Need For Additional Uterotonic Agents Research Articles

Efficacy and Safety of Carbetocin Versus Misoprostol in Cesarean Section: A Systematic Review and Meta-Analysis.

In the absence of comprehensive data investigating carbetocin versus misoprostol for reducing postpartum hemorrhage (PPH) during cesarean section (CS), we performed this investigation to compare the efficiency and side events of carbetocin versus misoprostol in the protection and reduction of PPH for women who underwent CS. Frominception to September 2022, we depended on searching through various databases for eligible trials involving Cochrane, Web of Science, PubMed, Scopus, and Google Scholar. From the efficacy prospect, we found that carbetocin substantially decreased intraoperative blood loss (p<0.001), hemoglobin/hematocrit levels (p<0.001), and the need for blood transfusion (p=0.002)/additional surgical interventions (p=0.003) than misoprostol. However, we revealed no substantial variation between both drugs for the need for additional uterotonic agents (p=0.08). From the safety prospect, we found that incidences of fever (p=0.002), heat sensation (p=0.007), metallic taste (p=0.01), and shivering (p=0.0002) were lower incarbetocin administration than in misoprostol. However, headache (p=0.34) and palpitation (p=0.11) incidences revealed no substantial variation between both drugs. In conclusion, from the efficacy and safety prospect, for women who underwent CS, carbetocin is more effective and safer in preventing and reducing PPH than misoprostol.

Prophylactic Methylergonovine and Oxytocin Compared With Oxytocin Alone in Patients Undergoing Intrapartum Cesarean Birth: A Randomized Controlled Trial.

To evaluate whether the administration of prophylactic methylergonovine in addition to oxytocin in patients undergoing intrapartum cesarean birth reduces the need for additional uterotonic agents. This was a single-center, placebo-controlled, randomized trial of patients undergoing intrapartum cesarean birth. Patients were randomly allocated to receive intravenous oxytocin 300 mL/minute plus intramuscular methylergonovine 0.2 mg (1 mL) or intravenous oxytocin 300 mL/minute plus intramuscular normal saline (1 mL). The primary outcome was the receipt of additional uterotonic agents. Secondary outcomes included surgeon assessment of uterine tone, incidence of postpartum hemorrhage, quantitative blood loss, and blood transfusion. To detect a twofold decrease in the need for additional uterotonic agents (assuming a 42% baseline) with a two-sided type 1 error of 5% and power of 80%, a sample size of 76 patients per group was required. From June 2019 through February 2021, 80 patients were randomized to receive methylergonovine plus oxytocin and 80 were randomized to receive to oxytocin alone. Significantly fewer patients who were allocated to the methylergonovine group received additional uterotonic agents (20% vs 55%, relative risk [RR] 0.4, 95% CI 0.2-0.6). Participants receiving methylergonovine were more likely to have satisfactory uterine tone (80% vs 41%, RR 1.9, 95% CI 1.5-2.6), lower incidence of postpartum hemorrhage (35% vs 59%, RR 0.6, 95% CI 0.4-0.9), lower mean quantitative blood loss (967 mL vs 1,315 mL; mean difference 348, 95% CI 124-572), and a lower frequency of blood transfusion (5% vs 23%, RR 0.2, 95% CI 0.1-0.6). The administration of prophylactic methylergonovine in addition to oxytocin in patients undergoing intrapartum cesarean birth reduces the need for additional uterotonic agents. ClinicalTrials.gov, NCT03904446.

Intravenous Tranexamic acid versus placebo during Caesarian section: A comparative study.

Objectives:To evaluate the effectiveness of Tranexamic Acid in preventing postpartum hemorrhage against placebo in high-risk women undergoing cesarean section.Methods:A double-blinded placebo-controlled comparative trial was conducted at the Obstetrics and Gynecology Department of Nishtar Hospital for one year, from 15th June 2020 to 15th June 2021. A total of 60 women who were at high risk of postpartum hemorrhage and had to undergo elective cesarean sections were included in the study. Among them, initial 30 patients were administered Tranexamic Acid before skin incision whereas later 30 were treated as the placebo group. These women were then observed for blood loss during surgery and within 24 hrs. after surgery and any postoperative complications such as thromboembolic events, the need for additional uterotonic agents, and blood transfusions.Results:Out of 60 women, 30 were placed in each group. The groups had no significant difference in terms of baseline data and post-partum hemorrhage-associated risk factors (p>0.05). However, the occurrence rate of primary post-partum hemorrhage (blood loss greater than 1000 ml) was significantly less in a tranexamic acid group than the placebo group (16.6% vs 60%, respectively, p<0.01). Similarly, the requirement of additional uterotonic agents (13.3% vs 43.3%, respectively) and the need for blood transfusion (6.0% vs 23.3%, respectively) was lower in a tranexamic group than in the placebo group.Conclusion:The study highlighted the significance of tranexamic acid in controlling post-partum hemorrhages, the requirement of additional uterotonic agents, improving post-partum hemoglobin, and the need for blood transfusion.

Effects of tranexamic acid on the amount of bleeding following vaginal delivery and its adverse effects: a double-blind placebo controlled randomized clinical trial

Introduction Postpartum hemorrhage (PPH) is the most important concern after delivery. Tranexamic acid (TXA), an anti-fibrinolytic agent, has been suggested for prevention and treatment of PPH. Objective The purpose of the present study was to find the effects of TXA on the amount of bleeding following vaginal delivery and its adverse effects. Materials and methods The study was performed as a randomized double blind placebo controlled clinical trial on low risk pregnant women who delivered vaginally. The patients were randomly assigned into two groups. Women in the intervention group received 10 mg/kg infusion of TXA in 100 mL normal saline and the control group received one vial of distilled water (as placebo) in 100 mL normal saline. The primary outcome was amount of bleeding after delivery. The secondary outcomes were decreased in hemoglobin level, need for additional uterotonic agents and need for blood transfusion. All were evaluated 6 h after delivery and compared in the two groups. Participants were followed up to six weeks after delivery for any TXA side effects. Results Two hundred and seven women finished the study. There were no significant differences between the two groups in terms of demographic data and risk factors for bleeding. Mean blood loss and need to misoprostol was more in the control group (p=.033 and p=.000, respectively). Hemoglobin level was higher in the TXA group 6 h after delivery. None of the subjects needed blood transfusion, uterine balloon tamponade or emergency hysterectomy. Adverse effects were higher in the TXA group, however, there were no side effects between weeks 3 and 6 in both groups. There were no thromboembolic events during six weeks after delivery. Conclusions Tranexamic acid can reduce the amount of bleeding after vaginal delivery in low risk women without having serious complications. Also, it may decrease the need for additional uterotonic agents. Trial registration number and registry website: IRCT20091023002624N22.

A comparison of the efficacy of carbetocin and oxytocin on hemorrhage-related changes in women with cesarean deliveries for different indications

ObjectiveTo compare the efficacy of carbetocin and oxytocin on hemorrhage-related changes in women with cesarean deliveries (CS) for different indications. Materials and methodsA retrospective cohort study was conducted on 1568 women with CS before labor onset (elective CS, n = 1153) or during labor (intrapartum CS, n = 415) after 24 weeks’ gestation. We compared the fall in hemoglobin (Hb) and hematocrit (Hct) levels after CS, estimated blood loss, the need for additional uterotonic agents, blood transfusion, and the rate of postpartum hemorrhage between women with carbetocin and women with oxytocin treatment, stratified by indications for CS. ResultsFor women with elective CS, decreased Hb and Hct falls were noted with carbetocin treatment compared to oxytocin treatment in women with indications for prior CS, fetal malpresentation, and multiple gestation. The need for additional uterotonics was less in CS for prior CS, fetal malpresentation, and cephalopelvic disproportion and fewer transfusions in CS for multiple gestation in women with carbetocin compared to women with oxytocin treatment. For women with intrapartum CS, carbetocin was associated with decreased use of additional uterotonic agents and transfusion in CS for dysfunctional labor. ConclusionCarbetocin and oxytocin had differential effects on hemorrhage-related changes in women with CS for different indications.

Sublingual Misoprostol vs Intravenous Tranexamic Acid in reducing Blood Loss during Cesarean Section: A Prospective Randomized Study

ABSTRACT Introduction The increasing incidence of cesarean sections in India has caused a rise in the incidence of postpartum hemorrhage (PPH). There has been expanding interest in the role of misoprostol and tranexamic acid (TXA) in preventing and managing PPH during lower (uterine) segment cesarean section (LSCS). However, the lack of a published study comparing the efficacies of these drugs prompted us to conduct this study. Aims and objectives To compare the efficacies of sublingual misoprostol (600 μg) and intravenous TXA injection (500 mg) in reducing blood loss during LSCS by assessing intraoperative blood loss, perioperative hemoglobin (Hb) fall, and need for additional uterotonic agents. Materials and methods A total of 163 pregnant patients undergoing emergency/elective LSCS during the study period from 2013 to 2014 were randomly assigned to two groups — group I (82) received sublingual misoprostol 600 μg and group II (81) intravenous TXA 500 mg at cord clamping. Visual estimation of blood loss was done and 48 hours postoperative Hb and packed cell volume were measured to compare with preoperative values. Need for added uterotonics, blood transfusion, and adverse effects of drugs was assessed. The two groups were again subgrouped based on presence or absence of risk factors for PPH. Results The TXA significantly reduced blood loss compared with misoprostol (416 vs 505 mL) in patients without high-risk factors for PPH. Misoprostol caused significantly higher minor side effects while TXA reduced operation time. Conclusion The TXA can be routinely used after cord clamping along with oxytocin in patients undergoing elective/emergency LSCS to reduce perioperative blood loss, especially in those without risk factors for PPH. How to cite this article Bose D, Beegum R. Sublingual Misoprostol vs Intravenous Tranexamic Acid in reducing Blood Loss during Cesarean Section: A Prospective Randomized Study. J South Asian Feder Obst Gynae 2017;9(1):9-13.

Comparison of active vs. expectant management of the third stage of labor in women with low risk of postpartum hemorrhage: a randomized controlled trial.

To compare the 'strictly' active management protocol in women with low risk of postpartum hemorrhage using the expectant management protocol with respect to changes in hematologic parameters, uterotonics, blood transfusions, or additional interventions. A randomized controlled prospective trial in which 934 singleton parturients enrolled; 654 were randomly assigned to the active and mixed management groups. The primary outcome parameter was the reduction in hemoglobin concentrations due to delivery, and the secondary outcome parameters were changes in hemoglobin of more than 3 g/dL (ΔHb ≥ 3 g/dL), durations of the third stage of labor, need for additional uterotonic agents, blood transfusions, manual removal of the placenta, and surgical evacuation of retained products of conception. The mean postpartum hemoglobin concentration was significantly higher (P = 0.04) in the active management group with a significantly lower reduction (P = 0.03). Falls of hemoglobin levels of more than 3 g/dL (ΔHb ≥ 3g/dL) were less common in the active management group though not significantly (P = 0.32). The mean duration of the third stage of labor was significantly (P < 0.001) shorter in the active management group. There was no significant difference between the two groups with regard to the need for additional uterotonic agents, uterine atony, blood transfusion, manual removal of the placenta, surgical evacuation of retained products of conception, and prolonged third stage of labor. Although active management of the third stage of labor was associated with higher postpartum hemoglobin levels, it did not influence the risk of 'severe postpartum hemorrhage' in women with low risk of postpartum hemorrhage.

Prophylactic B-Lynch suture (modified technique) versus prophylactic carbetocin and prophylactic oxytocin during cesarean section in women at high risk for atonic postpartum hemorrhage

Objective The aim of this study was to compare the effect of prophylactic B-Lynch suture, carbetocin, and oxytocin in the prevention of atonic postpartum hemorrhage (PPH) following cesarean section in pregnant women at high risk for atonic PPH. Study design This randomized controlled prospective study was conducted on 453 pregnant women at a high risk of developing PPH scheduled to undergo cesarean section. They were randomized during cesarean section to either undergo prophylactic B-Lynch suturing, receive prophylactic 100 μg of intravenous carbetocin, or receive prophylactic 20 U of oxytocin intravenous infusion on 1000 ml saline at a rate of 250 ml/h. The primary outcomes included the mean operative blood loss, the occurrence of major obstetric hemorrhage (blood loss≥1000 ml), and the need for additional uterotonic agents or additional interventions to control bleeding. Secondary outcomes included objective changes in hemoglobin preoperatively and postoperatively, occurrence of severe anemia, need for blood transfusion, side effects (e.g. paralytic ileus), and postnatal hospital stay. Results Patients with prophylactic B-Lynch suture developed less PPH and required less intervention with less mean operative blood loss than those who received carbetocin and oxytocin, with nearly similar safety profile. Conclusion B-Lynch suture seems to be more effective in maintaining adequate uterine tone and preventing excessive blood loss in patients with a high risk of developing PPH following cesarean section.

Carbetocin for the prevention of postpartum hemorrhage: a systematic review and meta-analysis of randomized controlled trials

Objective: To compare the efficacy and safety profile of carbetocin with other uterotonic agents in preventing postpartum hemorrhage.Methods: PubMed, Web of Science, Scopus and EBSCOhost were searched for relevant randomized controlled trials published until September 2013.Results: Carbetocin was associated with a significantly reduced need for additional uterotonic agents (RR = 0.68, 95% CI: 0.55–0.84, I2 = 4%) compared with oxytocin in women following cesarean delivery. However, with respect to postpartum hemorrhage, severe postpartum hemorrhage, mean estimated blood loss and adverse effects, our analysis failed to detect a significant difference. Studies comparing carbetocin with syntometrine in women undergoing vaginal delivery demonstrated no statistical difference in terms of risk of postpartum hemorrhage, severe postpartum hemorrhage or the need for additional uterotonic agents, but the risk of adverse effect was significantly lower in the carbetocin group.Conclusions: Carbetocin has been associated with a similar low incidence of adverse effects to oxytocin and at least as effective as syntometrine and may become an alternative uterotonic agent for the prevention of postpartum hemorrhage. Further studies should be conducted to determine the safety and efficacy profile of carbetocin in women with cardiac disorders and to analyze the cost-effectiveness and minimum effective dose of carbetocin.

Comparison of Oral Misoprostol with Intramuscular Oxytocin in the Active Management of Third Stage of Labour

Aims: This study aimed at comparing the efficacy of oral misoprostol 600 mcg with intramuscular oxytocin 10 IU in the active management of third stage of labour. Methods: This prospective comparative study was performed in Tribhuvan University Teaching Hospital to compare the efficacy of oral misoprostol with intramuscular oxytocin in the third stage of labour for the prevention of postpartum hemorrhage. One hundred and twenty women without risk of PPH were randomly allocated to receive either 600 mcg misoprostol orally (Group A) or 10 unit of oxytocin intramuscularly (Group B) within 1 minute of delivery. The efficacy and the safety of these two drugs were analyzed on the basis of percentages fall in hemoglobin (Hb) and hematocrit (Hct) level from before delivery to 8 completed hours after delivery, need for additional uterotonic agents, need for exploration and uterine evacuation, need for blood transfusion, duration of third stage of labour and the numbers of retained placenta and need for MRP. Results: Oral misoprostol was observed to be equally effective as intramuscular oxytocin in prevention of post-partum hemorrhage (PPH). There was no statistical difference in the duration of third stage of labour, need for additional uterotonics, need for uterine exploration/evacuation and need for blood transfusion in the two groups. Conclusions: Routine use of oral misoprostol 600 mcg appears to be as effective as 10 IU intramuscular oxytocin in minimizing blood loss during the third stage of labour.

Carbetocin at elective Cesarean delivery: a randomized controlled trial to determine the effective dose, part 2

The aim of this study was to determine the intravenous dose of carbetocin required to produce effective uterine contraction in 95% of women (ED95) undergoing elective Cesarean delivery under spinal anesthesia. One hundred and twenty term pregnant women at low risk for postpartum hemorrhage (PPH) undergoing elective Cesarean delivery under spinal anesthesia were randomly allocated to receive carbetocin in doses of 20, 40, 60, 80, or 100 μg iv upon delivery of the fetus. The obstetrician evaluated the efficacy of uterine tone as satisfactory or unsatisfactory, and in case of unsatisfactory tone, additional uterotonics were administered as per routine institutional practice. The primary outcome measure was satisfactory uterine tone at two minutes after carbetocin administration, and the secondary outcomes were the estimated blood loss, need for additional uterotonic agents within 24 hr, and side effects. Overall satisfactory uterine tone at two minutes was observed in 94.2% (113/120) of the women, and there was no difference across the different study groups. It was not possible to calculate the ED95 of carbetocin due to the even distribution of women with unsatisfactory uterine tone at two minutes across all dose groups (P = 0.60). Additional uterotonics within 24 hr were required in 13% (16/120) of the women. Side effects were similar across all dose groups, with an overall 42.5% incidence of hypotension following the administration of carbetocin. In women at low risk for PPH undergoing elective Cesarean delivery under spinal anesthesia, carbetocin is similarly effective in doses of 20-100 μg. There is a high incidence of hypotension associated with carbetocin in these doses. Further dose-finding studies are warranted, including doses lower than 20 μg. This trial was registered at www.clinicaltrials.gov (NCT01428817).

Carbetocin versus oxytocin in caesarean section with high risk of post-partum haemorrhage

the aims of the present study were to compare the haemodynamic effects of oxytocin and carbetocin and to assess the efficacy of these two drugs in terms of blood loss and the additional uterotonic needed in caesarean section at high risk of primary post-partum haemorrhage. women in the carbetocin group (group A) received a bolus of 100 μg IV; women in the control group (group B) received 20 IU of oxytocin in 1000 ml of 0,9% Na-Cl solution IV (150 mL/hour). The main parameter evaluated was the haemodynamic effects of drugs and the need for additional uterotonic agents. In addition we compared the drop in haemoglobin level, the uterine tone, the uterine fundal state and the diuresis. regarding the haemodynamic effects, both drugs have a hypotensive effect, but we found a greater reduction in blood pressure within the oxytocin group. Significantly more women needed additional uterotonic agents in the oxytocin group (23,5% vs 0%, p<0.01), though there was no significant difference in estimated blood loss and in the drop haemoglobin level (p>0.05). There was a significant difference in the diuresis, higher in carbetocin group (1300 ml ± 450 ml vs 1100 ml ± 250 ml, p=0.01). a single injection of carbetocin appears to be more effective than a continuous infusion of oxytocin to prevent the PPH, with a similar haemodynamic profile and minor antidiuretic effect.

Sublingual misoprostol to reduce blood loss at cesarean delivery.

This prospective randomized controlled study was carried out with the purpose of assessing the efficacy of sublingual misoprostol in decreasing intraoperative blood loss and the need for additional uterotonic agents at cesarean delivery. One hundred seventy-four women undergoing elective or emergency cesarean delivery were assigned randomly to receive either 400μg misoprostol or placebo sublingually at the time of cord clamping. An intravenous infusion of 20 units of oxytocin was started in all women at the same time. The primary outcome measures were intraoperative blood loss, need for additional uterotonic agents, and perioperative hemoglobin (Hb) fall. The maternal demographic factors, indications for cesarean delivery, and high-risk factors were similar between the two groups. Mean intraoperative blood loss was significantly less in misoprostol group as compared with placebo group (595±108 vs. 651±118ml, P=0.025). Fewer women needed additional uterotonic agents in misoprostol group (22.2 vs. 42.8%; P=0.0035; RR 0.52, 95% CI 0.33-0.82). Perioperative Hb fall was significantly less in misoprostol group (0.87±0.29 vs. 1.01±0.26g, P=0.0018). Sublingual misoprostol decreases intraoperative blood loss and the need for additional uterotonic agents at cesarean delivery.

Oxytocin bolus versus oxytocin bolus and infusion for control of blood loss at elective caesarean section: double blind, placebo controlled, randomised trial

Objectives To determine the effects of adding an oxytocin infusion to bolus oxytocin on blood loss at elective caesarean section.Design Double blind, placebo controlled, randomised trial, conducted from February 2008...

Efficacy of Intravenous Tranexamic Acid in Reducing Blood Loss after Elective Cesarean Section: A Prospective, Randomized, Double-Blind, Placebo-Controlled Study

We sought to determine the efficacy and safety of tranexamic acid (TA) in reducing blood loss during elective cesarean section (CS). We performed a randomized, double-blind, placebo-controlled study of 660 women who underwent elective CS. The patients were randomly selected to receive an intravenous infusion of either TA (1 g/10 mL in 20 mL of 5% glucose; N = 330) or 30 mL 5% glucose prior to surgery. The primary outcome was the estimated blood loss following CS. No demographic difference was observed between groups. The mean estimated blood loss was significantly lower in women treated with TA compared with women in the placebo group (499.9 ± 206.4 mL versus 600.7 ± 215.7 mL, respectively; P < 0.001), and the proportion of women in the TA group who had an estimated blood loss >1000 mL was significantly lower than in the placebo group (7 [2.1%] versus 19 [5.8%], respectively; relative risk [RR] 2.7; 95% confidence interval [CI] 1.1 to 6.3; P < 0.03). Furthermore, more women in the placebo group than in the TA group required additional uterotonic agents (48 [14.5%] versus 28 [8.5%], respectively; RR 1.7; 95% CI 1.1 to 2.6; P = 0.02). Maternal and neonatal outcomes did not differ significantly. TA significantly reduced bleeding during CS, the percentage of patients with blood loss >1000 mL, and the need for additional uterotonic agents. Furthermore, the incidence of thromboembolic events did not increase. Our results suggest that TA can be used safely and effectively to reduce CS bleeding.

The impact of routine carbetocin use at caesarean section

BackgroundCarbetocin is a long-acting oxytocin agonist. Studies suggest it is as effective as oxytocin at preventing postpartum haemorrhage (PPH) and reduces the need for additional uterotonic agents. St Michael's Hospital...

Utilization of carbetocin for prevention of postpartum hemorrhage after cesarean section: a randomized clinical trial

A randomized study involving pregnant women was conducted to compare the effectiveness of a single intravenous (IV) injection of carbetocin with that of a standard 2-h oxytocin IV infusion with respect to intraoperative blood loss in the prevention of uterine atony after cesarean section (CS). The two treatments also were compared for safety and ability to maintain adequate uterine tone and to reduce the incidence and severity of postpartum hemorrhage (PPH) in women at risk for this condition. Between 1 September 2007 and 5 January 2008, we enrolled 104 patients with at least one risk factor for PPH undergoing CS in a randomized, controlled clinical trial. We compared the effect of a single 100 microg IV dose of carbetocin with that of a standard 2-h ten international units (IU) IV infusion of oxytocin. The primary outcome was the proportion of patients requiring additional oxytocic intervention for uterine atony. Fiftytwo women received 100 microg carbetocin IV immediately after placental delivery, while 52 women received 10 IU oxytocin IV infusion. Complete blood count was collected at entry and 24 h postpartum. All outcome measures, including the need for additional uterotonic agents or uterine massage, and blood loss, were analyzed using chi-square, Fisher exact, and Student's t tests. A single 100 microg IV injection of carbetocin was as effective as a continuous 2-h infusion of oxytocin in controlling intraoperative blood loss after placental delivery. Mean blood loss after carbetocin administration was 30 ml less than after oxytocin administration (P = 0.5). The percentage of patients with blood loss < or =500 ml was greater with carbetocin (81 vs. 55%; P = 0.05). Carbetocin enhanced early postpartum uterine involution. The fundus was below the umbilicus in more patients who received carbetocin at 0, 2, 6, and 24 h on the ward (P < 0.05). The main additional uterotonic agent used was a further administration of oxytocin (20 IU in physiological solution 500 ml at an infusion rate of 200 ml/h). In the carbetocin group, 20 of the 52 women (38.4%) required at least one uterine massage compared to 30 of the 52 women (57.7%) in the oxytocin group (P < 0.01). Overall, uterotonic intervention was clinically indicated in two of the women (3.8%) receiving carbetocin compared to five of the women (9.6%) given an IV oxytocin infusion (P < 0.01). The odds ratio of treatment failure requiring oxytocic intervention was 1.83 (95% confidence interval, CI, 0.9-2.6) times higher in the oxytocin group compared with the carbetocin group. Carbetocin makes possible to obtain, with a single IV injection, results equivalent to those of oxytocin on the maintenance of uterine tonicity and the limitation of blood losses, in the peri- and in the post-operative period, during a delivery by CS. It has in addition a comparable tolerance. Even in our series adverse events are practically of the same type and similar frequency in both study groups. Thus, the effectiveness of carbetocin consists, thanks to its long half-life, on an unique injection, whereas oxytocin requires repeated injections or a perfusion of several hours, with a variability of the administered doses.

Buccal misoprostol to prevent hemorrhage at cesarean delivery: A randomized study

The purpose of this study was to assess the efficacy of buccal misoprostol to decrease uterine atony, hemorrhage, and the need for additional uterotonic agents during cesarean delivery. Patients who underwent cesarean delivery were assigned randomly to either 200-microg misoprostol or placebo placed in the buccal space. A dilute intravenous oxytocin infusion was given to all patients at delivery of the placenta. The primary outcome variable was the need for additional uterotonic agents. A total of 352 women received random assignments. Demographic and intrapartum characteristics were similar between the groups. More women in the placebo group required 1 additional uterotonic agent (43% vs 26%; P < .01; relative risk, 1.3; 95% CI, 1.10, 1.50). There was not a difference between the groups in the incidence of postpartum hemorrhage or a difference in preoperative and postoperative hemoglobin level. Buccal misoprostol reduces the need for additional uterotonic agents during cesarean delivery.

Comparison of Carbetocin and Oxytocin for the Prevention of Postpartum Hemorrhage Following Vaginal Delivery: A Double-Blind Randomized Trial

Objectives: To compare the efficacy of a single 100 µg intramuscular (IM) carbetocin injection, a long-acting oxytocin agonist, to a 2-hour 10 IU oxytocin intravenous (IV) infusion, in reducing the incidence and severity of postpartum hemorrhage (PPH) in women at risk for this condition.Methods: A randomized, double-blind, placebo-controlled study was conducted at 2 hospital centres, including 160 women with at least I risk factor for PPH. Eighty-three women received 100 µg carbetocin IM and an IV placebo immediately after placental delivery, while 77 women received placebo IM and oxytocin IV infusion. Complete blood count was collected at entry and 24 hours postpartum. All outcome measures, including the need for additional uterotonic agents or uterine massage, blood loss, and drop in hemoglobin and hematocrit, were analyzed using chi-square, Fisher exact, and Student t tests.Results: Population profile and risk factors for PPH were similar for each group. No significant difference was observed in the number of women requiring additional uterotonic medication (12 in each group). However, in the carbetocin group, 36 of the 83 women (43.4%) required at least I uterine massage compared to 48 of the 77 women (62.3%) in the oxytocin group (P < .02). Overall, uterotonic intervention was clinically indicated in 37 of the women (44.6%) receiving carbetocin compared to 49 of the women (63.6%) given an IV oxytocin infusion (P < .02). There were no differences in laboratory PPH indicators between the 2 groups.Conclusions: Women receiving a single 100 µg IM carbetocin injection required significantly less uterotonic intervention compared to women receiving a continuous 2-hour IV oxytocin infusion. A single IM carbetocin injection is more likely to prevent PPH in women at risk when compared to a continuous oxytocin IV infusion.

Comparison of two oxytocin regimens to prevent uterine atony at cesarean delivery: a randomized controlled trial

OBJECTIVE: To determine if high-dose oxytocin reduces the need for additional uterotonic agents at cesarean. METHODS: A randomized, double-masked trial of two oxytocin regimens was performed to prevent postpartum uterine atony in laboring women. The pharmacy prepared sequentially numbered oxytocin solutions containing either 10 U/500 mL or 80 U/500 mL of lactated Ringer’s solution infused over 30 minutes after cord clamping. The need for additional uterotonic agents was determined by the surgical team. Hypotension was diagnosed and treated with crystalloid or a pressor agent. To detect a 50% decrease in the need for additional uterotonic agents and considering a β error of 0.2, 220 patients would be required in each group (α = 0.05, two-tailed χ 2 test). RESULTS: The low-dose group ( n = 163) received 333 mU/min, and the high-dose group ( n = 158) received 2667 mU/min of oxytocin. The groups were similar with respect to risk factors for atony. Women in the low-dose group received additional uterotonic medication significantly more often than those in the high-dose group (39% compared with 19%, P < .001, relative risk 2.1, 95% confidence interval 1.4, 3.0). Moreover, more women in the low-dose group received methylergonovine, 15-methyl prostaglandin F 2α or both (9% compared with 2%, relative risk 4.8, 95% confidence interval 1.4, 16) after additional oxytocin (median 20 U) had been added to the study solution. The incidence of hypotension was similar in both groups. CONCLUSION: Compared with an infusion rate of 333 mU/min, oxytocin infused at 2667 mU/min for the first 30 minutes postpartum reduces the need for additional uterotonic agents at cesarean delivery.