Use Of Uterotonics Research Articles

Trends and regional variations in prescriptions dispensed to stimulate uterine contractions at the end of pregnancy in Belgium: A community-based study from 2003 to 2018.

To investigate trends and regional variations in uterotonics dispensed around birth between 2003 and 2018 in Belgium. Data, including outpatient and inpatient prescriptions were extracted from a nationally representative prescription database. The prevalence of uterotonics dispensed during a period including the 7 days before birth, the delivery day and the 7 days after birth was computed over three 4-year-long study periods from 2003 to 2018. The trends between periods and associations between the use of at least one uterotonic and maternal age, region of residence, delivery type and social status were assessed using logistic regression. In total, 31 675 pregnancies were included in the study. The proportion of pregnancies exposed to at least one uterotonic decreased significantly from 92.9% (95%CI, 92.3-93.4) in 2003-2006 to 91.4% (95%CI, 90.7-92.0) in 2015-2018 for vaginal births and from 95.5% (95%CI, 94.5-96.4) to 93.7% (95%CI, 92.6-94.7) for caesarean sections. However, for vaginal births, the proportion of oxytocin increased from 84.5% (95%CI, 83.7-85.2) to 89% (95%CI 88.3-89.7). A significant association was found between uterotonic agent use and maternal age, region of residence, and delivery type. The dispensation of some uterotonic agents differed significantly between the regions. The proportion of pregnancies exposed to at least one uterotonic was high across the study period but decreased slightly between 2003 and 2018. Important variations in uterotonic use between regions highlight the need for improved national guidance.

Reducing Hemorrhage-Related Maternal Morbidity Using Interdisciplinary Simulation Training.

Postpartum hemorrhage (PPH) remains a major cause of preventable maternal morbidity in the United States. Postpartum hemorrhage simulations were developed to improve provider recognition and treatment; however, there exist few studies that investigate their effects on individual outcomes. Our objective is to estimate the effect of a simulation-based educational intervention on PPH-related maternal morbidity outcomes. We conducted a retrospective cohort analysis of hemorrhage outcomes at a single institution between March 2012 and January 2016 during the implementation of a high-fidelity PPH simulation. Women with PPH defined as an estimated blood loss greater than 500 mL for vaginal delivery and 1000 mL for cesarean delivery were included. The primary outcome was a composite of hemorrhage-related maternal morbidity (maternal death, hysterectomy, intensive care unit admission, blood transfusion, or unanticipated procedures to treat postpartum bleeding). Multivariable logistic regression adjusted for confounding variables between presimulation and postsimulation outcomes. During the study period, 19,927 deliveries occurred with 4.5% of patients (888) experiencing hemorrhage. Women in the presimulation (n = 278) versus postsimulation groups (n = 610) had similar demographics. Although the PPH rate increased after simulation [2.8% pre vs. 6.1% post, odds ratio (OR), 2.25; 95% confidence interval (CI), 1.95-2.60], composite hemorrhage-related morbidity was lower after simulation training (44% pre vs. 35% post; OR, 0.70; 95% CI, 0.52-0.93). This reduction persisted after adjusting for confounding variables of mode of delivery and time from delivery to first uterotonic use (adjusted OR, 0.66; 95%, CI 0.49-0.89). Despite an increased PPH rate, simulation education was associated with a reduction in a hemorrhage-related maternal composite morbidity.

Intravenous Carbetocin Versus Rectal Misoprostol for the Active Management of the Third Stage of Labor: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Globally, postpartum hemorrhage (PPH) is the top cause of maternal death. Multiple uterotonic medications are available to prevent PPH; however, it is still unclear whether one is the most effective. The current study compared the efficacy and safety of intravenous carbetocin with rectal misoprostol for the active management of the third stage of labor in order to prevent PPH. Eligible studies were found utilizing digital medical sources, including the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science (WOS), PubMed, Scopus, and Google Scholar, from inception until September 2022. Only randomized controlled trials (RCTs) that matched the inclusion requirements were chosen. We used the Cochrane Risk of Bias scale (version 2) to assess the quality of the included studies. The Review Manager (version 5.4 for Windows) was used to conduct the meta-analysis. The results were summarized as mean difference (MD) or risk ratio (RR) with a 95% confidence interval (CI) in fixed- or random-effects models according to the degree of between-study heterogeneity. Collectively, we screened 621 articles after omitting duplicates and eventually included three RCTs for analysis. Overall, 404 patients were included in these studies; 202 patients were allocated to the intravenous carbetocin group whereas 202 patients were allocated to the rectal misoprostol group. Two RCTs were judged as “low” risk of bias, whereas one RCT was judged as having “some concerns” regarding the quality assessment. Regarding efficacy endpoints, the intravenous carbetocin group had significantly lower blood loss (n=3 RCTs, MD=-117.74 mL, 95% CI [-185.41, -50.07], p<0.001), need for additional uterotonics (n=2 RCTs, RR=0.06, 95% CI [0.01, 0.46], p=0.007), need for uterine massage (n=2 RCTs, RR=0.40, 95% CI [0.20, 0.80], p=0.009), and need for blood transfusion (n=2 RCTs, RR=0.38, 95% CI [0.15, 0.95], p=0.04) compared with the rectal misoprostol group. Regarding safety endpoints, the rates of diarrhea (n=3 RCTs, RR=0.18, 95% CI [0.06, 0.55], p=0.003) and chills (n=2 RCTs, RR=0.31, 95% CI [0.12, 0.83], p=0.02) were significantly lower in the intravenous carbetocin group compared with the rectal misoprostol group. However, there was no significant difference between both groups regarding the rates of headache (n=3 RCTs, RR=1.23, 95% CI [0.06, 1.91], p=0.35) and facial flushing (n=2 RCTs, RR=0.88, 95% CI [0.46, 1.68], p=0.70). In conclusion, it was discovered that intravenous carbetocin was a superior substitute for rectal misoprostol for the active management of the third stage of labor. With far fewer side effects, intravenous carbetocin decreased postpartum blood loss and further uterotonic use. For women who have a high risk of PPH, intravenous carbetocin is advised.

Major obstetric hemorrhage management

Postpartum hemorrhage (PPH) is to this day one of the leading causes of maternal death and its diagnosis is still highly subjective, as it relies on unprecise estimates of the amount of blood loss. There are three areas in which PPH outcomes can be improved: prevention, treatment and rescue. PPH can escalate to a graver clinical picture of Severe Acute Maternal Morbidity (SAMM) due to an inaccurate estimate of the blood loss, inability to identify an at-risk patient, delays in testing and availability of hemoderivatives, and lack of clear guidelines and interdisciplinary communication. Many factors can predispose to PPH and in clinical practice the many causes of its insurgence are summarized with the 4T formula: Tone (uterine atony), Trauma (laceration/hematoma), Tissue (retained tissue/invasive placenta), Thrombin (coagulation). Some precautions can be taken in preventing PPH such as the use of uterotonics, the administration of oxytocin, the timing of umbilical cord clamping, and the monitoring of anemia and the platelet to fibrinogen concentration ratio. In recent years studies have been published with the goal of leading PPH diagnosis and management through universal guidelines, point-of-care testing and interdisciplinary approaches. The proposed algorithms, albeit not yet validated, are useful in the clinical practice; similarly beneficial is the use of reliable predictive panels such as the Modified Early Obstetric Warning System.

Intravenous Oxytocin Dosing Regimens for Postpartum Hemorrhage Prevention Following Cesarean Delivery: A Systematic Review and Meta-Analysis

(Am J Obstet Gynecol. 2021;225:250.e1–250.e38. [Epub May 4, 2021]) Postpartum hemorrhage (PPH) is a leading cause of maternal mortality. A common cause of PPH is uterine atony. To decrease the nearly 20% of 295,000 worldwide maternal deaths from PPH, there has been an increase in the use of uterotonics for all women during delivery. In 2018 the World Health Organization (WHO) recommended 10 IU of oxytocin to be administered to all women for both vaginal and cesarean deliveries (CD) to improve uterine atony and prevent PPH. There is insufficient evidence that 10 IU was an optimal amount for both types of delivery and the dose was based on insufficient evidence from an outdated Cochrane systematic review. The purpose of this review was to analyze the dosing regimens of IV oxytocin used for CD and to determine if any regimens are superior to others.

Multicenter, Randomized, Double-Blind, and Positive Drug-Controlled Clinical Trial on Prevention of Postpartum Hemorrhage after Vaginal Delivery with Ergometrine Maleate

To evaluate the safety and efficacy of using ergometrine maleate injection combined with oxytocin injection, with oxytocin injection as the control, to prevent postpartum hemorrhage after vaginal delivery. A total of 305 cases who underwent vaginal delivery between December 2018 and November 2019 in 16 hospitals across China were enrolled and included in the full analysis set (FAS) and the safety analysis set (SS). Among the 299 subjects who completed the trial, 277 were included in the per protocol set (PPS). The subjects were randomly assigned by 1∶1 ratio to two groups, 152 cases in Group A, the experimental group receiving oxytocin injection plus ergometrine injection, and 153 cases in Group B, the control group, receiving oxytocin injection. The difference in total bleeding volume at 2 h, 6 h and 24 h postpartum in the two groups was documented and compared. Other measures were also compared between the two groups, including the proportion of additional use of uterotonics and hemostatic drugs or other hemostatic measures 2 h and 24 h postpartum, the proportion of subjects needing blood transfusion, the time of placenta retention, proportion of subjects with prolonged hospital stay due to uterine asthenia, the vital signs, lab test indicators and the incidence of adverse reactions in the two groups. The total bleeding volume at 2 h, 6 h and 24 h after delivery was significantly lower in the experimental group (P<0.05). There was no significant difference between the two groups in the proportion of additional use of uterotonics and hemostatic drugs or other hemostatic measures 2 h and 24 h postpartum, the proportion of subjects needing blood transfusion and the time of placenta retention, heart rate, respiration, lab test indicators, or the incidence of adverse reaction (P>0.05). Ergometrine maleate injection showed evident therapeutic efficacy in preventing hemorrhage after vaginal delivery, causing fewer adverse reactions and ensuring greater safety, and therefore, presenting promising prospects for clinical application.

UTEROTONIC USE IN THE ACTIVE MANAGEMENT OF THIRD STAGE OF LABOR (AMTSL): SYSTEMATIC REVIEW

&lt;p&gt;&lt;strong&gt;Background:&lt;/strong&gt; Maternal mortality rate in Indonesia has decreased from 184/100,000 live birth (LB) (2016) to 177/100,000 LB (2017), but this number is still high enough than SDGs target of 70/100,000 LB. The one of direct cause of maternal death is hemorrhage, especially postpartum hemorrhage (PPH). Causes of PPH are uterine atony, laceration of birth canal, resistant placenta and uterine inversion. PPH prevention method is Active Management of Third Stage of Labor (AMTSL). The objective of this systematic review is to analyze the use of uterotonics in AMTSL.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods:&lt;/strong&gt; This systematic review used the PRISMA protocol, articles taken from Google Scholar, Science Direct, and Pub Med. The time span of the research article was 2010 to 2021.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Result:&lt;/strong&gt; The results of the study describe that the use of uterotonics in single use or combination in third stage of labor can reduce the risk of PPH and shorten the time of the stage. The side effects were reported in misoprostol and methyl ergometrine than oxytocin. In addition, combination therapy with oxytocin and misoprostol can reduce the length of the third stage and the potential for a decrease in hemoglobin within 24 hours of delivery. In Indonesia, if oxytocin is not available, maternal nipple stimulation is performed as nonpharmacological therapy or ergometrine 0.2 mg is given to patients without complications of high blood pressure.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusion:&lt;/strong&gt; The use of uterotonics is adjusted to its cost-effectiveness, ability to store and refrigerate also the benefits compare to the side effects to the patients.&lt;/p&gt;

Prophylactic uterotonic use is associated with decreased postpartum hemorrhage in grand multiparous women

Grand multiparity, defined as five or more prior deliveries, confers unique obstetric complications. Postpartum hemorrhage (PPH) due to uterine atony is thought to be a risk factor due to progressive uterine relaxation. While oxytocin administration at time of delivery decreases risk of PPH, previous studies did not demonstrate benefit in use of additional uterotonics. We aim to evaluate whether additional prophylactic uterotonics in grand multiparas is associated with decreased PPH.

The Role of Oxytocin in the Prevention of Postpartum Hemorrhage in Low-Resource Settings

Postpartum hemorrhage remains one of the leading causes of maternal death globally. Oxytocin is the uterotonic agent of choice for the prophylaxis of this complication. However, its use in low-resource settings is associated with clinical, political, economic and cultural constraints. The goal of this article is to describe the use of oxytocin for postpartum hemorrhage prophylaxis in low-resource settings. A literature review on the topic was carried out, and 24 articles were included. The information was organized into seven sections: the evaluation of the efficacy of oxytocin compared to other uterotonics, the use of oxytocin in home births, the training of healthcare professionals, the quality of the available oxytocin, the new formulations, the risks associated with the use of uterotonic and the adopted health policies. Despite the progress achieved widespread access to oxytocin for postpartum hemorrhage prophylaxis in low-resource settings is less than desirable. The main difficulties encountered were the shortage of skilled healthcare professionals for oxytocin administration, deficiencies concerning the quality of the drug and the inadequacy of available clinical guidelines. In order to reduce maternal mortality caused by postpartum hemorrhage in low-resource settings, it is essential to improve the knowledge of healthcare professionals, to implement good practices on the use of uterotonics, to optimize resource management and to overcome cultural barriers that prevent the demand for health services.

Carbetocin versus oxytocin following vaginal and Cesarean delivery: a before-after study.

A nationwide shortage of oxytocin in Canada resulted in a temporary switch from oxytocin to carbetocin for all postpartum women at our institution. This change offered a unique opportunity to conduct a pragmatic comparative assessment of the efficacy of carbetocin and oxytocin. In a retrospective before-after study, we reviewed the medical records from 641 women in the carbetocin group and 752 women in the oxytocin group . The standard carbetocin dosing was 100 µg iv following vaginal and intrapartum Cesarean delivery, while for elective Cesarean delivery it was 50 µg, with an additional 50 µg if required. The standard oxytocin dosing was 5 IU iv followed by 2.4 IU·hr-1 for four to six hours after vaginal delivery, while for Cesarean delivery it was 1-3 IU iv, three minutes apart, up to 10 IU if required, followed by the same maintenance. In both modalities of delivery, if uterine tone was suboptimal, the maintenance dose of oxytocin could be increased to 4.8 IU·hr-1. In both groups, additional uterotonics were used as required. The primary outcome was the need for additional uterotonics. Secondary outcomes included estimated and calculated blood loss, the occurrence of postpartum hemorrhage, and the need for blood transfusion. The incidence of additional uterotonic use was not different between the carbetocin and oxytocin groups (12.0% vs 8.8%; P = 0.05; odds ratio, 1.39; 95% confidence interval, 0.97 to 2.00). The incidence of postpartum hemorrhage was higher in the carbetocin group than in the oxytocin group (10.3% vs 6.6%; P = 0.01). Blood transfusion was more common in the carbetocin group (1.4% vs 0.3%; P = 0.02). There was no difference in the use of additional uterotonics when carbetocin or oxytocin were used in a cohort of women undergoing vaginal deliveries and both elective and emergency Cesarean deliveries.

Heat stable carbetocin vs. oxytocin for the prevention of post-partum hemorrhage in emergency caesarean delivery: a randomized controlled trial.

To evaluate the uterotonic effect of carbetocin compared with oxytocin in emergency cesarean delivery in Iraq. A double-blinded randomized noninferiority single center trial. Three-hundred patients were systematically randomized to intravenous bolus injection of 10 IU oxytocin or 100mcg carbetocin after delivery in a ratio of 2:1. The primary outcome was additional uterotonic use when inadequate uterine tone occur in the first 24h after delivery. Secondary outcomes include the need for blood transfusion, blood pressure and pulse rate changes within an hour of drugs administration. Noninferiority margins for the relative risks outcomes was 4%. Addition uterotonics use was significantly lower in carbetocin group with a risk ratio of 0.36. Carbetocin was superior to oxytocin in reducing the need for additional uterotonic drugs by 12% and non-inferior to oxytocin for blood transfusion 3.5%. Noninferiority was not shown for the outcome of sever blood loss. Miner changes in blood pressure and pulse rate were observed in carbetocin group compared to oxytocin but clinically were not significant. Heat stable carbetocin is effective in reducing additional uterotonics use compared to oxytocin without clinically significant change in blood pressure or pulse rate, therefore, can be a potential alternative in Iraq.

The dilemma of cesarean myomectomy: Is it safe or not?

To evaluate the safety and effectiveness of myomectomy during cesarean section. The data of fifty-four pregnant who underwent cesarean myomectomy and twenty-six pregnant with uterine leiomyoma who had cesarean section without myomectomy between the years of 2017 and 2020 in our tertiary clinic were examined retrospectively. There was no significant difference in terms of maternal age, weeks of gestation, gravida, parity, use of additional uterotonics, type of leiomyoma, size of leiomyoma, cesarean indications, blood transfusion requirement, postoperative fever, preoperative hemoglobin (g/dl), change in hemoglobin (g/dl), preoperative hematocrit (%), change in hematocrit (%), length of hospital stay between the two groups (p˃0.05). While no significant difference was observed according to the location of the leiomyomas between the anterior, fundal and posterior location between the two groups, cervical leiomyomas were significantly higher in the CS group (p˂0.05). This study shows that cesarean myomectomy is a safe procedure in selected cases. It also offers the advantage of avoiding a second operation in patients.

Clinical, Therapeutic and Epidemiology Aspects of Uterine Rupture in the Gyneco-Obstetrics Departement of the Sikasso Hospital

Introduction: Uterine rupture is one of the main causes of maternal and fetal mortality in Mali. Method: This was a descriptive cross-sectional prospective study in the Gynecology - Obstetrics department of the Sikasso hospital from January 01, 2018 to June 30, 2019, i.e. eighteen months. The study covered all cases of childbirth recorded in the Gynecology - Obstetrics Department of Sikasso Hospital during the study period. Results: During these 18 months of study, we recorded 68 cases of uterine rupture out of a total of 4,815 deliveries, ie a frequency of 1.41%. Regarding the mode of admission, 93% were evacuated against 7% who came on their own. For the evacuated patients, 82.4% arrived by ambulance against 13.2% by personal car and 4.4% by public transport. The duration of labor was ≥ 12 hours in 22.1% of cases. Lesions were associated with rupture in 19.1% of cases. The use of uterotonics was responsible for uterine rupture in 54.4% of cases and 7.4% of patients had a generally narrowed pelvis. Simple hysterorrhaphy was performed in 30%, hysterorrhaphy associated with tubal ligation resection in 50% and subtotal hysterectomy in 20% of cases. Lack of schooling, the lack and poor quality of prenatal care have been factors that increase maternal and perinatal morbidity and mortality. The maternal-fetal prognosis was poor with 11.7% maternal deaths and 86.8% perinatal deaths. Conclusion: Better screening of populations at risk, quality ANC, early diagnosis and rapid and adequate management will improve the maternal-fetal prognosis.

Uterine massage to reduce blood loss after vaginal delivery

Postpartum hemorrhage (PPH) is a major cause of maternal mortality and disability. A need for simple, inexpensive techniques to prevent PPH and provide treatment exists, particularly in cases where uterotonics cannot be accessed. Uterine massage is recommended as part of the routine active management of the third stage of labor. This study was conducted to determine the effectiveness of uterine massage after delivery of the placenta in reducing postpartum blood loss. Thus, a randomized controlled trial was conducted in Turkey between March 2018 and September 2018. A total of 176 pregnant women (88 in the control and 88 in the uterine massage groups) were randomly allocated to the two groups: one group receiving sustained uterine massage, while the other comprising the control group. The uterine massage group was administered transabdominal uterine massage, starting immediately after delivery of the placenta and continuing every 15 min for a duration of 2 h until the uterus hardened. The blood loss within 2 h of delivery was recorded. Level of significance was taken as p < 0.05, and the chi-square, t, and Mann–Whitney U tests as well as Spearman’s correlation and linear regression were employed in the analysis of the data. The average amount blood loss within 2 h of the delivery was significantly higher in the control group than in the massage group (X = 170.49 ± 61.46 and X = 186.20 ± 47.59, p < 0.05). A statistically significant difference was present between the uterine massage and control groups in terms of hemoglobin, hematocrit, WBC, and RCB pre-delivery and pre-discharge (first 24 h) values and in the use of additional uterotonics and the amount of blood loss (p < 0.05). The results of the analysis show that postpartum uterine massage has a reducing effect on the amount of PPH.

P.46 Carbetocin vs oxytocin in the prevention of postpartum haemorrhage in caesarean section: A retrospective analysis

Introduction: We introduced carbetocin (100 μ g IV bolus) to our formulary in 2018 to replace oxytocin (5U IV bolus + 40U/4 h IV infusion) as the first line prophylactic uterotonic administered routinely at caesarean delivery for the prevention of postpartum haemorrhage (PPH). Our aims were to address safety incidents reported with oxytocin infusions, facilitate use of uterotonics, reduce use of second-line uterotonics, reduce the risk of PPH and improve maternal experience. We reviewed whether these aims had been met.

Barriers to optimal and appropriate use of uterotonics during active labour and for prevention of postpartum haemorrhage in public health care facilities: An exploratory study in five states of India

ObjectiveThe main objective is to understand the practices regarding use of uterotonics during active labour and for prevention of postpartum haemorrhage and the barriers for its optimal and appropriate use at different levels of health facilities in five states of India. Study DesignMixed methods approach comprising of cross-sectional observational study of existing practices of uterotonics use during labour and early postpartum period for 1479 vaginal deliveries at 56 facilities. Quantitative data was collected using pre-tested proformas filled by on-site observers and qualitative data was collected by in-depth interviews of 125 maternity care providers of the observed facilities. Main outcome measureProviders’ knowledge, attitude and patterns of use of uterotonics during active labour and for prevention of postpartum haemorrhage during childbirth. ResultsOn-site observation and interviews indicated inappropriate choice of uterotonics administered in varied doses for labour management across facilities. Unnecessary augmentation of labour was observed in 44.7% low-risk pregnancies and only 31% women were administered uterotonics in optimal doses for preventing postpartum haemorrhage. Only 46.4% providers in the observed facilities reported to have received maternal and child healthcare training according to the updated guidelines. Lack of supportive supervision for mandated practices among peers emerged as an important barrier for appropriate uterotonics usage in labour. ConclusionThere is an urgent scope of standardizing the institutional health policies regarding administration of uterotonics during labour and for prevention of postpartum haemorrhage. Capacity building of maternity care providers regarding appropriate uterotonics usage is recommended for all levels of health facilities.

Umbilical vein injection for management of retained placenta.

Umbilical vein injection for management of retained placenta.

309 Resolved low-lying placenta and placenta previa is associated with increased risk of postpartum hemorrhage

Second trimester diagnosis of low placentation, defined as low-lying placenta and placenta previa, is a risk factor for postpartum hemorrhage (PPH), but it is unknown if resolved low placentation leads to higher rates of PPH. Initial implantation of the placenta in the lower uterine segment increases vascularity and may cause unsuccessful contraction of the vascular beds at delivery. We hypothesize despite resolution of low placentation, women are at increased risk of PPH at delivery. This retrospective cohort includes women who delivered at Mount Sinai Hospital from 2015-2019, diagnosed with low placentation at mid-trimester anatomy survey with resolution on subsequent ultrasound. Women with normal placentation at mid-trimester anatomy survey were randomly selected for comparison. Demographic and neonatal characteristics were compared. Primary outcome was PPH. Secondary outcomes included blood transfusion, use of additional uterotonic medication or procedures to control bleeding. Outcomes were assessed using a logistic regression model adjusting for age, BMI and race/ethnicity. Resolved low placentation was associated with older age, lower BMI, White race, IVF and a posterior placenta (p<0.01). Patients with resolved low vs. normal placentation had greater odds of PPH (aOR 3.3, 95% CI 1.9-5.7; p<0.01), additional uterotonic use (aOR 2.1, 95% CI 1.5-3.1; p<0.01) and a trend toward increased rates of additional procedures (aOR 3.6, 95% CI 1.2-11.0; p=0.02) and blood transfusion (aOR 2.0, 95% CI 0.9-4.2; p=0.07). Composite neonatal morbidity was increased in the resolved low placentation cohort (9.1% vs. 4.0%, p<0.01), likely driven by higher rates of hypoglycemia (p<0.01). Women with resolved low placentation are at increased risk of PPH compared to those with normal placentation throughout pregnancy. The trend toward higher rates of additional procedures and blood transfusion suggest women with resolved low placentation may be at increased risk of morbidity. This may alter counseling and delivery management and increase preparation for PPH in these patients.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

557 Pregnancy outcomes associated with pragmatic use of aspirin at a single tertiary care center

ACOG recommends low-dose aspirin (ASA) for preeclampsia prophylaxis in high-risk women. Randomized trials have also shown decreased preterm birth (PTB) with ASA use. We evaluated rates of PTB, preeclampsia, and other adverse perinatal outcomes associated with pragmatic antepartum ASA use in high-risk women (Table 1). Retrospective cohort study of all deliveries at a single center (2013-2018). Patients with known fetal anomalies were excluded. Women were categorized by documented antepartum use of ASA (irrespective of dose/initiation GA). The primary outcome was any PTB. Other outcomes included preeclampsia, perinatal outcomes, and bleeding parameters. Outcomes were compared between cohorts (ASA vs no ASA); multivariable generalized estimating equations were used to calculate adjusted odds ratios (95% CI) with the no ASA group as the reference. Of 23,602 women who met inclusion criteria, 3069 (13%) had documented ASA use. Women receiving ASA were more likely to be single, Black, obese, multiparous, have medical comorbidities, and use government insurance (all p<0.01). While women in the ASA group had more PTBs in univariate analysis, after multivariable adjustments, they were less likely to have a PTB (aOR 0.63 [0.52-0.77], specifically PTB <34weeks (aOR 0.55 [0.44-0.68]). There was no difference in preeclampsia, placental abruption, fetal or maternal death between groups. Additionally, neonates of women in the ASA group were significantly less likely to be admitted to the NICU (aOR 0.76 [0.60-0.95]) Of note, there was higher EBL with ASA, but there was no increase in uterotonic use, wound morbidity, or blood transfusion in the ASA group (Table 2). Even outside of strict protocols in randomized trials, pragmatic antepartum ASA use is associated with decreased risk of PTB, specifically early PTB, and neonates requiring NICU admission. While there was no reduction in preeclampsia or other rare outcomes, the benefits we confirm in high-risk women should prompt studies in lower-risk women to evaluate if there is a universal benefit to antepartum ASA use.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Intramuscular oxytocin versus Syntometrine® versus carbetocin for prevention of primary postpartum haemorrhage after vaginal birth: a randomised double-blinded clinical trial of effectiveness, side effects and quality of life.

To compare intramuscular oxytocin, Syntometrine® and carbetocin for prevention of postpartum haemorrhage after vaginal birth. Randomised double-blinded clinical trial. Six hospitals in England. A total of 5929 normotensive women having a singleton vaginal birth. Randomisation when birth was imminent. Primary: use of additional uterotonic agents. Secondary: weighed blood loss, transfusion, manual removal of placenta, adverse effects, quality of life. Participants receiving additional uterotonics: 368 (19.5%) oxytocin, 298 (15.6%) Syntometrine and 364 (19.1%) carbetocin. When pairwise comparisons were made: women receiving carbetocin were significantly more likely to receive additional uterotonics than those receiving Syntometrine (odds ratio [OR] 1.28, 95% CI 1.08-1.51, P=0.004); the difference between carbetocin and oxytocin was non-significant (P=0.78); Participants receiving Syntometrine were significantly less likely to receive additional uterotonics than those receiving oxytocin (OR 0.75, 95% CI 0.65-0.91, P=0.002). Non-inferiority between carbetocin and Syntometrine was not shown. Use of Syntometrine reduced non-drug PPH treatments compared with oxytocin (OR 0.64, 95% CI 0.42-0.97) but not carbetocin (P=0.64). Rates of PPH and blood transfusion were not different. Syntometrine was associated with an increase in maternal adverse effects and reduced ability of the mother to bond with her baby. Non-inferiority of carbetocin to Syntometrine was not shown. Carbetocin is not significantly different to oxytocin for use of additional uterotonics. Use of Syntometrine reduced use of additional uterotonics and need for non-drug PPH treatments compared with oxytocin. Increased maternal adverse effects are a disadvantage of Syntometrine. IM carbetocin does not reduce additional uterotonic use compared with IM Syntometrine or oxytocin.