2364/3613, 65.4%) most commonly with Syntocinon intravenous infusion (1155/2364, 48.8%). There was a poor involvement of consultant obstetricians and anesthetists in managing PPH cases, which was more prevalent when managing major PPH (p=0.0001).ConclusionThere are still variations in managing PPH in the UK against national guidelines. More senior doctor involvement and regular service evaluation are needed to improve maternal outcomes following PPH.

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“…There are some differences between the published protocol for this review (Gallos 2015) and the full review, these are listed below.…”

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confidence: 99%

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

Gallos

Papadopoulou

Man

et al. 2018

Cochrane Database of Systematic Reviews

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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, , the World Health Organization (WHO) International Clinical Trials Registry Platform ( ) (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 ...

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

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

Cited by 32 publications

References 24 publications

Carbetocin at elective caesarean section: a sequential allocation trial to determine the minimum effective dose in obese women

Carbetocin at elective caesarean section: a sequential allocation trial to determine the minimum effective dose in obese women

Management of obstetric postpartum hemorrhage: a national service evaluation of current practice in the UK

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

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