Postpartum Hemorrhage Prophylaxis Research Articles

An update on the management of bleeding disorders during pregnancy.

The morbidity and mortality of postpartum hemorrhage (PPH) in women with an underlying bleeding disorder requires vigilance by the hematologist. Recent studies suggest that women with underlying bleeding disorders may be 'undertreated' at the time of delivery in aiming for too low a target elevation that historically per numerous society guidelines has aimed for VWF/FVIII:C levels to be 'only' greater than 50% when in actuality the levels should be akin to what is achieved in a normal pregnancy. The result appears to be an increase in the rate and degree of PPH. In this context, although recent studies imply DDAVP is well tolerated, DDAVP may not be appropriate because it may not raise the levels into the normal supraphysiological range nor maintain it for several days. Particularly in women with rare bleeding disorders, i.e., non- C or VWF deficient, adjunctive antifibrinolytic therapy, e.g., tranexamic acid, appears to be in order as a prophylactic measure. Women with an underlying bleeding disorder appear to be at a heightened risk for PPH if the respective coagulation factor level is not appropriately replaced to the level that is physiologically achieved in a normal pregnancy. Furthermore, there appears to be underuse of tranexamic acid for prophylaxis of PPH in this population.

Active management of the third stage of labor may reduce breastfeeding duration due to pain and physical complications.

Evidence is growing that active management of the third stage of labor using prophylactic uterotonics may be associated with lower breastfeeding rates. The reasons underlying this relationship are incompletely understood. The aim of this article is to examine the experiences of mothers who stopped breastfeeding in relation to administration of parenteral uterotonics for postpartum hemorrhage prophylaxis. Two hundred eighty-eight mothers with an infant 0-6 months of age who had a vaginal birth completed a self-report questionnaire examining injections of uterotonics during the third stage of labor, breastfeeding at birth, breastfeeding duration, and, where applicable, reasons for breastfeeding cessation, whether physical, social, or psychological. No significant association was found between infant feeding mode at birth (breast/formula) and injection of uterotonics. However, mothers who had received uterotonics were significantly less likely to be breastfeeding at all at 2 and 6 weeks. Among mothers who had stopped breastfeeding, those who had received parenteral prophylactic uterotonics were significantly more likely to report stopping breastfeeding for physical reasons such as pain or difficulty. These findings suggest that injection of prophylactic uteronics may reduce breastfeeding duration, but not initiation. This may be attributable to the effects of oxytocin or ergometrine on the physiology of lactation, leading to difficulties with infant latch and milk supply. If breastfeeding rates are to be optimized, this hypothesis needs to be explored in randomized controlled trials of third-stage management. Meanwhile, mothers who receive parenteral uterotonics may need additional support to establish breastfeeding.

Tranexamic acid to reduce postpartum hemorrhage: A MANDATE systematic review and analyses of impact on maternal mortality.

Postpartum hemorrhage (PPH) is a major cause of maternal mortality, with almost 300,000 cases and ~72,000 PPH deaths annually in sub-Saharan Africa. Novel prevention methods practical in community settings are required. Tranexamic acid, a drug to reduce bleeding during surgical cases including postpartum bleeding, is potentially suitable for community settings. Thus, we sought to determine the impact of tranexamic acid on PPH-related maternal mortality in sub-Saharan Africa. We created a mathematical model to determine the impact of interventions on PPH-related maternal mortality. The model was populated with baseline birth rates and mortality estimates based on a review of current interventions for PPH in sub-Saharan Africa. Based on a systematic review of literature on tranexamic acid, we assumed 30% efficacy of tranexamic acid to reduce PPH; the model assessed prophylactic and treatment tranexamic acid use, for deliveries at homes, clinics, and hospitals. With tranexamic acid only in the hospitals, less than 2% of the PPH mortality would be reduced. However, if tranexamic acid were available in the home and clinic settings for PPH prophylaxis and treatment, a nearly 30% reduction (nearly 22,000 deaths per year) in PPH mortality is possible. These analyses point to the importance of preventive and treatment interventions compatible with home and clinic use, especially for sub-Saharan Africa, where the majority of births occur at home or community health clinics. Given its feasibility to be given in the home, tranexamic acid has potential to save many lives.

Which Uterotonic Is Better to Prevent the Postpartum Hemorrhage? Latest News in Terms of Clinical Efficacy, Side Effects, and Contraindications: A Systematic Review

Postpartum hemorrhage (PPH) is a potentially fatal complication of vaginal and cesarean deliveries. The active management of the third stage of labor provides administration of prophylactic uterotonic drugs just before or immediately after delivery, since they reduce the risk of PPH by 60%. Overview on all available uterotonics for PPH prevention to clarify indications and contraindications in choice among drugs. Systematic review of the literature. Oxytocin is the first choice for PPH prophylaxis. Ergot alkaloids, syntometrine, and prostaglandins are second-line uterotonic agents. Misoprostol is not effective as oxytocin but it may be used when the latter is not available. Carbetocin should be used instead of continuous oxytocin infusion in elective cesarean sections for PPH prevention and to decrease the need for therapeutic uterotonics. Prophylactic oxytocics should be offered routinely in the third stage of labor in all women. The prophylactic use of uterotonics should be individualized.

How Birth Interval and Antenatal Care Affects Postpartum Haemorrhage Prevention in Maiduguri, Nigeria

The following work studied how birth interval and antenatal care contribute to occurence of postpartum haemorrhage and how these factors modulates the preventive efficacies of oxytocin injection and misoprostol tablets in postpartum haemorrhage. A total of 1140 pregnant women who have received either oxytocin injection or oral misoprostol in third stage of labour as a prophylaxis of postpartum haemorrhage, were enrolled within three health care facilities in Maiduguri, Nigeria. Each patient was observed at parturition and for 24 h after during which blood lost was estimated to the nearest ml. Maternal characteristics were recorded in a structured proforma. The relationship of the occurrence of PPH (blood loss > 500 ml) and mean blood loss was studied with respect to the prophylactic medication used and some obstetric factors. The occurrence of PPH in subjects that had ‘inadequate’ resting period (29.3 %) was higher than that of the ‘adequate’ resting period group (2 %). Misoprostol exhibited greater PPH prevention in the “inadequate” resting period category (83.9 versus 38.8%). The enrolees that had inadequate antenatal care exhibited higher occurrence of PPH than the adequate group (21.6 versus 16.6%). In the misoprostol medication sub-group, there was significantly (p < 0.001) higher occurrence of PPH in the “adequate ANC” category (37.6%) than in the “inadequate ANC” category (7.1%). Inadequate birth interval and inadequate antenatal care are risk factors for PPH. The relative efficacies of oral misoprostol and parenteral oxytocin significantly vary with varying level of antenatal care and birth interval.

How some demographic factors affects postpartum haemorrhage prevention in Maiduguri, Nigeria

Aim: The following work studied how tribal affiliation, educational level and occupation of some women that had PPH in Maiduguri metropolis between September 2007 and March 2009 relate with PPH occurrence. The study was aimed at identifying possible risk factors and also to compare the relative prevention efficacies of oxytocin or misoprostol within the matrix of these factors. Method: A total of 1800 pregnant women who have received either oxytocin injection or oral misoprostol in third stage of labour as a prophylaxis of postpartum haemorrhage, were enrolled within three health care facilities in Maiduguri, Nigeria. Each patient was observed at parturition and for 24 h after, during which blood lost was estimated to the nearest millilitres. Demographic characteristics were recorded in a structured proforma. The relationship of the occurrence of PPH (occurrence of blood loss > 500 ml) and mean blood loss (MBL) was studied with respect to the prophylactic medication used and some demographic factors. Results: The incidence of PPH was higher in Igbo, and some “minority” tribes of Borno state (Babur, Bura, Mafa). The tribes that constituted the majority of the study population (Kanuri, and Hausa) exhibited low incidences of PPH. Significant relationships were demonstrated between PPH and educational levels and occupations of participants. Conclussions: It was concluded that PPH occurrence is related to tribal affiliation, educational level and occupation, and the relative efficacies of oxytocin and misoprostol varies between the tribal groups.

A randomised comparison of three doses of sublingual misoprostol on postpartum myometrial contractility

ObjectivesTo compare the postpartum uterine activity and side effects of various doses of sublingual misoprostol with intramuscular oxytocin.Methods35 women who did not require augmentation and who delivered vaginally were randomised...

Randomized Double Masked Trial of Zhi Byed 11, a Tibetan Traditional Medicine, Versus Misoprostol to Prevent Postpartum Hemorrhage in Lhasa, Tibet

The objective of this study was to compare a Tibetan traditional medicine (the uterotonic Zhi Byed 11 [ZB11]) to oral misoprostol for prophylaxis of postpartum hemorrhage (PPH). We conducted a double-blind randomized controlled trial at three hospitals in Lhasa, Tibet, People's Republic of China. Women (N = 967) were randomized to either ZB11 or misoprostol groups. Postpartum blood loss was measured in a calibrated blood collection drape. The primary combined outcome was incidence of PPH, defined as measured blood loss (MBL) > or = 500 mL, administration of open label uterotonics, or maternal death. We found that the rate of the combined outcome was lower among the misoprostol group (16.1% versus 21.8% for ZB11; P = .02). Frequency of PPH was lower with misoprostol (12.4% versus 17.4%; P = .02). There were no significant differences in MBL > 1000 mL or mean or median MBL. Fever was significantly more common in the misoprostol group (P = .03). The rate of combined outcome was significantly lower among women receiving misoprostol. However, other indices of obstetric hemorrhage were not significantly different.

POST PARTUM HAEMORRHAGE PROPHYLAXIS

Post partum hemorrhage (PPH) is defined as the loss of greater than 500ml of blood from the genitaltract in the first 24 hours following delivery. PPH occurs in 2-11% of all deliveries. Objective: To compare the efficacyof misoprostol and ergometrine for the prophylaxis of Post Partum Haemorrhage. Design: Prospective study. Setting:Gynaecology and Obstetrics Department Military Hospital Rawalpindi. Period: From 01 July 2006 to 31 Dec 2006.Patients &amp; Methods: A total of 200 patients were recruited in the study, they were divided in two groups, group – I (n100) included those patients who were administered ergometrine intravenously at the time of delivery of head for theprophylaxis of post partum haemorrhage, Group – 2 (n-100) included those patients who were administered Misoprostol800 microgram per rectally just before the start of cesarean section for the same purpose. Blood loss was calculatedobjectively by squeezing the soaked pads and quantifying the amount of clots in a kidney tray of standard size to beequal to 500ml.Results: In group I (n-100) 15 patients had mild PPH blood loss &gt;500ml, out of them 03 had severePPH requiring bimanual message and 02 patients required blood transfusion, in group II( n-100). 08 patients had PPH,blood loss &gt;500 ml, out of them 01 patient required uterine message and none required blood transfusion. Chi-squaretest was applied to compare the efficacy of the two groups, P&gt;0.05 showed no significant difference in the efficacy ofthe two groups but the side effects were obviously less in the Misoprostol group. No patient in group II had GI symptomswhile 36 patient in group I had retching and, vomiting and 03 patients had raised B.P after the administration ofergometrine. Conclusion: Misoprostol administered per rectally has equal efficacy to ergometrine given intravenouslyfor the prophylaxis of post partum haemorrhage but the side effect profile and patient tolerability is better withMisoprostol.

Misoprostol for preventing PPH: some lessons learned

During the past decade, The Lancet has led the debate over the use of misoprostol for prevention of postpartum haemorrhage. A letter published in 1996 first suggested the use of misoprostol for the third stage of labour.1 Here was a drug that seemed perfectly designed to reduce blood loss in childbirth. Misoprostol is an inexpensive heat-stable prostaglandin E1 analogue with strong uterotonic activity that can be given without the need for sterile needles and syringes. Huge interest was generated and, in the ensuing 10 years, more than 30 randomised trials in more than 30 000 women2 were done to study misoprostol for prophylaxis of postpartum haemorrhage.

A Preliminary Study of Cutaneous Blood Flow Associated With Postpartum Use of Oral Misoprostol

Objective: To evaluate cutaneous blood flow, as identified by Doppler fluximetry, to understand the etiology of shivering associated with the postpartum use of oral misoprostol.Methods: Eligible participants were recruited from a group of women who were enrolled in an ongoing randomized trial comparing 400 µg of oral misoprostol to 5 IU of intravenous oxytocin for postpartum hemorrhage prophylaxis. The laser Doppler fluximeter was used to noninvasively measure changes in peripheral tissue perfusion (flux). A skin probe attached to the upper arm recorded flux and skin temperature. Baseline levels were obtained before delivery and for 30 minutes postpartum (maximum flux) after the women received the study drug. Continuous variables were analyzed with Student t-test or paired t-test, with the Wilcoxon signed rank test used for non-parametric ordinal data. Categoric data were analyzed with the chi-square test or Fisher’s exact test.Results: Sixteen women Were enrolled, and 10 women had a vaginal delivery and received the study drugs. Among these 10 women, a significant difference between baseline and maximum flux levels was demonstrated for beth women treated with oxytocin (P = .04) and for those treated with misoprostol (P = .04). Women treated with oxytocin also had a significant change in skin temperature (P = .04). Maximum flux levels were not significantly different between the women receiving misoprostol compared with those receiving oxytocin (P = .42).Conclusions: Shivering associated with oral misoprostol may not be due to a resetting of the hypothalamic thermoregulatory centre. Further study is needed to determine whether shivering associated with oral misoprostol is dose-dependent or related to locally mediated phenomena.

Preventing the recurrence of atonic postpartum hemorrhage: a double‐blind trial

We conducted a double-blind randomized controlled trial to compare a conventional regimen of oxytocin and ergometrine with administration of the prostaglandin E2 analogue, sulprostone, for prophylaxis of postpartum hemorrhage in high-risk women. Women with a history of postpartum hemorrhage > or = 1000 were assigned to two coded prophylactic regimens. Drugs, given respectively at delivery of the anterior shoulder and after delivery of the placenta, were oxytocin and ergometrine in the control group, and sulprostone and placebo in the experimental group. Eighty-one women, 69 of whom actually participated in the trial, were investigated. Both the women and the caregivers were unaware of treatment allocation. Although the trial was terminated prematurely there was a slight, but not statistically significant, preference for the sulprostone regimen in terms of blood loss and use of blood transfusion. No serious adverse effects were noted with either of the two regimens. Prostaglandins may be more effective for preventing recurrence of severe postpartum hemorrhage than the oxytocin and ergometrine combination, but they do not eliminate the risk entirely.