Oxytocin and arterial embolisation: use or overuse?

Abstract

Inter-country variations in maternal mortality, even in countries where maternal death is rare, can be an important indication that care can be improved. Maternal mortality from postpartum haemorrhage (PPH) is four times higher in France than the UK. Further investigation is clearly needed to identify reasons for this observed difference and to begin to develop preventive actions. This population-based study of all women with PPH at more than 100 hospitals in France includes women who may be regarded as having a ‘near-miss’ maternal morbidity: PPH managed with second and third-line interventions such as arterial embolisation, pelvic vessel ligation, uterine compression sutures and hysterectomy. This approach, studying women with severe morbidity, is recognised as the way forward in countries where maternal death rates are low in order to glean important information to aid prevention. As the authors note, these are observational data, although collected in the context of a trial, and hence any comparison of effectiveness of different therapies has to be interpreted with caution. Nevertheless, some messages for clinical practice are very clear. Six percent of women managed with an invasive treatment for PPH had no prior treatment with uterotonics; a similar observation was made in a national study in the UK (Knight et al, BJOG 2007; 114:1380-7). Fifty-eight percent of the women who had an invasive therapy for PPH had uterine atony as the primary cause of the haemorrhage, and yet overall only 83% of women had a prophylactic uterotonic for the third stage of labour; 73% in women with a vaginal delivery. This contrasts directly to the estimated 60% of women in France who receive oxytocin for augmentation of labour. Oxytocin exposure in labour is known to be associated with risk of PPH and is likely to render third stage prophylaxis less effective. Misuse of uterotonics was a factor identified to be associated with maternal death from PPH in the UK (Paterson-Brown et al, Saving Lives, Improving Mothers’ Care 2014, NPEU. p45-55). Oxytocin, but at the right time, seems then to be the clear message from these data – more cautious use in labour and more liberal use for third stage prophylaxis and PPH treatment. A four times higher mortality rate in one high resource country over another is unacceptable, and universal oxytocin prophylaxis for the third stage of labour should surely become the expected norm in France and elsewhere. The use of uterine artery embolisation for management of PPH is much higher in France than other countries, and the authors speculate that clinicians in France have a lower threshold for its use. Although defining PPH robustly can be difficult given the known inaccuracy of estimation of blood loss (Bose et al, BJOG 2006; 113:919-24), given the high costs of this as an intervention, guidelines must incorporate robust recommendations on when its use is appropriate. The authors speculate that the situation will be improved with prior use of intrauterine balloon tamponade, but its evidence-base is limited, and there are undoubtedly situations when its use exacerbates rather than improves the situation when women are in extremis (Paterson Brown et al, see above). The main message has to be, whatever the circumstances, preventing and controlling the haemorrhage, and controlling it early, is imperative to improve outcomes for women. None declared. Completed disclosure of interests form available to view online as supporting information.