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Oxytocin as First-line Uterotonic Therapy for Postpartum Hemorrhage

 

Am Fam Physician. 2021 Jun 1;103(11):656-657.

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OXYTOCIN VS. MISOPROSTOL FOR POSTPARTUM HEMORRHAGE

BenefitsHarms

1 in 43 treated with oxytocin (Pitocin) vs. misoprostol (Cytotec) had decreased risk of blood transfusion

1 in 4 patients treated with misoprostol vs. oxytocin had complications, such as fever or vomiting

OXYTOCIN VS. MISOPROSTOL FOR POSTPARTUM HEMORRHAGE

BenefitsHarms

1 in 43 treated with oxytocin (Pitocin) vs. misoprostol (Cytotec) had decreased risk of blood transfusion

1 in 4 patients treated with misoprostol vs. oxytocin had complications, such as fever or vomiting

Details for This Review

Study Population: Patients being actively managed in the third stage of labor who also have postpartum hemorrhage

Efficacy End Points: Composite outcome of maternal death or severe morbidity (primary); need for blood transfusion (secondary)

Harm End Points: Fever, vomiting (secondary)

Narrative: Postpartum hemorrhage (i.e., more than 500 mL of maternal blood loss) is the leading cause of postpartum maternal mortality worldwide and a significant contributing cause of neonatal morbidity and mortality.1 Uterine atony is the most common cause of postpartum hemorrhage. Although the World Health Organization recommends using prophylactic uterotonics for all delivering patients, postpartum hemorrhage still occurs in up to 15% of births worldwide. There is consensus among maternal health organizations that uterotonics should be considered as first-line therapy for postpartum hemorrhage.2 However, there is no consensus on a recommended first-line agent.

When readily available, oxytocin (Pitocin) is commonly used as the first-line uterotonic. Oxytocin monotherapy decreases the need for blood transfusion and has fewer adverse effects than misoprostol (Cytotec) monotherapy or misoprostol plus oxytocin.3 The effect of oxytocin therapy on mortality or severe maternal morbidity is unclear. A pairwise meta-analysis of two trials, including 1,787 participants, suggests that using misoprostol as first-line therapy increases the risk of blood transfusion compared with oxytocin (risk ratio = 1.47; 95% CI, 1.02 to 2.14).3

This Cochrane review compared uterotonics to treat postpartum hemorrhage and involved seven studies and 3,738 total patients.3 All included studies were two-arm clinical trials in hospital settings in Argentina, Burkina Faso, Ecuador, Egypt, Gambia, Pakistan, South Africa, Thailand, Turkey, or Vietnam. Of the participants, 98% delivered vaginally. Prophylactic uterotonics were used in all but one trial (978 participants).4

One trial with 809 participants reported a composite outcome of death or severe morbidity,

Author disclosure: No relevant financial affiliations.


The views expressed are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Uniformed Services University of the Health Sciences, Fort Belvoir Community Hospital, the Department of Defense, or the U.S. government.

Copyright © 2021 MD Aware, LLC (theNNT.com). Used with permission.

This series is coordinated by Christopher W. Bunt, MD, AFP assistant medical editor, and the NNT Group.

A collection of Medicine by the Numbers published in AFP is available at https://www.aafp.org/afp/mbtn.

References

show all references

1. Say L, Chou D, Gemmill A, et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health. 2014;2(6):e323–e333....

2. World Health Organization. WHO recommendations for the prevention and treatment of postpartum haemorrhage. 2012. Accessed January 5, 2021. https://www.who.int/reproductivehealth/publications/maternal_perinatal_health/9789241548502/en/

3. Parry Smith WR, Papadopoulou A, Thomas E, et al. Uterotonic agents for first-line treatment of postpartum haemorrhage: a network meta-analysis. Cochrane Database Syst Rev. 2020;(11):CD012754.

4. Winikoff B, Dabash R, Durocher J, et al. Treatment of post-partum haemorrhage with sublingual misoprostol versus oxytocin in women not exposed to oxytocin during labour: a double-blind, randomised, non-inferiority trial. Lancet. 2010;375(9710):210–216.

5. Blum J, Winikoff B, Raghavan S, et al. Treatment of post-partum haemorrhage with sublingual misoprostol versus oxytocin in women receiving prophylactic oxytocin: a double-blind, randomised, non-inferiority trial. Lancet. 2010;375(9710):217–223.

6. Hofmeyr GJ, Ferreira S, Nikodem VC, et al. Misoprostol for treating postpartum haemorrhage: a randomized controlled trial [ISRCTN72263357]. BMC Pregnancy Childbirth. 2004;4(1):16.

7. Walraven G, Dampha Y, Bittaye B, et al. Misoprostol in the treatment of postpartum haemorrhage in addition to routine management: a placebo randomised controlled trial. BJOG. 2004;111(9):1014–1017.

8. Zuberi NF, Durocher J, Sikander R, et al. Misoprostol in addition to routine treatment of postpartum hemorrhage: a hospital-based randomized-controlled trial in Karachi, Pakistan. BMC Pregnancy Childbirth. 2008;8:40.

9. Widmer M, Blum J, Hofmeyr GJ, et al. Misoprostol as an adjunct to standard uterotonics for treatment of post-partum haemorrhage: a multicentre, double-blind randomised trial. Lancet. 2010;375(9728):1808–1813.

10. Committee on Practice Bulletins-Obstetrics. Practice bulletin no. 183: postpartum hemorrhage. Obstet Gynecol. 2017;130(4):e168–e186.

11. Prevention and management of postpartum haemorrhage: green-top guideline no. 52. BJOG. 2017;124(5):e106–e149.

12. Leduc D, Senikas V, Lalonde AB. No. 235-active management of the third stage of labour: prevention and treatment of postpartum hemorrhage. J Obstet Gynaecol Can. 2018;40(12):e841–e855.

13. National Institute for Health and Care Excellence. Intrapartum care for healthy women and babies. NICE clinical guidelines, no. 190. Accessed February 24, 2021. https://www.ncbi.nlm.nih.gov/books/NBK555206/

 

 

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