Preventing postpartum hemorrhage after cesarean delivery: a network meta-analysis of available pharmacologic agents

Guidelines for intraoperative care in cesarean delivery: Enhanced Recovery After Surgery Society recommendations (part 2)-2025 update

Enhanced recovery after cesarean delivery protocols include evidence-based interventions which are designed to improve patient experience and maternal and neonatal outcomes, whilst reducing healthcare related costs. This is the first update to the Enhanced Recovery After Surgery Society guidelines for intraoperative care in cesarean delivery published in 2018. Interventions were selected based on expert consensus. An updated literature search was conducted in September 2024 involving the Embase, PubMed MEDLINE, EBSCO Cumulative Index of Nursing and Allied Health Literature, Scopus, and Web of Science databases. Targeted searches were performed by a medical librarian to identify relevant articles published since the 2018 Enhanced Recovery After Surgery Society guidelines publication, which evaluated each intraoperative enhanced recovery after cesarean delivery intervention, focusing on randomized clinical trials and large observational studies (≥800 patients) to maximize search feasibility and relevance. Following a review of the evidence, consensus was achieved surrounding the quality of evidence and strength of recommendation for each proposed intervention according to the Grading of Recommendations, Assessment, Development, and Evaluation system. The ten recommended enhanced recovery after cesarean delivery intraoperative intervention categories are: (i) use of personal support persons (very low evidence, strong recommendation); (ii) prophylactic antibiotics (moderate to high evidence, strong recommendation); (iii) abdominal and vaginal preparation (moderate evidence, strong recommendation); (iv) antiemetic prophylaxis (low evidence, strong recommendation); (v) prevention of spinal hypotension (low evidence, strong recommendation); (vi) maintenance of normothermia (moderate evidence, strong recommendation); (vii) maintenance of euvolemia (low evidence, strong recommendation), (viii) optimal use of uterotonics (moderate evidence, strong recommendation); (ix) multimodal analgesia (low evidence, strong recommendation); and (x) early initiation of skin-to-skin care (moderate evidence, strong recommendation). The ten recommended intraoperative interventions outlined above represent the best evidence to date and should be considered in the absence of contraindications in patients undergoing cesarean delivery to optimize patient recovery and outcomes.

Carbetocin versus oxytocin in prevention of postpartum hemorrhage after cesarean delivery in high-risk women. A systematic review and meta-analysis

OBJECTIVES

To assess the value of carbetocin in prevention of postpartum hemorrhage (PPH) after Cesarean delivery (CD).

SEARCH STRATEGY

Screening of PubMed, Web Of Science, Scopus, register clinical trials registry and Google scholar from inception to December 2023. The keywords used included postpartum hemorrhage, intraoperative blood loss, postoperative blood loss, Cesarean delivery and their MeSH terms.

SELECTION CRITERIA

All RCTs that compared carbetocin to oxytocin in women undergoing CD with risk factor for PPH. Fourteen studies including 3068 participants. Thirteen were written in English and one in Polish.

DATA COLLECTION AND ANALYSIS

The extracted data included location of the trial, number of centers involved in recruitment, the number of participants and their characteristics, details of the study groups and dose time and route of intervention and its comparator, primary and secondary outcome parameters and trial registration number and timing in relation to patients recruitment. The evaluated outcomes parameters included intraoperative and 1st 24 h post-operative blood loss, PPH, the hemoglobin changes after the procedure, the need for any additional uterotonic agents, surgical interventions or blood transfusion and drugs side effects.

MAIN RESULTS

Blood loss during the 1st 24 h after CD was evaluated in 11 studies with 2497 participants and revealed a mean difference (MD) of -111.07 with 95% CI of [-189.34 and -32.80 (P = 0.005, I2 97%). The hemoglobin changes after the operation was evaluated in 8 studies with 1646 participants and revealed a MD of -0.46 with 95% CI of -0.14 and -0.79 (P = 0.03, I2 96%). The incidence of PPH > 500 ml was reported in 8 studies with 1787 participants and revealed an Odd Ratio (OR) of 0.52 with 95%CI of [0.36, 0.77] (P < 0.001, I2 0%). The need for additional uterotonic agents was evaluated in 12 studies with 2663 participants and revealed an OR of 0.17 with 95% CI of 0.07 and 0.37 (P < 0.001, I2 88%). The need for blood transfusion was evaluated in 10 studies with 2439 participants and revealed an OR of 0.27 with 95% CI of 0.12 and 0.57 (P < 0.001, I2 20%). The need for additional interventions was evaluated in 3 studies with 1311 participants and revealed an OR of 0.67 with 95% CI of 0.28 and 1.60 (P = 0.37, I2 59%).

CONCLUSION

Carbetocin decreased the blood loss during the 1st 24 h after CD, post-operative hemoglobin drop, PPH the need for additional uterotonic agents and blood transfusion when compared to oxytocin.

Reoperation following Cesarean Birth: An Analysis of Incidence, Indications, and Procedures Using a National Surgical Database

This study aimed to determine the incidence of reoperation after uncomplicated cesarean birth, describe the types of procedures and indications for reoperation, and identify risk factors associated with reoperation using a national surgical database.A retrospective cross-sectional study was conducted using the American College of Surgeons National Surgical Quality Improvement Program database, encompassing data from January 1, 2019, to December 31, 2021. A total of 43,492 patients who underwent cesarean birth were included. Patients who underwent concurrent nongynecologic procedures or hysterectomies were excluded. The primary outcomes measured were the incidence of unplanned reoperation within 30 days of cesarean birth, types of reoperative procedures, indications for reoperation, and associated risk factors. Statistical analyses included Student's t-test, Wilcoxon rank-sum test, chi-squared test, and multivariable logistic regression.Out of 43,492 cesarean deliveries, 397 (0.9%) required unplanned reoperation. Significant risk factors for reoperation included smoking (adjusted odds ratio [aOR]: 1.96, 95% confidence interval [CI]: 1.49-1.56), hypertension (aOR: 1.83, 95% CI: 1.27-2.62), bleeding disorders (aOR: 2.11, 95% CI: 1.15-3.89), American Society of Anesthesiologists (ASA) class > 3 (aOR: 2.23, 95% CI: 1.29-3.84), and concurrent myomectomy (aOR: 4.39, 95% CI: 1.06-18.2). The most common indications for reoperation were postpartum hemorrhage (47%), wound disruption or infection (18%), and hematoma or hemoperitoneum (14%). The most frequently performed reoperative procedures were exploratory laparotomy without hysterectomy (27%), uterine curettage (23%), and wound debridement or drainage (22%).Reoperation following cesarean birth is a relatively uncommon but significant event, occurring in 0.9% of cases. Key risk factors include smoking, hypertension, bleeding disorders, ASA class > 3, and concurrent myomectomy. This study provides comprehensive data on the clinical characteristics and indications for reoperation following cesarean birth in a diverse, multi-institutional US cohort. The findings highlight the need for enhanced perioperative monitoring and targeted interventions for high-risk patients to improve maternal outcomes. · In this retrospective cross-sectional study of 43,492 cesarean deliveries, the incidence of unplanned reoperation was found to be 0.9%.. · Significant risk factors for reoperation included smoking, hypertension, bleeding disorders, American Society of Anesthesiologists (ASA) class > 3, and concurrent myomectomy at the time of cesarean birth.. · The most common indications for reoperation were postpartum hemorrhage, wound disruption or infection, and hematoma or hemoperitoneum.. · The most common reoperative procedures were exploratory laparotomy without hysterectomy, uterine curettage, and wound debridement or drainage..

Effect of phenylephrine infusion on postpartum blood loss after cesarean delivery: a placebo-controlled, randomized clinical trial

BACKGROUND

Preclinical studies have documented the role of alpha-adrenergic agonists in myometrial contraction. Phenylephrine is frequently used to prevent and treat post-spinal hypotension during cesarean delivery. We hypothesized phenylephrine would reduce postpartum blood loss due to alpha-1 receptor-mediated uterine and vascular smooth muscle contraction.

OBJECTIVES

This translational study aimed to evaluate the role of phenylephrine in reducing postpartum blood loss due to alpha-1 receptor mediated uterine and vascular smooth muscle contraction.

METHODS

This was a prospective, randomized, placebo-controlled, blinded, pilot, clinical trial. Low-risk parturients undergoing cesarean delivery under spinal anesthesia were recruited in this study. The women were randomized to receive phenylephrine or placebo (normal saline) infusion. Each mL of phenylephrine contained 60 micrograms. The study drug began simultaneously with the start of spinal anesthesia, and was stopped at the end of surgery. The infusion rate was started at 50 mcg/min and was titrated to maintain the systolic blood pressure between 80% and 120 % of baseline. The primary outcome measure was postpartum blood loss till 24 hours postpartum, and it was assessed using a surgical swab weighing technique added to suction canister blood contents. The secondary outcomes were incidence of hypertension, hypotension, Apgar score, cord blood gas analysis and neonatal intensive care unit admission (NICU) admission.

RESULTS

One hundred six women received study drugs and were eligible for final analysis. The demographic data, obstetric profiles, and medications were comparable. In the phenylephrine group, the mean postpartum blood loss (median [interquartile range]) was significantly lower ([420 {349-502} vs 494 {397-600} mL; p=.009]). Additionally, a significantly lower number of women had >500 mL of blood loss in the phenylephrine group (26.4% vs 47.1%; p=.02). Furthermore, more women in the control arm needed blood transfusion (37.7% vs 16.9%; p=.01). Six women each had bradycardia and hypertension in the phenylephrine group. NICU admission, Apgar score, and umbilical artery PH were comparable.

CONCLUSION

Continuous phenylephrine infusion led to a statistically significant but clinically inconsequential reduction in postpartum blood loss in low-risk parturients undergoing cesarean delivery under spinal anesthesia.

Implementation of an oxytocin bolus protocol for cesarean delivery at a Texas level IV maternal center: a single-center retrospective study

Objective

We hypothesized that patients who underwent cesarean delivery and received oxytocin boluses followed by an infusion would have a lower incidence of secondary uterotonic administration compared to patients who had an oxytocin infusion without boluses.

Methods

Patients who had cesarean deliveries at our hospital from September 1, 2021 through December 31, 2021 and from September 1, 2022 through December 31, 2022, corresponding to the oxytocin bolus and oxytocin infusion cohorts, respectively, were included. Patient demographic, physical, and clinical characteristic data were collected by a study investigator. Intramyometrial oxytocin, intramuscular methylergonovine, intramuscular carboprost tromethamine, and sublingual misoprostol were defined as secondary uterotonics.

Results

There were 266 and 283 patients in the oxytocin bolus and oxytocin infusion cohorts, respectively. The odds ratio for patients in the oxytocin bolus cohort receiving a secondary uterotonic was 0.25 (95% confidence interval 0.16, 0.41; P < 0.01).

Conclusion

Patients in the oxytocin bolus cohort were approximately 75% less likely to receive a secondary uterotonic agent compared to patients in the oxytocin infusion cohort. A limitation of this study was that we defined intramyometrial administration of oxytocin as a secondary uterotonic, and our results may not be generalizable to hospitals that do not use intramyometrial oxytocin.

Evidence-based cesarean delivery: intraoperative management from skin incision until placental delivery (Part 8)

The goal of standardizing the technique of the routine, uncomplicated cesarean delivery (CD) is to decrease maternal morbidity while optimizing neonatal outcomes. During the procedure, a family-oriented CD is recommended. The low transverse cesarean skin incision (created with either scalpel or diathermy) is preferred with either the Joel-Cohen or Pfannenstiel methods being acceptable. For patients with obesity (BMI > 35kg/m2), surgeons may also elect either the Cohen (including supraumbilical) or Pfannenstiel (infraumbilical or infrapannus) technique as there are similar outcomes, however the Cohen approach has been associated with lower Apgar scores and decreased surgeon satisfaction related to the feasibility of the incision. Diathermy may be preferred for subcutaneous tissue opening as compared to sharp dissection. Though postoperative recovery outcomes may be improved with an extraperitoneal approach to CD, a transperitoneal technique is the current standard of care. The initial fascial incision is made sharply, further extension can be carried out either sharply or bluntly. Inferior dissection of the rectus muscle can be omitted and routine cutting of the muscles is not needed. If necessary, a Maylard modification is acceptable. Though based on limited data, blunt peritoneal entry and extension should be considered. With regards to uterine entry and delivery: bladder flap creation should be omitted, a low transverse hysterotomy is recommended with blunt cephalo-caudad expansion, and manual delivery of the fetal head should be performed. If the fetal head is impacted, then reverse breech extraction may be preferred for maternal benefit. Delayed cord clamping is recommended for at least 30 seconds and up to 120 seconds (recommended for preterm deliveries) with either routine or selected umbilical cord gas collection being considered. In areas where available, carbetocin is more effective in prevention of postpartum hemorrhage (PPH). Otherwise, the combination of oxytocin plus either misoprostol or methergine should be utilized. There is insufficient evidence regarding the effectiveness of uterine massage for PPH prevention. Spontaneous removal of the placenta with gentle cord traction is recommended.

Effectiveness of Remimazolam on Preventing Adverse Reactions Caused by Carboprost Tromethamine During Cesarean Section

PURPOSE

To evaluate the effectiveness of remimazolam in preventing adverse reactions triggered by carboprost tromethamine during cesarean section procedures.

METHODS

A total of 200 parturients scheduled for cesarean sections at risk of postpartum hemorrhage in our hospital from October 2022 to July 2023 were included. The participants were assigned via random number table method to either a study group or a control group, resulting in 100 cases in each. All parturients received combined spinal and epidural anesthesia (CSEA) during cesarean section, followed by administration of carboprost tromethamine (250 µg) for preventing postpartum hemorrhage after childbirth. CSEA was performed with 1.8 to 2 mL of 0.5% bupivacaine and 7 to 10 mL of 2% lidocaine. The study group was given remimazolam via intravenous infusion at a rate of 0.3 mg/kg/h commencing at 1 minute prior to CSEA and concluding with a final dosage adjustment 20 minutes preceding the end of surgery, while the control group was given the same volume of saline within this time frame. Primary outcome measures were adverse reactions and sedative effects of the parturients.

FINDINGS

Nausea and vomiting were the only adverse reactions that exhibited significant differences between groups. The study group reported significantly fewer cases (32 cases) of nausea and vomiting when compared to the 48 cases observed in the control group. Moreover, the use of remimazolam appeared to alleviate the severity of nausea and vomiting, as evidenced by the significantly lower incidence of Grade III event and the higher risk of Grade I event in comparison with the control group (P < 0.05). The Apgar scores of newborns at birth and 5 minutes after birth were compared, and no statistically significant difference was found (P > 0.05). Parturients receiving remimazolam exhibited better effective sedation outcomes and were more satisfied with the treatment when compared with controls (P < 0.05). There were no significant differences in postpartum bleeding volume at 2 and 12 hours postpartum, as well as in the duration of postpartum bleeding between the two groups (P > 0.05).

IMPLICATIONS

Intravenous administration of remimazolam effectively prevents adverse reactions induced by carboprost tromethamine during cesarean section performed under CSEA, thereby improving sedative effects.

Situations in Which Oxytocin Was Administrated by Paramedics in Out-of-Hospital Births: A Retrospective Analysis over Six Years in the Polish Population

Introduction: Postpartum haemorrhage (PPH) is a leading cause of maternal mortality worldwide, particularly in low- and middle-income countries, complicating 1% to 10% of deliveries. Despite improvement in prevention and management, variations in PPH definitions and measurement methods contribute to challenges in accurately assessing its incidence, with up to 90% of PPH-related deaths in high-income countries deemed avoidable through timely intervention. Oxytocin is the primary drug administered during labour or miscarriage, causing an increase in uterine muscle tone, which reduces bleeding and the risk of complications. The aim of the study was to assess the rate of oxytocin use by paramedics for out-of-hospital births in Poland and to verify adherence to WHO-recommended protocols for preventing postpartum haemorrhage in emergency prehospital settings. Methods: We conducted a cross-sectional study using data from the Polish Central System for Emergency Medical Services Missions Monitoring covering all EMS interventions nationwide from 2018 to 2023. The study included cases where oxytocin was administered during EMS interventions for pregnant women, identified through ICD-10 codes (O30-O92), with 62 verified cases meeting the inclusion criteria. Results: Over 6 years, oxytocin was administered in 62 cases when paramedics responded to emergencies involving pregnant women. The mean age of the patients to whom the oxytocin was administered was 29.48 years (SD = 6.25) and ranged from 15 to 43 years. Conclusions: Oxytocin is rarely administered by EMS teams at the prehospital stage. Oxytocin should be considered for incorporation into the set of medications that EMS teams can administer in prehospital settings. There is a need to train EMS teams in the management of pregnancy-related emergencies in accordance with the current medical guidelines.

Intramyometrial and intravenous oxytocin compared to intravenous carbetocin for prevention of postpartum hemorrhage in elective cesarean section-A quasi-randomized controlled phase IV non-inferiority interventional trial

INTRODUCTION

Our objective was to assess non-inferiority of the unique approach used in our institution of combined 10 IU IM (intramyometrial) and 10 IU IV (intravenous) oxytocin to carbetocin IV in preventing severe postpartum blood loss in elective cesarean sections. The design was a prospective controlled phase IV non-inferiority interventional trial. The setting was a tertiary center at University Hospital, Zurich, Switzerland.

MATERIAL AND METHODS

The population consisted of 550 women undergoing elective cesarean section after 36 completed weeks of gestation at low risk for postpartum hemorrhage (PPH). Participants were assigned to either combined oxytocin regimen (10 IU IM and 10 IU IV) or carbetocin (100 μg IV). Non-inferiority for oxytocin for severe PPH was assessed with a 0.05 margin using the Newcombe-Wilson score method. The main outcome measures were severe postpartum blood loss defined as delta hemoglobin (∆Hb, Hb prepartum-Hb postpartum) ≥30 g/L.

RESULTS

Non-inferiority of combined oxytocin (IM/IV) in preventing severe postpartum blood loss was not shown (17 women in the oxytocin group vs. 7 in the carbetocin group). The number needed to treat when using carbetocin was 28. The risk difference for ∆Hb ≥30 g/L was 0.04 (oxytocin 0.06 vs. 0.03), 95% confidence interval (CI) (0.00-0.08). No significant difference was observed for ∆Hb (median 12 [IQR 7.0-19.0] vs. 11 [5.0-17.0], p = 0.07), estimated blood loss (median 500 [IQR 400-600] vs. 500 [400-575], p = 0.38), or the PPH rate defined as estimated blood loss ≥1000 mL (12[4.5] vs. 5 [2.0], risk difference 0.03, 95% CI (-0.01 to 0.06), p = 0.16). More additional uterotonics were administered in the oxytocin group compared to the carbetocin group (15.2% vs. 5.9%, p = 0.001). Total case costs were non-significantly different in the oxytocin group (US $ 10 146 vs. 9621, mean difference 471.4, CI (-476.5 to 1419.3), p = 0.33).

CONCLUSIONS

Combined (IM/IV) oxytocin is not non-inferior to carbetocin regarding severe postpartum blood loss defined as postpartum Hb decrease ≥30 g/L in elective cesarean sections. We recommend carbetocin for use in clinical practice for elective cesarean sections.

Effect of administration routes of oxytocin on hemoglobin in neonates with delayed umbilical cord clamping: a multi-centre randomized controlled clinical trial

PURPOSE

To evaluate the effect of intravenous infusion versus intramyometrial injection of oxytocin on hemoglobin levels in neonates with delayed umbilical cord clamping during cesarean section.

METHODS

The multi-centre randomized controlled trial was performed at three hospitals from February to June 2023. Women with term singleton gestations scheduled for cesarean delivery were allocated to receive an intravenous infusion of 10 units of oxytocin or a myometrial injection of 10 units of oxytocin during the surgery. The primary outcome was neonatal hemoglobin at 48 to 96 h after birth. Secondary outcomes were side-effects of oxytocin, postpartum haemorrhage, phototherapy for jaundice, feeding at 1 month, maternal and neonatal morbidity and re-admissions.

RESULTS

A total of 360 women were randomized (180 women in each group). The mean neonatal hemoglobin did not show a significant difference between the intravenous infusion group (194.3 ± 21.7 g/L) and the intramyometrial groups (195.2 ± 24.3 g/L) (p = 0.715). Secondary neonatal outcomes, involving phototherapy for jaundice, feeding at 1 month and neonatal intensive care unit admission were similar between the two groups. The maternal outcomes did not differ significantly between the two groups, except for a 200 mL higher intraoperative infusion volume observed in the intravenous group compared to the intramyometrial group.

CONCLUSION

Among women undergoing elective cesarean delivery of term singleton pregnancies, there was no significant difference in neonatal hemoglobin at 48 to 96 h after birth between infants with delayed cord clamping, whether the oxytocin was administrated by intravenous infusion or intramyometrial injection.

TRIAL REGISTRATION

Chinese Clinical trial registry: ChiCTR2300067953 (1 February 2023).

Prostaglandin Injection for Myoma Expulsion (PRIME): Case Series of a Novel Approach to Hysteroscopic Resection of FIGO Type 2 Myomas

STUDY OBJECTIVE

To evaluate the use of dilute carboprost tromethamine injection at the endometrium/myoma junction during hysteroscopy to facilitate myoma expulsion and removal in a single procedure.

DESIGN

Case series.

SETTING

Single high-volume academic medical center.

PATIENTS

Seven patients aged 32 to 51 years old with FIGO type 2 uterine myomas and symptoms of abnormal uterine bleeding or infertility undergoing hysteroscopic resection with a morcellation device from November 2022 to July 2023.

INTERVENTION

Dilute injection of carboprost tromethamine (10 µg/mL) at time of hysteroscopic myomectomy.

MEASUREMENTS AND MAIN RESULTS

The main outcome measure was ability to complete the hysteroscopic myomectomy in a single procedure using a hysteroscopic morcellator. Secondary outcomes included total operative time, fluid deficit, and postoperative pharmacologic side effects and/or surgical complications. Among our 7 patients, all had successful single procedure complete resections of myomas ranging from 0.9 to 4.6 cm in maximal diameter. Average operative time was 30 minutes, and average fluid deficit was approximately 839 mL. The carboprost dosages used ranged from 30 to 180 µg. One patient experienced prolonged postoperative nausea and vomiting that resolved with antiemetics. One patient experienced postoperative endometritis that improved with antibiotics.

CONCLUSION

In this pilot study, injection of dilute carboprost intraoperatively facilitated one-step hysteroscopic myomectomy of FIGO 2 myomas, via enhanced extrusion of the intramural portion of the fibroid into the uterine cavity, with both short operative times and acceptable fluid deficits.

Preventing postpartum hemorrhage: A network meta-analysis on routes of administration of uterotonics

1.

OBJECTIVE

To perform a network meta-analysis to specify the route of administration that maximises the effectiveness of each of the available prophylactic uterotonics without increasing the risk for side effects. 2.

DATA SOURCES

Literature searches on 12th September 2022 included: CENTRAL, MEDLINE, Embase, CINAHL, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform. The reference lists of the retrieved study records were also searched. 3.

STUDY ELIGIBILITY CRITERIA

Population: Randomized controlled trials involving women in the third stage of labour after a vaginal or caesarean delivery in hospital or community settings.

INTERVENTIONS

Systemically administered prophylactic uterotonics of any route and dose for primary postpartum hemorrhage prevention. Comparison: Any other prophylactic uterotonic, or a different route or dose of a given uterotonic, or placebo, or no treatment. Outcomes (primary): postpartum hemorrhage ≥ 500 mL and ≥ 1000 mL. 4.

STUDY APPRAISAL AND SYNTHESIS METHODS

Risk of bias and trustworthiness assessments were performed, according to Cochrane's guidance. Direct, indirect and network meta-analyses were conducted, and results were summarized either as risk ratio or mean difference with 95% confidence intervals for dichotomous and continuous outcomes, respectively. The certainty of generated evidence was assessed according to the GRADE approach. Cumulative probabilities were calculated and the surface under the cumulative ranking curve was used to create a ranking of the available drugs. 5.

RESULTS

One hundred eighty-one studies involving 122,867 randomised women were included. Most studies were conducted in hospital settings in lower-middle income countries and involved women delivering vaginally. When compared with intramuscular oxytocin, carbetocin (RR 0.58, 95 % CI 0.40-0.84) and oxytocin (RR 0.75, 95 % CI 0.59-0.97) by an intravenous bolus, and intramuscular ergometrine plus oxytocin combination (RR 0.71, 95 % CI 0.56-0.91) are probably more effective in preventing primary postpartum hemorrhage. Intramuscularly administered oxytocin and carbetocin by an intravenous bolus have a favourable side effects profile. 6.

CONCLUSIONS

Generated evidence was generally moderate and global inconsistency was low. Carbetocin and oxytocin by an intravenous bolus, and intramuscular ergometrine plus oxytocin combination are probably the top uterotonics for primary postpartum hemorrhage prevention. Large scale studies exploring different routes of administration for available prophylactic uterotonics, and women's views should be conducted.

Uterine packing with chitosan-covered tamponade to treat postpartum hemorrhage

Postpartum hemorrhage remains a major cause of maternal mortality and morbidity worldwide with higher rates found in resource-challenged countries. Conventional use of uterotonics such as oxytocin, prostaglandins, and medications to support coagulation, such as fibrinogen and tranexamic acid, are helpful but may not be sufficient to arrest life-threatening postpartum hemorrhage. Severe postpartum hemorrhage leads to an increased need for blood transfusions and the use of invasive techniques, such as intrauterine balloon tamponade, compression sutures, and arterial ligation, as advanced steps in the management cascade. In extreme cases where hemorrhage is resistant to these therapies, a hysterectomy may be necessary to avoid possible maternal death. Uterine packing with a chitosan-covered tamponade is an emerging tool in the armamentarium of the obstetrical team, especially when resources for advance surgical and other invasive options may be limited. Modified chitosan-impregnated gauze was originally described in the management of acute hemorrhage in the field of military medicine, combining the physiological antihemorrhaging effect of modified chitosan with a compression tamponade for the acute treatment of wound bleeding. The first described use in obstetrics was in 2012, showing that the chitosan-covered tamponade is an effective intervention to arrest ongoing therapy-resistant postpartum hemorrhage. Further studies showed a reduction in hysterectomies and blood transfusions. The method is, however, underreported and is not yet an established method used worldwide. To demonstrate the step-by-step application of the intrauterine chitosan-covered tamponade in the management of therapy-resistant postpartum hemorrhage, we have produced a teaching video to illustrate the important steps and techniques to optimize the effectiveness and safety of this novel intervention.

Third stage of labor: evidence-based practice for prevention of adverse maternal and neonatal outcomes

The third stage of labor is defined as the time period between delivery of the fetus through delivery of the placenta. During a normal third stage, uterine contractions lead to separation and expulsion of the placenta from the uterus. Postpartum hemorrhage is a relatively common complication of the third stage of labor. Strategies have been studied to mitigate the risk of postpartum hemorrhage, leading to the widespread implementation of active management of the third stage of labor. Initially, active management of the third stage of labor consisted of a bundle of interventions including administration of a uterotonic agent, early cord clamping, controlled cord traction, and external uterine massage. However, the effectiveness of these interventions as a bundle has been questioned, leading to abandonment of some components in recent years. Despite this, upon review of selected international guidelines, we found that the term "active management of the third stage of labor" was still used, but recommendations for and against individual interventions were variable and not necessarily supported by current evidence. In this review, we: (1) examine the physiology of the third stage of labor, (2) present evidence related to interventions that prevent postpartum hemorrhage and promote maternal and neonatal health, (3) review current global guidelines and recommendations for practice, and (4) propose future areas of investigation. The interventions in this review include pharmacologic agents to prevent postpartum hemorrhage, cord clamping, cord milking, cord traction, cord drainage, early skin-to-skin contact, and nipple stimulation. Treatment of complications of the third stage of labor is outside of the scope of this review. We conclude that current evidence supports the use of effective pharmacologic postpartum hemorrhage prophylaxis, delayed cord clamping, early skin-to-skin contact, and controlled cord traction at delivery when feasible. The most effective uterotonic regimens for preventing postpartum hemorrhage after vaginal delivery include oxytocin plus ergometrine; oxytocin plus misoprostol; or carbetocin. After cesarean delivery, carbetocin or oxytocin as a bolus are the most effective regimens. There is inconsistent evidence regarding the use of tranexamic acid in addition to a uterotonic compared with a uterotonic alone for postpartum hemorrhage prevention after all deliveries. Because of differences in patient comorbidities, costs, and availability of resources and staff, decisions to use specific prevention strategies are dependent on patient- and system-level factors. We recommend that the term "active management of the third stage of labor" as a combined intervention no longer be used. Instead, we recommend that "third stage care" be adopted, which promotes the implementation of evidence-based interventions that incorporate practices that are safe and beneficial for both the woman and neonate.

Side-effects of intravenously versus intramuscularly oxytocin for postpartum hemorrhage: a systematic review and meta-analysis of randomized controlled trials

Background: Oxytocin is the gold standard uterotonic agent for prevention of postpartum hemorrhage. However, there is no consensus with clear evidence about the side-effects of oxytocin administered intravenously or intramuscularly for management of the third stage of labor. We conducted a systematic review and meta-analysis of randomized controlled trials to evaluate the side-effects of intravenously or intramuscularly oxytocin for preventing postpartum hemorrhage in the third stage of labor. Methods: Six representative databases were searched from the inception to July 2023. Randomized controlled trials which explored the intravenously and intramuscularly oxytocin and provided at least one side-effect were included. Statistical analysis included random or fixed-effect meta-analyses using relative risk. Results: Nine studies included, involving 8,295 participants. Ten types of side-effects were reported. There was no statistical difference in hypotension (RR = 1.01, 95%CI = 0.88-1.15), anemia (0.98, 0.83-1.15), tachycardia (0.90, 0.69-1.17), shivering (0.90, 0.69-1.17), headache (0.86, 0.31-2.37), nausea (0.70, 0.20-2.42), vomiting (0.97, 0.26-3.58), uvular edema (0.82, 0.23-2.91), diarrhea (0.97, 0.26-3.58), and fever (0.97, 0.26-3.58) between intravenously or intramuscularly groups. Conclusion: There are no significant differences of side-effects between intravenously and intramuscularly administration of oxytocin for preventing postpartum hemorrhage in the third labor. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=407571.

Association of adverse outcomes with three-tiered risk assessment tool for obstetrical hemorrhage

BACKGROUND

Guidelines promote stratification for the risk for postpartum hemorrhage among parturients, although the evidence for the associated differential morbidity among the groups remains inconsistent among published reports.

OBJECTIVE

Using the California Maternal Quality Care Collaborative schema modified by the American College of Obstetrics and Gynecology, we compared the composite maternal hemorrhagic outcome and the composite neonatal adverse outcome among singletons who were categorized after delivery by the researchers as low-, medium-, or high-risk for postpartum hemorrhage. We hypothesized that the composite outcomes would be significantly different among the individuals in the different 3-tiered categories.

STUDY DESIGN

This was a retrospective cohort study of all singleton parturients with a gestational age of at least 14 weeks who delivered at a single site within 1 year. The composite maternal hemorrhagic outcome included any of the following: estimated blood loss ≥1000 mL, use of uterotonics (excluding prophylactic oxytocin) or Bakri balloon, surgical management of postpartum hemorrhage, blood transfusion, hysterectomy, thromboembolism, admission to the intensive care unit, or maternal death. The composite neonatal adverse outcome included Apgar score <7 at 5 minutes, birth injury, bronchopulmonary dysplasia, intraventricular hemorrhage, neonatal seizure, sepsis, ventilation > 6 hrs., brachial plexus palsy, hypoxic-ischemic encephalopathy, or neonatal death. Multivariable Poisson regression models with robust error variance were used to estimate the adjusted relative risks with 95% confidence intervals.

RESULTS

Of the 4544 deliveries in the study period, 4404 (96.7%) met the inclusion criteria, and among them, 1745 (39.6%) were categorized as low, 1376 (31.2%) as medium, and 1283 (29.1%) as high risk. Overall, 941 (21.4%) participants experienced the composite maternal hemorrhagic outcome with 285 (16.4%) of those being in the low-risk group, 319 (23.2%) in the medium-risk group, and 337 (26.3%) in the high-risk group. Among all parturients, 95.7% in the low-, 89.4% in the medium-, and 85.3% in the high-risk group neither had an estimated blood loss or a quantified blood loss ≥1000 mL nor were transfused. After multivariable adjustment and when compared with the low-risk group, there was a significantly higher risk for the composite maternal hemorrhagic outcome in the medium-risk group (adjusted relative risk, 1.23; 95% confidence interval, 1.05-1.43) and in the high-risk group (adjusted relative risk, 1.51; 95% confidence interval, 1.31-1.75). Overall, 366 newborns (8.4%) developed the composite neonatal adverse outcome with 76 (4.2%) in of those being in the low-risk group, 153 (11.3%) in the medium-risk group, and 140 (11.1%) in the high-risk group. After multivariable adjustment and when compared with the low-risk group, there were no significant differences in the composite neonatal adverse outcome in the medium- (adjusted relative risk, 1.27; 95% confidence interval, 0.97-1.68) or the high-risk group (adjusted relative risk, 1.29; 95% confidence interval, 0.98-1.68).

CONCLUSION

Although 8 of 10 parturients categorized as high risk neither had blood loss ≥1000 mL nor underwent transfusion, the risk stratification provides information regarding the composite maternal hemorrhagic outcome.

Indications, risk factors, and outcomes of emergency peripartum hysterectomy: A 7-year retrospective study at a tertiary center in Turkey

Objective

To determine the incidence, indications, the risk factors, complications, maternal morbidity and mortality of emergency peripartum hysterectomy (EPH), and perinatal outcomes at a tertiary hospital, Turkey.

Methods

We analyzed 71 cases of EPH from 2012 to 2019 at a tertiary hospital in a retrospective study. There were 142 control patients.

Results

There were 71 EPH out of 69,504 deliveries, for an overall incidence of 1.02 per 1000 births. The main indication for peripartum hysterectomy was abnormal placentation (67.6%), followed by uterine atony (28.1%), and uterine rupture (4.2%). Cesarean section (CS) and previous CS are major risk indicators for EPH. Other risk indicators are advanced maternal age (≥ 35 years) and multiparity. All patients with abnormal placentation had a previous CS. 93% of EPH were performed during and/or after CS, and 7% after vaginal delivery. 69% of EPH were made in total and 31% were subtotal. The three most common maternal morbidity included: wound infection and febrile morbidity (26.7%), bladder injury (16.9%), and disseminated intravascular coagulopathy (11.2%). There were no maternal deaths but perinatal mortality was 4%.

Conclusion

The most common indication for EPH was abnormal placentation. Also, CS and previous CS are major risk factors of EPH. Other risk factors for EPH are advanced maternal age (≥ 35 years) and multiparity. Moreover, all unnecessary CS should be avoided.

Maternal plasma cytokines and the subsequent risk of uterine atony and postpartum hemorrhage

OBJECTIVES

To determine whether the maternal plasma concentrations of cytokines are higher in pregnant women with postpartum hemorrhage (PPH) compared to pregnant women without PPH.

METHODS

A retrospective case-control study included 36 women with PPH and 72 matched controls. Cases and controls were matched for gestational age at delivery, labor status, delivery route, parity, and year of sample collection. Maternal plasma samples were collected up to 3 days prior to delivery. Comparison of the plasma concentrations of 29 cytokines was performed by using linear mixed-effects models and included adjustment for covariates and multiple testing. A false discovery rate adjusted p-value <0.1 was used to infer significance. Random forest models with evaluation by leave-one-out and 9-fold cross-validation were used to assess the combined value of the proteins in predicting PPH.

RESULTS

Concentrations of interleukin (IL)-16, IL-6, IL-12/IL-23p40, monocyte chemotactic protein 1 (MCP-1), and IL-1β were significantly higher in PPH than in the control group. This difference remained significant after adjustment for maternal age, clinical chorioamnionitis, and preeclampsia. Multi-protein random forest proteomics models had moderate cross-validated accuracy for prediction of PPH [area under the ROC curve, 0.69 (0.58-0.81) by leave-one-out cross validation and 0.73 (0.65-0.81) by 9-fold cross-validation], and the inclusion of clinical and demographic information did not increase the prediction performance.

CONCLUSIONS

Pregnant women with severe PPH had higher median maternal plasma concentrations of IL-16, IL-6, IL-12/IL-23p40, MCP-1, and IL-1β than patients without PPH. These cytokines could serve as biomarkers or their pathways may be therapeutic targets.

Preventing postpartum hemorrhage with combined therapy rather than oxytocin alone

Postpartum hemorrhage is the leading cause of maternal morbidity and mortality worldwide, with uterine atony estimated to account for 70% to 80% of cases, thereby remaining the single most common cause. Pharmacotherapy remains the first-line preventative therapy for postpartum hemorrhage. These therapies may be single (oxytocin, carbetocin, methylergonovine, ergometrine, misoprostol, prostaglandin analogs, or tranexamic acid) or combination therapies, acting in an additive, infra-additive, or synergistic fashion to prevent postpartum hemorrhage. Evidence is strong for the use of oxytocin, the first-line uterotonic agent in the United States for prevention of postpartum hemorrhage. Although carbetocin, a long-acting analog of oxytocin, is not yet available for use in the United States, it is likely the most effective single pharmacologic therapy for prevention of postpartum hemorrhage and need for additional uterotonics. Use of second-line uterotonics such as methylergonovine, misoprostol, and carboprost in combination with oxytocin has an additive or synergistic effect and a greater risk reduction for postpartum hemorrhage prevention compared with oxytocin alone. Therefore, combined therapy rather than oxytocin alone should be advised for preventing postpartum hemorrhage. Tranexamic acid has been found to be both effective and safe for decreasing maternal mortality in women with postpartum hemorrhage, and prophylactic use of tranexamic acid may decrease the need for packed red blood cell transfusions and/or uterotonics. The WOMAN-2 Trial, designed to assess if tranexamic acid prevents postpartum hemorrhage in women with moderate to severe anemia undergoing vaginal delivery, is currently recruiting participants. The additive, infra-additive, or synergistic action of oxytocin in combination with other second-line therapies deserves further study.

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.