What measured blood loss tells us about postpartum bleeding: a systematic review

Abstract

BackgroundMeta-analyses of postpartum blood loss and the effect of uterotonics are biased by visually estimated blood loss.ObjectivesTo conduct a systematic review of measured postpartum blood loss with and without prophylactic uterotonics for prevention of postpartum haemorrhage (PPH).Search strategyWe searched Medline and PubMed terms (labour stage, third) AND (ergonovine, ergonovine tartrate, methylergonovine, oxytocin, oxytocics or misoprostol) AND (postpartum haemorrhage or haemorrhage) and Cochrane reviews without any language restriction.Selection criteriaRefereed publications in the period 1988–2007 reporting mean postpartum blood loss, PPH (≥500 ml) or severe PPH (≥1000 ml) following vaginal births.Data collection and analysisRaw data were abstracted into Excel by one author and then reviewed by a co-author. Data were transferred to SPSS 17.0, and copied into RevMan 5.0 to perform random effects meta-analysis.Main resultsThe distribution of average blood loss (29 studies) is similar with any prophylactic uterotonic, and is lower than without prophylaxis. Compared with no uterotonic, oxytocin and misoprostol have lower PPH (OR 0.43, 95% CI 0.23–0.81; OR 0.73, 95% CI 0.50–1.08, respectively) and severe PPH rates (OR 0.61, 95% CI 0.29–1.29; OR 0.74, 95% CI 0.52–1.04, respectively). Oxytocin has lower PPH (OR 0.65, 95% CI 0.60–0.70) and severe PPH (OR 0.71, 95% CI 0.56–0.91) rates than misoprostol, but not in developing countries.ConclusionOxytocin is superior to misoprostol in hospitals. Misoprostol substantially lowers PPH and severe PPH. A sound assessment of the relative merits of the two drugs is needed in rural areas of developing countries, where most PPH deaths occur.

The Effect of the Combined Use of Methylergonovine and Oxytocin during Caesarean Section in the Prevention of Post‐partum Haemorrhage

“…In a study investigating the efficacy of methylergonovine (which was less commonly used in the prevention of post-partum haemorrhage due to its side effects) in the control of bleeding, patients administered methylergonovine were compared with patients receiving 15-methyl PGF2a. While 15-methyl PGF2a was effective in the control of bleeding during the post-partum first hours, the performances of each of the drugs by the post-partum 3rd day showed both to be successful, with similar rates [9].…”

“…In a meta-analysis of 17 studies, while the rate of post-partum haemorrhage varied between 4% and 51% without uterotonic treatment, it was shown that the rate of post-partum haemorrhage regressed to the following values with prophylactic oxytocin infusion, misoprostol treatment and ergometrine treatment, respectively: 0-32%, 1-45% and 0-37%. In the same study, the blood loss occurring with the administration of prophylactic uterotonic treatment was compared [9,[17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33]. It was found that this was reduced by an average of 151-499 mL in the patients administered with oxytocin, 155-433 mL in the patients administered with misoprostol and 149-476 mL in the patients administered with ergometrine.…”

“…In a meta-analysis of 29 studies comparing the administration of misoprostol with intravenous injections of oxytocin to prevent post-partum haemorrhage, the haemorrhage frequency for patients who were given prophylaxis was found to be similar or less than that for those who were not. Additionally, it was indicated that the infusion of oxytocin could be more effective than the administration of intramuscular misoprostol [9]. From the wide range of studies of post-partum haemorrhage prophylaxis, a variety of results have been obtained on treatments and their efficacies.…”

Rethinking WHO Guidance

“…The issue is not whether WHO should keep misoprostol on the essential drug list, but rather who should be allowed access to misoprostol, which is an issue that each nation should decide, depending on its own national needs and priorities. 2 there is no excuse for the lack of awareness of the methodologically stringent review and meta-analysis, 3 which clearly demonstrates that methodologically sound studies find a substantial and highly significant benefit in the provision of misoprostol for postpartum haemorrhage prevention. The authors superficially discuss study quality while ignoring the valid implications thereof in their analysis and interpretation.…”

“…Pathfinder might note that the Cochrane systematic review could not conduct a meta-analysis of community trials and comes to the same conclusion 'all four recent trials have design and setting differences that make the summing up of their results difficult.' 3 We identified randomized controlled trials of misoprostol in community and home setting from academic databases and systematic reviews and meta-analyses; our methods critically appraised study design, intervention and outcomes of these studies (see method section).…”