OB Hemorrhage - Medical Treatment Resources

OBJECTIVE: To compare rectally administered misoprostol to intravenously administered oxytocin for the management of third-stage labor.
STUDY DESIGN: Subjects were randomized to receive two, 200-microg misoprostol tablets rectally (study medication) plus 2 mL saline in Ringer's lactate intravenously or two lactose tablets rectally plus 20 units oxytocin in Ringer's lactate intravenously (control medication). Blood loss was determined by estimation, measurement, and change in hematocrit values from admission to postpartum day 1. Subjects were excluded if cesarean delivery was required.
RESULTS: A total of 325 women underwent analysis. By estimation, 21% of subjects and 15% of controls had postpartum hemorrhage (P =.17). By using measured blood loss, we determined that 70 of 154 (46%) study subjects and 61 of 161 (38%) control subjects had postpartum hemorrhage (P =.17). For 36 (23%) misoprostol subjects and 18 (11%) oxytocin subjects at least one additional agent was required to control bleeding (P =.004).
CONCLUSION: Rectal misoprostol (400 microg) was no more effective than intravenous oxytocin in preventing postpartum hemorrhage.

BACKGROUND: Postpartum haemorrhage is a leading cause of maternal morbidity and mortality. Active management of the third stage of labour, including use of a uterotonic agent, has been shown to reduce blood loss. Misoprostol (a prostaglandin E1 analogue) has been suggested for this purpose because it has strong uterotonic effects, can be given orally, is inexpensive, and does not need refrigeration for storage. We did a multicentre, double-blind, randomised controlled trial to determine whether oral misoprostol is as effective as oxytocin during the third stage of labour.
METHODS: In hospitals in Argentina, China, Egypt, Ireland, Nigeria, South Africa, Switzerland, Thailand, and Vietnam, we randomly assigned women about to deliver vaginally to receive 600 microg misoprostol orally or 10 IU oxytocin intravenously or intramuscularly, according to routine practice, plus corresponding identical placebos. The medications were administered immediately after delivery as part of the active management of the third stage of labour. The primary outcomes were measured postpartum blood loss of 1000 mL or more, and the use of additional uterotonics without an unacceptable level of side-effects. We chose an upper limit of a 35% increase in the risk of blood loss of 1000 mL or more as the margin of clinical equivalence, which was assessed by the confidence interval of the relative risk. Analysis was by intention to treat.
FINDINGS: 9264 women were assigned misoprostol and 9266 oxytocin. 37 women in the misoprostol group and 34 in the oxytocin group had emergency caesarean sections and were excluded. 366 (4%) of women on misoprostol had a measured blood loss of 1000 mL or more, compared with 263 (3%) of those on oxytocin (relative risk 1.39 [95% CI 1.19-1.63], p<0.0001). 1398 (15%) women in the misoprostol group and 1002 (11%) in the oxytocin group required additional uterotonics (1.40 [1.29-1.51], p<0.0001). Misoprostol use was also associated with a significantly higher incidence of shivering (3.48 [3.15-3.84]) and raised body temperature (7.17 [5.67-9.07]) in the first hour after delivery.
INTERPRETATION: 10 IU oxytocin (intravenous or intramuscular) is preferable to 600 microg oral misoprostol in the active management of the third stage of labour in hospital settings where active management is the norm.

Postpartum hemorrhage due to uterine atony is the primary direct cause of maternal mortality globally. Management strategies in developed countries involve crystalloid fluid replacement, blood transfusions, and surgery. These definitive therapies are often not accessible in developing countries. Long transports from home or primary health care facilities, a dearth of skilled providers, and lack of intravenous fluids and/or a safe blood supply often create long delays in instituting appropriate treatment. We review the evidence for active management of third-stage labor and for the use of specific uterotonics. New strategies to prevent and manage postpartum hemorrhage in developing countries, such as community-based use of misoprostol, oxytocin in the Uniject delivery system, the non-inflatable antishock garment to stabilize and resuscitate hypovolemic shock, and the balloon condom catheter to treat intractable uterine bleeding are reviewed. New directions for clinical and operations research are suggested.

BACKGROUND: Primary postpartum haemorrhage (PPH) is one of the top five causes of maternal mortality in both developed and developing countries.
OBJECTIVES: To assess the effectiveness and safety of pharmacological, surgical and radiological interventions used for the treatment of primary PPH.
SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 October 2006).
SELECTION CRITERIA: Randomised controlled trials comparing pharmacological, surgical techniques and radiological interventions for the treatment of PPH.
DATA COLLECTION AND ANALYSIS: We assessed studies for eligibility and quality, and extracted data, independently. We contacted authors of the included studies for more information.
MAIN RESULTS: Three studies (462 participants) were included. Two placebo-controlled randomised trials compared misoprostol (dose 600 to 1000 mcg) with placebo and showed that misoprostol use was not associated with any significant reduction of maternal mortality (two trials, 398 women; relative risk (RR) 7.24, 95% confidence interval (CI) 0.38 to 138.6), hysterectomy (two trials, 398 women; RR 1.24, 95% CI 0.04 to 40.78), the additional use of uterotonics (two trials, 398 women; RR 0.98, 95% CI 0.78 to 1.24), blood transfusion (two trials, 394 women; RR 1.33, 95% CI 0.81 to 2.18), or evacuation of retained products (one trial, 238 women; RR 5.17, 95% CI 0.25 to 107). Misoprostol use was associated with a significant increase of maternal pyrexia (two trials, 392 women; RR 6.40, 95% CI 1.71 to 23.96) and shivering (two trials, 394 women; RR 2.31, 95% CI 1.68 to 3.18).One unblinded trial showed better clinical response to rectal misoprostol compared with a combination of syntometrine and oxytocin. We did not identify any trial dealing with surgical techniques, radiological interventions or haemostatic drugs for women with primary PPH unresponsive to uterotonics. AUTHORS'
CONCLUSIONS: There is insufficient evidence to show that the addition of misoprostol is superior to the combination of oxytocin and ergometrine alone for the treatment of primary PPH. Large multi-centre, double-blind, randomised controlled trials are required to identify the best drug combinations, route, and dose of uterotonics for the treatment of primary PPH. Further work is required to assess the best way of managing women who fail to respond to uterotonics therapy.

BACKGROUND: The European Project on obstetric Haemorrhage Reduction: Attitudes, Trial, and Early warning System (EUPHRATES) is a set of five linked projects, the first component of which was a survey of policies for management of the third stage of labour and immediate management of postpartum haemorrhage following vaginal birth in Europe.
OBJECTIVES: The objectives were to ascertain and compare policies for management of the third stage of labour and immediate management of postpartum haemorrhage in maternity units in Europe following vaginal birth.
DESIGN: Survey of policies.
SETTING: The project was a European collaboration, with participants in 14 European countries.
SAMPLE: All maternity units in 12 countries and in selected regions of two countries in Europe.
METHODS: A postal questionnaire was sent to all or a defined sample of maternity units in each participating country.
MAIN OUTCOME MEASURES: Stated policies for management of the third stage of labour and the immediate management of postpartum haemorrhage.
RESULTS: Policies of using uterotonics for the management of the third stage were widespread, but policies about agents, timing, clamping and cutting the umbilical cord and the use of controlled cord traction differed widely. For immediate management of postpartum haemorrhage, policies of massaging the uterus were widespread. Policies of catheterising the bladder, bimanual compression and in the choice of drugs administered were much more variable.
CONCLUSIONS: Considerable variations were observed between and within countries in policies for management of the third stage of labour. Variations were observed, but to a lesser extent, in policies for the immediate management of postpartum haemorrhage after vaginal birth. In both cases, policies about the pharmacological agents to be used varied widely.

PURPOSE OF REVIEW: Haemorrhage remains a cause of significant maternal morbidity and mortality. This review summarizes the prevention, management and treatment of obstetric haemorrhage and highlights recent advances and developments.
RECENT FINDINGS: Postpartum haemorrhage is the most common cause of major obstetric haemorrhage and is usually due to uterine atony. Pharmacological treatment has not altered much in recent years with oxytocin and ergometrine remaining first-line options. Although controversy surrounds its advantages over other uterotonics, the use of misoprostol has been increasing, especially in resource-poor countries. Placenta accreta is becoming more common, a sequelae to the rising caesarean section rate. Interventional radiology may reduce blood loss in these cases. Uterine compression sutures, intrauterine tamponade balloons and cell salvage have all made their debut in the last decade.
SUMMARY: Accurate diagnosis and appropriate management of obstetric haemorrhage can reduce maternal morbidity and mortality. This review outlines the current evidence.

The most common causes of maternal death are pregnancy induced hypertension (PIH), embolism, and obstetrical hemorrhage. Obstetrical hemorrhage is known as the most preventable cause of maternal mortality. Hemorrhage accounted for 15.25% of all reported maternal mortalities in New York State between 2003 and 2005. Ninety seven percent (97%) of all hemorrhage deaths occurred while women were hospitalized. These deaths spanned all socioeconomic classes and, in addition to the deaths, an even larger number of "near misses", women who had severe hemorrhages but survived, were reported. Because most of the deaths from hemorrhage occur in the hospital, and because it is a highly preventable cause of death, New York State and New York City Health Departments, in collaboration with American College of Obstetricians and Gynecologists (ACOG), District II/NY, have sent clinical recommendations and a poster for labor/delivery or surgical suite staff to all hospitals with obstetric services in the state. Access to educational slide sets on prevention of maternal death through improved management of hemorrhage is available at this site.