Use Of Uterotonic Agents Research Articles

Resolved but Not Forgotten: The Effect of Resolved Placenta Previa on Labor Management.

Placenta previa is diagnosed in up to 15% of pregnancies at the anatomy ultrasound and 0.5% persist to term. There is limited data regarding pregnancy outcomes with resolved previa. We aimed to examine patients with resolved placenta previa to determine if abnormal placentation at any time during pregnancy is associated with adverse events during labor. Patients with placenta previa were identified after second trimester ultrasound, included if placenta previa resolved with the placental edge greater than 2 cm from the internal cervical os, and excluded if placenta previa persisted to term, resolution occurred prior to 20 weeks, patients underwent a prior cesarean delivery, or delivered at an outside institution. Time-matched controls were identified among patients with normal placental location. Demographic data and outcomes were collected. Student's t-test, Wilcoxon's rank-sum test, Chi-square, Fisher's exact test, and univariable and multivariable logistic regression were used as appropriate RESULTS: Overall, 560 patients had placenta previa, 275 had resolved placenta previa, 285 were excluded. Resolved placenta previa patients were significantly older with lower prepregnancy body mass index (BMI), were significantly more likely to be a current smoker, have used assisted reproductive technology, and have had previous uterine surgeries. Overall, 10.2% of patients with resolved placenta previa experienced postpartum hemorrhage, compared with 2.1% in the normal placentation group. Patients with resolved placenta previa were 5.2 times more likely to have a postpartum hemorrhage (odds ratio [OR] = 5.2, 95% confidence interval [CI]: 2.1-12.7; p < 0.01) and 3.4 times more likely to require extra uterotonic medications (OR = 3.4, 95% CI: 1.9-6.2; p < 0.01). There is no difference with regard to rates of operative delivery for fetal distress (OR = 1.2, 95% CI: 0.7-1.9; p = 0.48), or category-II or-III fetal heart tracing around the time of delivery. Patients with resolved placenta previa had a higher rate of postpartum hemorrhage and use of uterotonic agents. This information might have important clinical implications and could be incorporated into the hemorrhage risk assessment during labor. · This study aimed to determine if patients with resolved placenta previa had an increased risk of expedited delivery due to fetal distress during labor.. · Patients age with resolved placenta previa have similar risk factors to those with persistent placenta previa, including older maternal, lower prepregnancy BMI, current smoking status, use of assisted reproductive technology (ART) and history of previous uterine surgeries. They were not at increased risk for operative vaginal delivery or cesarean section due to fetal distress. They did require increased uterotonic use and were at an increased risk for postpartum hemorrhage. · Patients with resolved placenta previa should undergo hemorrhage precautions at the time of admission..

Mild thrombocytopenia and the risk for postpartum hemorrhage in twin pregnancies.

We aimed to investigate the association of mild thrombocytopenia with postpartum hemorrhage (PPH) and blood transfusion among women with twin gestations. A retrospective cohort study (Jan 2015 to May 2019) was performed. Women with twin pregnancies and pre-delivery mild thrombocytopenia were compared to those with normal platelet count. The primary outcome was the rate of PPH, defined as a composite of one or more of the following: (1) need for packed red blood cell transfusion; (2) postpartum hemoglobin decline of ≥3g/dL; and (3) the use of postpartum uterotonics agents in addition to oxytocin. Of 1085 women who were included in final analysis, 315 (30.9%) had mild thrombocytopenia (and 770 (69.1%) served as controls. The rate of PPH was increased in the study group (14% vs. 9.4%, P =0.03), as was the use of uterotonic agents (3.8% vs. 1.3%, respectively, P =0.02). The rate of blood product transfusion and hemoglobin decline >3g/dL was not significantly different between the groups. In multivariate logistic regression analysis, mild thrombocytopenia was associated with a higher risk for PPH (OR 1.55 [95% CI 1.02-2.35], P =0.02). Mild thrombocytopenia in twin pregnancies is associated with an increased risk of interventions such as the use of uterotonic agents.

The First International Guideline for Oxytocin Safely Decreased Oxytocin Amount During Cesarean Section: A Single-Institution Retrospective Analysis

Purpose: It is routine to administer oxytocin following delivery of the neonate during cesarean section. However, there are many kinds of administration methods. Heesen et al. published an international consensus statement in 2019 on the use of uterotonic agents, including oxytocin during cesarean section [1]. Our institution adapted the guideline-based oxytocin infusion method. We verified the validity of the new approach after one year. Methods: A single-center retrospective study of consecutive patients who underwent cesarean section with a new protocol or the conventional manner from November 2019 to December 2020 was conducted. The primary endpoint was a significant difference in the amount of intraoperative hemorrhage and the total oxytocin amount. Secondary endpoints included differences in the incidence of intraoperative complications. Results: The study included 174 patients: 66 in the new protocol group and 108 in the conventional group. There was a statistically significant difference between the two groups for oxytocin amount (new protocol 4.2 [3.2-5.9] vs. conventional 5.0 [5.0-10] IU, p&lt;0.01) with equivalent intraoperative hemorrhages (new protocol 558 [337-963] vs. conventional 683 [484-1012] g, p=0.08). There was no significant difference in the incidence of nausea. Conclusion: The new guideline-based oxytocin administration safely decreased the intraoperative oxytocin amount in our institution.

P.102 Uterotonic drug use: a snapshot of clinical practice within obstetric departments in the UK

Introduction: Postpartum haemorrhage (PPH) is the third highest cause of direct maternal death in the UK and Ireland. [1] Knight M, Bunch K, Tuffnell D et al on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care – Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2015-17. Google Scholar Uterine atony is the leading cause of PPH. A range of uterotonic drugs are used for the prevention and treatment of PPH. There has been wide variation, within the UK and internationally, on the use of uterotonic agents. 2 West R, West S, Simons R, McGlennan A. Impact of dose finding studies on anaesthetic prescribing practice of oxytocin in the United Kingdom. Anaesthesia 2013; 68: 1021 –5. Google Scholar , 3 Thorneloe B, Carvalho JCA, Downey K, Balki M. Uterotonic drug usage in Canada: a snapshot of the practice in obstetric units of university-affiliated hospitals. Int J Obstet Anesth. 2019;37:45-51. Google Scholar A publication to guide the use of uterotonic agents during caesarean section has recently been published. [4] Heesen M, Carvalho B, Carvalho JCA, et al. International consensus statement on the use of uterotonic agents during caesarean section. Anaesthesia. 2019;74:1305-19. Google Scholar

Fetal heart rate monitoring in labor: from pattern recognition to fetal physiology.

The journey of human labor involves hypoxic and mechanical stresses as a result of progressively increasing frequency, duration and strength of uterine contractions and resultant compression of the umbilical cord. In addition, occlusion of the spiral arteries during myometrial contractions also leads to repetitive interruptions in the utero-placental circulation, predisposing a fetus to progressively worsening hypoxic stress as labor progresses. The vast majority of fetuses are equipped with compensatory mechanisms to withstand these hypoxic and mechanical stresses. They emerge unharmed at birth. However, some fetuses may sustain an antenatal injury or experience a chronic utero-placental insufficiency prior to the onset of labor. These may impair the fetus to compensate for the ongoing hypoxic stress secondary to ongoing uterine contractions. Non-hypoxic pathways of neurological damage such as chorioamnionitis, fetal anemia or an acute fetal hypovolemia may potentiate fetal neurological injury, especially in the presence of a super-imposed, additional hypoxic stress. The use of utero-tonic agents to induce or augment labor may increase the risk of hypoxic-ischemic injury. Clinicians need to move away from pattern recognition guidelines (normal, suspicious, pathological), and apply the knowledge of fetal physiology to differentiate fetal compensation from decompensation. Individualization of care is essential to optimize outcomes.

556 Resolved but not forgotten: does a diagnosis of resolved placenta previa affect labor and delivery?

Placenta previa (PP) is diagnosed in up to 15% of pregnancies at the anatomy ultrasound (US) and 0.5% persist to term. There is limited data regarding pregnancy outcomes with resolved previa (RPP). We aim to examine patients with RPP to determine if abnormal placentation at any time during pregnancy is associated with adverse events during labor. Anatomy US done at the Mount Sinai West Fetal Evaluation Unit between Mar 2018 - June 2020 were reviewed. Patients with PP were identified, included if PP resolved with placental edge >2cm from os, excluded if PP persisted to term, resolution occurred prior to 20 weeks, prior cesarean delivery or missing outcomes. Time matched controls identified among patients with normal placentation. Demographic data and outcomes collected. Student t-test, Wilcoxon rank-sum test, Chi-square, Fisher exact test, Univariable and multivariable logistic regression were used as appropriate A total of 8,881 US were performed, 560 with PP, 275 identified as RPP, 285 excluded. RPP patients were significantly older with lower pre pregnancy BMI. Patients with RPP were significantly more likely to be a current smoker, have used assisted reproductive technology, have had previous uterine surgeries (Table 1). Patients with RPP were 5.2 times more likely to have a post partum hemorrhage (PPH) (OR 5.2, 95% CI 2.1-12.7; p<0.01) and 3.4 times more likely to require extra uterotonic medications (OR 3.4, 95% CI 1.9-6.2; p<0.01). As the placental edge gets farther away from the os at resolution, the risk of PPH decreases (OR 0.9, 95% CI 0.9-1.0; p=0.03). There is no difference with regards to rates of operative delivery or cesarean delivery for fetal distress (OR 1.2, 95% CI 0.7-1.9; p=0.48), or Cat II/III fetal heart tracing at delivery. Patients with RPP had a higher rate of PPH and use of uterotonic agents. They were also more likely to have similar underlying risk factors of patients with persistent PP. This information might have important clinical implications and could be incorporated into the hemorrhage risk assessment during labor.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Fetal heart rate monitoring in labor: from pattern recognition to fetal physiology.

The journey of human labor involves hypoxic and mechanical stresses as a result of progressively increasing frequency, duration and strength of uterine contractions and resultant compression of the umbilical cord. In addition, occlusion of the spiral arteries during myometrial contractions also leads to repetitive interruptions in the utero-placental circulation, predisposing a fetus to progressively worsening hypoxic stress as labor progresses. The vast majority of fetuses are equipped with compensatory mechanisms to withstand these hypoxic and mechanical stresses. They emerge unharmed at birth. However, some fetuses may sustain an antenatal injury or experience a chronic utero-placental insufficiency prior to the onset of labor. These may impair the fetus to compensate for the ongoing hypoxic stress secondary to ongoing uterine contractions. Non-hypoxic pathways of neurological damage such as chorioamnionitis, fetal anemia or an acute fetal hypovolemia may potentiate fetal neurological injury, especially in the presence of a super-imposed, additional hypoxic stress. The use of utero-tonic agents to induce or augment labor may increase the risk of hypoxic-ischemic injury. Clinicians need to move away from "pattern recognition" guidelines ("normal," "suspicious," "pathological"), and apply the knowledge of fetal physiology to differentiate fetal compensation from decompensation. Individualization of care is essential to optimize outcomes.

International Consensus Statement on the Use of Uterotonic Agents During Cesarean Section

(Anaesthesia. 2019;74:1305–1319) Uterotonics are routinely used after delivery to manage uterine tone. While various guidelines exist for general management during cesarean deliveries, management of uterine tone following vaginal delivery, and treatment of postpartum hemorrhage, no previous international guideline has addressed uterotonic management during and following cesarean section. The use of uterotonics is largely based on tradition and varies in the choice of drug, timing of administration, dose, route, and speed, and maintenance of administration. Both first-line (oxytocin, carbetocin) and second-line uterotonics carry risk for adverse effects such as hypotension, tachycardia, and ST-segment depression. This consensus statement provides 10 recommendations for the use of uterotonic agents during cesarean section.

Postpartum Haemorrhage in the Developing World A Review of Clinical Management Strategies

The developing world is disproportionately burdened with high rates of maternal mortality. Despite widespread reduction in maternal deaths due to improved antepartum, intrapartum, and postpartum care in developed nations, mortality rates are persistently high in many countries unable to provide advanced medical care. Postpartum haemorrhage accounts for a substantial proportion of maternal deaths in developing countries. This review addresses the clinical management strategies aimed at the prevention and treatment of postpartum haemorrhage that are effective in lowresource settings. The review was conducted by searching the English-language medical literature using MEDlINE (1950 - Feb 2009) and the online search engine Google Scholar. Four relevant strategies were identified in the literature: active management of the third stage of labour (AMSTl), the use of uterotonic agents including misoprostol, accurate measurement of blood loss, and internal and external compression techniques. Despite known intervention options, additional research on effective management strategies and their implementation is needed to address postpartum haemorrhage in countries of the developing world.

PREVENTION OF OXYTOCIN-INDUCED HYPOTENSION IN CAESAREAN SECTION BY PHENYLEPHRINE: EFFECT OF PRELOAD Dr. Anita Chikara

Introduction: One of the leading causes of maternal mortality with uterine atony is Postpartum haemorrhage (PPH) and can be reduced by proper use of uterotonic agents like oxytocin which is most commonly used. Approximately 80% of the patients suffers Spinal-induced hypotension (SIH) for cesarean delivery (CD) and is a frequently encountered problem. Postpartum haemorrhage (PPH) is one of the leading causes of maternal mortality with uterine atony in about 50% cases. There are many approaches to prevent hypotension but no single approach has been shown as the gold standard, and each prophylactic treatment comes with accompanying risks. Crystalloid preload can prevent hypotension has a poor efficacy in preventing hypotension, due to rapid redistribution into the extracellular space. Phenylephrine is a short-acting alpha agonist, can be administered by bolus as well as by infusion to treat oxytocin induced hypotension. Phenylephrine obtunds oxytocin-induced decrease in systemic vascular resistance (SVR) and increase in heart rate and cardiac output&#x0D; Material and Methods: Patients were randomized to be in the colloid or crystalloid infusion groups. Normal singleton pregnancy, beyond 36 weeks gestation, between 19and 35 years of age, weight between 50 and 100 kg, and height ranging from 150-180 cm. Pre-anaesthetic evaluation of all the patients was done. Intravenous administration of preload was delivered for 30 min, prior to spinal anaesthesia and when the fluid load was complete, IV patency was maintained at a rate of 5 ml/hour and medications were flushed with LR. Standard monitoring for all patients was done through use of non-invasive blood pressure (NIBP) measurement, electrocardiography, and pulse oximetry. Oxygen (2 l/min) was administered via nasal cannula. The average Systolic BP and accompanying heart rate (HR) of these 3 measurements were recorded as mean baseline values. Patients feeling about nausea was recorded from start of anaesthesia at every 5 minutes interval. Results: Mean age in lacteted ringer solution group was 25.27±5.11 years while in hydroxyethyl starch group it was 26.19±4.67. Mean Spinal uterine incision time was 15.88±4.27 and 17.18±3.35 in lacteted ringer solution group and hydroxyethyl starch group respectively. Estimated blood loss in ml(mean±SD) was 443±59.44 and 479±61.32 in lacteted ringer solution group and hydroxyethyl starch group respectively. Systolic blood pressure baseline (mean±SD) 126.45±11.33 and 129.12±9.24 in lacteted ringer solution group and hydroxyethyl starch group respectively. Heart rate (mean±SD) was 88.87±9.45 and 88.21±10.55 in lacteted ringer solution group and hydroxyethyl starch group respectively. Significantly less phenylephrine was used in the colloid group (1058 ± 558 mcg) compared to the crystalloid group (1400 ± 513 mcg) (P = 0.0019) . There was no significant difference in the incidence of maternal nausea and vomiting, as well as APGAR scores at 1 and 5 min.&#x0D; Conclusion: In prevention of SIH and treatment, Phenylephrine with collids are found to be superior than crystelloids because of the sparing effect of phenylephrine associated with preloading colloids.&#x0D; Keywords: crystelloids, collids, lactated, cesarean delivery

Mild Thrombocytopenia and Postpartum Hemorrhage in Nulliparous Women With Term, Singleton, Vertex Deliveries.

To assess whether mild thrombocytopenia (platelet count 100-149 k/microliter) is associated with an increased risk of postpartum hemorrhage. Nulliparous women with term, singleton, vertex pregnancies undergoing labor at our institution between August 2016 and September 2017 were included. The primary exposure was mild thrombocytopenia, defined as platelet count 100-149 k/microliter, and the comparator was normal platelet count (150 k/microliter or greater). Those with severe thrombocytopenia (platelet count less than 100 k/microliter) were excluded from analysis. The primary outcome was postpartum hemorrhage, determined by International Classification of Diseases, Tenth Revision codes and the hospital discharge problem list. Secondary outcomes included use of uterotonic agents (methylergonovine maleate or carboprost tromethamine), total blood loss 1,000 mL or greater, and blood transfusion. Data were analyzed by t test, χ or Fisher exact test, and multivariable logistic regression, with significance at α <0.05. We evaluated 2,845 eligible women, of whom 2,579 (90.2%) had normal platelet count 150 k/microliter or greater, 266 (9.3%) had platelet count 100-149 k/microliter (mild thrombocytopenia), and 13 (0.5%) had platelet count less than 100 k/microliter (severe thrombocytopenia). Compared with women with normal platelet count, those with mild thrombocytopenia had a higher rate of postpartum hemorrhage (16.9% vs 8.5%, P<.001) and were more likely to have total blood loss 1,000 mL or greater (4.5% vs 1.7%, P=.002) and receive methylergonovine maleate (10.5% vs 5.9%, P=.003) or carboprost tromethamine (6.0% vs 1.6%, P<.001) or both (3.8% vs 1.0%, P<.001), but rates of blood transfusion were no different (1.9% vs 1.5%, P=.59). The association between mild thrombocytopenia and postpartum hemorrhage persisted after multivariable adjustment for potential confounders (adjusted odds ratio 2.2, 95% CI 1.5-3.2, P<.001). Among nulliparous women with term, singleton, vertex pregnancies undergoing labor, those with mild thrombocytopenia (platelet count 100-149 k/microliter) had a twofold greater likelihood of postpartum hemorrhage compared with those with normal platelet count.

Modern uterotonics: vitally required and dangerous... Literature review

Uterotonics are widely used in obstetrics for pre-induction and induction of labor, for prevention and treatment of postpartum hemorrhages. Oxytocin, carbetocin and misoprostol are used as uterotonic agents for prevention of postpartum hemorrhages. Oxytocin, ergometrine, syntomethrin and misoprostol are used for treatment of postpartum hemorrhages. Subject to the principle of active management of the third stage of labor, prophylactic use of uterotonics reduces the postpartum hypotonic bleeding risk by 60%.This review provides current data on the pharmacokinetics, doses, modes of use and possible complications of oxytocin drugs, prostaglandin E1 and E2 analogues, ergot alkaloids in obstetric practice. International consensus statement on the use of uterotonic agents during caesarean section (2019) are presented, taking into account the differences between their dose for planned and urgent Caesarean section.In addition to the uterotonic effect of oxytocin it has parasympathetic neuromodulation, vasodilation, negative inotropic and chronotropic effects, lowers blood pressure, and in large doses and fast administration can have a negative effect on the fetus. The author emphasizes that uterotonics of the second row should be considered as early as possible if the oxytocin/carbetocin does not give a good uterine tone, but remember that the combined use of oxytocin with ergometrine increases the risks of cardiac complications.Methylergometrine can lead to an increase in central venous pressure, as well as an increase in blood pressure, in some cases it can provoke ischemia and necrosis of the heart muscle.Misoprostol is used for labor pre-induction, induction and for prevention and off-label treatment of postpartum bleeding. Misoprostol increases the risk of uterine hyperstimulation and increased heart rate in fetus, and the mother's body temperature rises. Therefore the key to the effectiveness and safety of uterotonics is the correct use of the method, dose, route and administration speed, taking into account indications and contraindications, careful monitoring of the condition of pregnant woman, fetus, woman in childbirth, compliance with the recommended storage conditions for drugs.

International consensus statement on the use of uterotonic agents during caesarean section.

It is routine to give a uterotonic drug following delivery of the neonate during caesarean section. However, there is much heterogeneity in the relevant research, which has largely been performed in low-risk elective cases or women with uncomplicated labour. This is reflected in considerable variation in clinical practice. There are significant differences between dose requirements during elective and intrapartum caesarean section. Standard recommended doses are higher than required, with the potential for acute cardiovascular adverse effects. We recommend a small initial bolus dose of oxytocin, followed by a titrated infusion. The recommended doses of oxytocin may have to be increased in women with risk factors for uterine atony. Carbetocin at equipotent doses to oxytocin has similar actions, while avoiding the requirement for a continuous infusion after the initial dose and reducing the need for additional uterotonics. As with oxytocin, carbetocin dose requirements are higher for intrapartum caesarean sections. A second-line agent should be considered early if oxytocin/carbetocin fails to produce good uterine tone. Women with cardiac disease may be very sensitive to the adverse effects of oxytocin and other uterotonics, and their management needs to be individualised.

Impact of nonpneumatic antishock garment in the management of patients with hypoperfusion due to massive postpartum hemorrhage

Objective: The objective of this article was to compare hemodynamic and perfusion parameters as well as the clinical outcomes in critically ill patients with postpartum hemorrhage (PPH) who received treatment with a nonpneumatic antishock garment (NASG) as part of an intervention package, with a group of patients in similar conditions who did not receive an NASG. Methods: This observational study analyzed a historic cohort of 154 patients with PPH, secondary hypovolemic shock and signs of hypoperfusion who were admitted to this institution from 2012 to 2015. Group 1 (n= 77) was managed with NASG and Group 2 (n = 77) received interventions other than NASG. Hypoperfusion markers and maternal outcomes were compared in both groups. Results: Of 154 patients included in the analysis, 36.4% required a total abdominal hysterectomy (TAH) to achieve hemorrhage control, 98.2% of whom belonged to Group 2 and 1.8% to Group 1 (p = .001). The use of blood products was more common in Group 2 (p < .001), as was the administration of vasoactive agents. The mean number of days of hospitalization at the Obstetric High Dependency Unit (OHDU) was significantly lower in Group 1 and reached a statistically significant p value. Only two cases of maternal death occurred in Group 2. Discussion: The use of NASG in the management of PPH is a cost-effective strategy for patients with severe shock and signs of hypoperfusion and is optimal in a limited-resource scenario. In this study, the use of NASG was related to better outcomes in a statistically significant manner with better results regarding maternal outcomes such as uterine preservation and decreased transfusion requirements and hospital days. Conclusions: NASG, associated with the use of uterotonic agents and other strategies for PPH control, is a safe tool that helps reduce morbimortality in critically ill patients with PPH.

A Randomized Controlled Trial of Immediate versus Delayed Umbilical Cord Clamping in Multiple-Birth Infants Born Preterm

Background: Delayed cord clamping (DCC) improves placental transfusion and increases blood volume in preterm infants when compared with immediate cord clamping (ICC). However, evidence to support DCC in multiple-birth preterm infants is still lacking. Objective: To compare the outcomes of ICC versus DCC in preterm infants of multiple births. Study Design: Women with a multiple pregnancy, including twins and triplets with a gestational age of 28–36 weeks, were randomized to receive ICC (23 women and 50 infants) or DCC for 30–60 s (24 and 51 infants). The infants’ hematocrit on admission, superior vena cava (SVC) flow measured within 24 h, and hematocrit at 8 weeks of age were compared. The use of uterotonic agents during delivery was not controlled in this study. Result: All infants were delivered by cesarean section (CS) except for 2 sets of twins, 1 in each group. Maternal and infant baseline characteristics in both groups were comparable. There were no significant differences between the groups in admission hematocrit, SVC flow measured within 24 h, hematocrit at 8 weeks of age, or any other neonatal outcomes. The incidence of maternal postpartum hemorrhage (PPH) was higher in the DCC group (4.3% in ICC vs. 25% in DCC, p = 0.04). Conclusion: DCC for 30–60 s did not improve placental transfusion or increase systemic blood flow in multiple-birth infants born preterm, mostly by CS, when compared with ICC. The finding of a higher PPH rate in the DCC group raises concerns about the maternal safety of this procedure in this patient population.

Prophylactic use of ergot alkaloids in the third stage of labour.

Previous research has shown that the prophylactic use of uterotonic agents in the third stage of labour reduces postpartum blood loss and moderate to severe postpartum haemorrhage (PPH). PPH is defined as a blood loss of 500 mL or more within 24 hours after birth. This is one of a series of systematic reviews assessing the effects of prophylactic use of uterotonic drugs; in this review prophylactic ergot alkaloids as a whole, and different regimens of administration of ergot alkaloids, are compared with no uterotonic agents. This is an update of a Cochrane Review which was first published in 2007 and last updated in 2011. To determine the effectiveness and safety of prophylactic use of ergot alkaloids in the third stage of labour by any route (intravenous (IV), intramuscular (IM), or oral) compared with no uterotonic agents, for the prevention of PPH. For this update, we searched the Cochrane Pregnancy and Childbirth Group's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (19 September 2017); we also searched reference lists of retrieved studies. We included all randomised controlled trials or cluster-randomised trials comparing prophylactic ergot alkaloids by any route (IV, IM, or oral) with no uterotonic agents in the third stage of labour among women giving birth vaginally. Two review authors independently assessed trials for inclusion, extracted data and checked them for accuracy; they also assessed the risk of bias in included studies. Two review authors assessed the quality of the evidence using the GRADE approach. There were eight included studies: three studies had a low risk of bias and five studies had high risk of bias. The studies compared ergot alkaloids with no uterotonic agents, with a total of 2031 women in the ergot alkaloids group and 1978 women in the placebo or no treatment group. Seven studies used the IV/IM route of administration and one study used the oral route.Ergot alkaloids (any route of administration) versus no uterotonic agentsUse of ergot alkaloids in the third stage of labour decreased mean blood loss (mean difference (MD) -80.52 mL, 95% confidence interval (CI) -96.39 to -64.65 mL; women = 2718; studies = 3; moderate-quality evidence); decreased PPH of at least 500 mL (average risk ratio (RR) 0.52, 95% CI 0.28 to 0.94; women = 3708; studies = 5; I2 = 83%; low-quality evidence); increased maternal haemoglobin concentration (g/dL) at 24 to 48 hours postpartum (MD 0.50 g/dL, 95% CI 0.38 to 0.62; women = 1429; studies = 1; moderate-quality evidence); and decreased the use of therapeutic uterotonics (average RR 0.37, 95% CI 0.15 to 0.90; women = 2698; studies = 3; I2 = 89%; low-quality evidence). There were no clear differences between groups in severe PPH of at least 1000 mL (average RR 0.32, 95% CI 0.04 to 2.59; women = 1718; studies = 2; I2 = 74%; very low-quality evidence). The risk of retained placenta or manual removal of the placenta, or both, were inconsistent with high heterogeneity. Ergot alkaloids increased the risk of elevated blood pressure (average RR 2.60, 95% CI 1.03 to 6.57: women = 2559; studies = 3; low-quality evidence) and pain after birth requiring analgesia (RR 2.53, 95% CI 1.34 to 4.78: women = 1429; studies = 1; moderate-quality evidence) but there were no differences between groups in vomiting, nausea, headache or eclamptic fit.Results for IV/IM ergot alkaloids versus no uterotonic agents were similar to those for the main comparison of ergot alkaloids administered by any route, since most of the studies (seven of eight) used the IV/IM route. Only one small study (289 women) compared oral ergometrine with placebo and it showed no benefit of ergometrine over placebo. No maternal adverse effects were reported.None of the studies reported on any of our prespecified neonatal outcomes AUTHORS' CONCLUSIONS: Prophylactic IM or IV injections of ergot alkaloids may be effective in reducing blood loss, reducing PPH (estimated blood loss of at least 500 mL), and increasing maternal haemoglobin. Ergot alkaloids may also decrease the use of therapeutic uterotonics, but adverse effects may include elevated blood pressure and pain after birth requiring analgesia. There were no differences between groups in terms of other adverse effects (vomiting, nausea, headache or eclamptic fit). There is a lack of evidence on the effects of ergot alkaloids on severe PPH, and retained or manual removal of placenta. There is also a lack of evidence on the oral route of administration of ergot alkaloids.

Hemostatic Resuscitation in Postpartum Hemorrhage—A Supplement to Surgery

(Acta Obstet Gynecol Scand. 2015;94:680–692) Although postpartum hemorrhage is preventable, it remains a highly prevalent cause of maternal death in poorer countries and seems to be increasingly common in higher income countries as well. Although surgical options can be the most beneficial course of treatment, these measures may fail to stop the hemorrhage. The use of uterotonic agents, controlled cord traction, uterine massage, intrauterine balloon tamponade, or uterine artery embolization can also prove ineffective when health care professionals are faced with a persistent hemorrhage. It is therefore important to determine effective and affordable treatments that can be used in addition to surgical options and uterotonic agents to ensure that hemostasis is achieved. The authors of this review examined the existing literature to evaluate other supplemental methods that are currently used to treat postpartum hemorrhage.

A Rare Case: Spontaneous Uterine Rupture in First Pregnancy

Introduction: Spontaneous uterine rupture is potentially catastrophic for both the mother and fetus. It is associated with risk factors, such as uterine abnormalities, uterine scar, macrosomic fetus, cephalopelvic disproportion, and use of uterotonic agents for induction of labor. We present a case of spontaneous rupture of an unscarred primigravid uterus, which is extremely rare. Case Report: A 22-year-old primigravida at 22 weeks presented to the emergency department with complaints of syncope and mild dyspnea. On her physical examination, she had a Glasgow coma scale of 15, tension arterial of 60/30 mmHg, and pulse rate of 110 beats/minute. Her first abdominal ultrasound was reported as normal. After consultation, the obstetrician reported that the fetus had normal fetal heart rate, and there had been no abnormality with the patient’s pregnancy. After intravenous infusion of 1000 ml saline, her hypotension still proceeded, and her second USG revealed free fluid in the abdomen. An emergency laparotomy was performed for a probable diagnosis of intra-abdominal hemorrhage and the fetus found floating freely in the peritoneal cavity. The patient recovered and discharged healthy 5 days after the operation, while the fetus could not survive. Conclusion: Although it is extremely rare in primigravidas, an emergency physician should consider spontaneous uterine rupture in pregnant patients with hemodynamic instability.

Outcome of pelvic arterial embolization for postpartum hemorrhage: A retrospective review of 117 cases

ObjectiveThe aim of this study was to evaluate indications, efficacy, and complications associated with pelvic arterial embolization (PAE) for postpartum hemorrhage (PPH).MethodsWe retrospectively reviewed the medical records of 117 consecutive patients who underwent PAE for PPH between January 2006 and June 2013.ResultsIn our single-center study, 117 women underwent PAE to control PPH refractory to conservative management including uterine massage, use of uterotonic agents, surgical repair of genital tract lacerations, and removal of retained placental tissues. Among 117 patients, 69 had a vaginal delivery and 48 had a Cesarean section. The major indication for embolization was uterine atony (54.7%). Other causes were low genital tract lacerations (21.4%) and abnormal placentation (14.5%). The procedure showed a clinical success rate of 88.0% with 14 cases of PAE failure; there were 4 hemostatic hysterectomies and 10 re-embolizations. On univariate analysis, PAE failure was associated with overt disseminated intravascular coagulation (P=0.009), transfusion of more than 10 red blood cell units (RBCUs, P=0.002) and embolization of both uterine and ovarian arteries (P=0.003). Multivariate analysis showed that PAE failure was only associated with transfusions of more than 10 RBCUs (odds ratio, 8.011; 95% confidence interval, 1.531-41.912; P=0.014) and embolization of both uterine and ovarian arteries (odds ratio, 20.472; 95% confidence interval, 2.715-154.365; P=0.003), which were not predictive factors, but rather, were the results of longer time for PAE. Three patients showed uterine necrosis and underwent hysterectomy.ConclusionPAE showed high success rates, mostly without procedure-related complications. Thus, it is a safe and effective adjunct or alternative to hemostatic hysterectomy, when primary management fails to control PPH.

PL.62 Peri-Partum Hysterectomy: Still Required For Management of Post-Partum Haemorrhage?

BackgroundPostpartum haemorrhage (PPH) complicates 5–10% of all deliveries in the UK. While the use of uterotonic agents and compression devices has reduced the requirement for definitive surgical intervention, examination under...