Active Management of the Third Stage of Labour: Prevention and Treatment of Postpartum Hemorrhage

Leduc, Dean; Senikas, Vyta; Lalonde, André B.

doi:10.1016/s1701-2163(16)34329-8

Cited by 320 publications

(208 citation statements)

References 34 publications

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“…10 Furthermore, this dose is at least eight times higher than the ED 90 for carbetocin required in non-labouring women at full term undergoing elective CD (14.8 lg; 95% CI: 13.7 to 15.8).…”

Section: Discussionmentioning

confidence: 88%

“…9 The use of carbetocin as the first-line uterotonic drug at elective Cesarean delivery (CD) was introduced into the Society of Obstetricians and Gynaecologists of Canada (SOGC) 2009 Clinical Practice Guidelines. 10 Instead of Carbetocin at Cesarean delivery for labour arrest 867 administering a continuous oxytocin infusion to prevent PPH, they recommend administering carbetocin 100 lg as an intravenous bolus over one minute. As the current evidence for this recommended dose is weak, 11 our group conducted a series of dose-finding studies of carbetocin in women undergoing elective CD.…”

Section: Résumémentioning

confidence: 99%

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Carbetocin at Cesarean delivery for labour arrest: a sequential allocation trial to determine the effective dose

Nguyen-Lu

Carvalho

Farine

et al. 2015

Can J Anesth/J Can Anesth

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Purpose The aim of this study was to estimate the effective dose 90% (ED 90 ) of carbetocin to provide adequate uterine tone at Cesarean delivery (CD) for labour arrest. Methods We conducted a double-blind dose-finding study of carbetocin using a biased-coin up-and-down design in women undergoing CD for labour arrest under epidural anesthesia. Forty healthy term pregnant women who had received at least three hours of oxytocin infusion during labour were recruited for the study. Carbetocin was administered intravenously upon delivery of the anterior shoulder of the fetus. The first patient received 20 lg, and the dose for the subsequent patient was determined according to the response of the previous patient as per the biased-coin allocation scheme using increments or decrements of 20 lg (maximum 140 lg). Uterine tone was assessed by the obstetrician and rated as satisfactory or unsatisfactory throughout the intraoperative period. The primary outcome was satisfactory uterine tone with no need for additional uterotonic drugs intraoperatively. Secondary outcomes included use of additional uterotonic drugs postoperatively in the first 24 hr, estimated blood loss, and adverse effects. Results The ED 90 of carbetocin to produce adequate uterine tone was estimated at 121 lg (95% confidence interval [CI]: 111 to 130; 99% CI: 108 to 133) using the truncated Dixon and Mood (DM) method. The isotonic estimator of ED 90 was 140 lg; however, the observed response rate across all doses was \ 90%. Also, the 95% CI of the DM estimator is likely to have lower than expected coverage, while the 99% CI may have about 90% coverage. Therefore, these results should be interpreted with caution. The overall median (range) estimated blood loss was 1,014 (104-2,436) mL. The overall incidence of hypotension and tachycardia were 45% and 57.5%, respectively. At a dose of 140 lg, the incidence of tachycardia and intraoperative arrhythmias was 76% and 14%, respectively. Conclusion The ED 90 of carbetocin at CD for labour arrest, as determined in our study, should be interpreted with caution since it may be underestimated. This dose is higher than the currently recommended dose of 100 lg at elective CD and should not be used routinely given the uncertainty regarding its efficacy and the high incidence of arrhythmias at higher doses. This trial was registered at ClinicalTrials.gov, number: NCT01725243. RésuméObjectif L'objectif de cette étude était d'estimer la dose efficace à 90 % (DE 90 ) de la carbétocine pour atteindre un tonus utérin adapté lors d'un accouchement par césarienne (AC) pour arrêt de la progression du travail. Méthode Nous avons réalisé une étude de détermination de dose de carbétocine à double insu en nous fondant sur une méthodologie biaisée de pile ou face chez des femmes subissant un AC pour arrêt de progression du travail sous anesthésie péridurale. Quarante femmes enceintes en bonne santé et à terme ayant reçu une perfusion d'oxytocine pendant au moins trois heures pendant le travail obstétrical ont été recrutées p...

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“…10 Furthermore, this dose is at least eight times higher than the ED 90 for carbetocin required in non-labouring women at full term undergoing elective CD (14.8 lg; 95% CI: 13.7 to 15.8).…”

Section: Discussionmentioning

confidence: 88%

Section: Résumémentioning

confidence: 99%

Carbetocin at Cesarean delivery for labour arrest: a sequential allocation trial to determine the effective dose

Nguyen-Lu

Carvalho

Farine

et al. 2015

Can J Anesth/J Can Anesth

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“…Preeclampsia is associated with thrombocytopoenia and coagulopathy, and active management of the third stage [398], avoiding ergometrine (ergonovine maleate), should be performed to avoid postpartum haemorrhage [399][400][401][402][403][404].…”

Section: Commentsmentioning

confidence: 99%

RETIRED: Diagnosis, Evaluation, and Management of the Hypertensive Disorders of Pregnancy

Magee

Pels

Helewa

et al. 2008

Journal of Obstetrics and Gynaecology Canada

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421

218

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“…8 In 2009, the Society of Obstetricians and Gynaecologists of Canada (SOGC) suggested carbetocin as the first choice of uterotonic agent to prevent postpartum hemorrhage (PPH) after elective CD. 9 In lieu of an oxytocin infusion for CD, the SOGC Clinical Practice Guidelines recommend a single dose of carbetocin 100 lg as an intravenous bolus over one minute. 9 The justification for the 100 lg dose seems to be based on the fact that most clinical trials to date have used almost exclusively this dose, following the manufacturer's recommendation.…”

Section: Résumémentioning

confidence: 99%

“…9 In lieu of an oxytocin infusion for CD, the SOGC Clinical Practice Guidelines recommend a single dose of carbetocin 100 lg as an intravenous bolus over one minute. 9 The justification for the 100 lg dose seems to be based on the fact that most clinical trials to date have used almost exclusively this dose, following the manufacturer's recommendation. Unpublished data provided by the pharmaceutical company show the results of a study involving 18 women undergoing elective CD wherein none of the women had effective uterine contractions with doses of carbetocin below 60 lg, and 83% (five out of six) developed adequate uterine tone after receiving a dose of 100 lg.…”

Section: Résumémentioning

confidence: 99%

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

Cordovani

Balki

Farine

et al. 2012

Can J Anesth/J Can Anesth

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Purpose The primary objective of our study was to determine the minimum intravenous dose of carbetocin required to produce adequate uterine contraction in 95% of women (effective dose [ED] 95 ) undergoing elective Cesarean delivery (CD). Methods Eighty term pregnant women with low risk for postpartum hemorrhage (PPH) undergoing elective CD under spinal anesthesia were randomly allocated to receive carbetocin intravenously in doses of 80 lg, 90 lg, 100 lg, 110 lg, or 120 lg upon delivery. The consultant obstetrician evaluated the efficacy of the patient's uterine tone as satisfactory or unsatisfactory. In case of unsatisfactory uterine tone, additional uterotonics were administered as per routine institutional practice. Side effects were monitored during the study period. The main outcome measure was satisfactory uterine tone at two minutes after carbetocin administration. Results Satisfactory uterine tone was obtained in 70 subjects (87%) within the dose range of 80-120 lg of carbetocin. It was not possible to calculate the ED 95 of carbetocin due to the even distribution of women with satisfactory uterine tone across all dose groups (P = 0.99). Similarly, the side effects were similar across all dose groups. There was a high overall incidence of hypotension (55%) following the administration of carbetocin.Conclusions In women at low risk for PPH undergoing elective CD, carbetocin doses of 80-120 lg are similarly effective. There is a high incidence of hypotension associated with carbetocin in these doses, and further studies with doses lower than 80 lg are warranted to assess the balance of efficacy and side effects. This trial was registered at www.clinicaltrials.gov (NCT01262742). RésuméObjectif L'objectif principal de notre e´tude e´tait de de´terminer la dose intraveineuse minimum de carbe´tocine ne´cessaire pour obtenir une contraction ute´rine approprie´e chez 95 % des femmes (dose efficace [DE] 95 ) subissant une ce´sarienne programme´e. Méthodes Quatre-vingts femmes enceintes a`terme ayant un faible risque d'he´morragie du postpartum subissant une ce´sarienne programme´e sous rachianesthe´sie ont e´teŕ andomise´es pour recevoir des doses intraveineuses de 80 lg, 90 lg, 100 lg, 110 lg ou 120 lg de carbe´tocine au moment de l'accouchement. L'obste´tricien a e´valueĺ 'efficacite´du tonus ute´rin de la patiente comme satisfaisant ou non satisfaisant. En cas de tonus ute´rin non satisfaisant, des me´dicaments ute´rotoniques supple´mentaires ont e´teá dministre´s conforme´ment aux pratiques habituelles de l'e´tablissement. Les effets inde´sirables ont e´te´surveille´s pendant la dure´e de l'e´tude. Le crite`re de jugement principal a éte´un tonus ute´rin satisfaisant deux minutes apre`s l'administration de carbe´tocine.

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Active Management of the Third Stage of Labour: Prevention and Treatment of Postpartum Hemorrhage

Cited by 320 publications

References 34 publications

Carbetocin at Cesarean delivery for labour arrest: a sequential allocation trial to determine the effective dose

Carbetocin at Cesarean delivery for labour arrest: a sequential allocation trial to determine the effective dose

RETIRED: Diagnosis, Evaluation, and Management of the Hypertensive Disorders of Pregnancy

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

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