Treatment for primary postpartum haemorrhage
17 March 2014
Findings of the review: This updated review aimed to assess various treatments (uterotonics, haemostatic drugs, surgical interventions, radiological embolization, non-pneumatic antishock garment and aortic compression device) for the treatment of primary postpartum haemorrhage (PPH). Ten randomised clinical trials (4052 participants) were included in this review. No difference was found in maternal mortality, serious maternal morbidity, admission to intensive care or hysterectomy when misoprostol was compared with placebo (four trials), oxytocin infusion (two trials) and combined oxytocin and ergometrine (one trial). Oxytocin infusion was more effective than misoprstol in relation to blood loss greater than 1000 ml and use of additional uterotonics. Misoprostol was associated with more side-effects.
Trials assessing the effectiveness of estrogen, tranexamic acid, and lower segment compression were too small to draw meaningful conclusions. No trials evaluating surgical techniques or radiological interventions for women with PPH unresponsive to uterotonics and/or haemostatics were identified.
Implementation: Oxytocin infusion is recommended for the treatment of primary PPH. Efforts should be made to have oxytocin infusion available at all birth settings. Misoprostol can be used if oxytocin is not available. Misoprostol does not have any additional benefit in women who have already received oxytocin for the treatment of PPH. Further trials are needed to assess other treatment modalities (tranexamic acid, compression methods, surgical interventions, radiological embolization methods).
Citation: Mousa HA, Blum J, Abou El Senoun G, Shakur H, Alﬁrevic Z. Treatment for primary postpartum haemorrhage Cochrane Database of Systematic Review 2014, Issue 2. Art. No.: CD003249. DOI: 10.1002/14651858.CD003249.pub3.
Primary postpartum haemorrhage (PPH) is one of the top five causes of maternal mortality in both developed and developing countries.
To assess the effectiveness and safety of any intervention used for the treatment of primary PPH.
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2013).
Randomised controlled trials comparing any interventions for the treatment of primary PPH.
Data collection and analysis
We assessed studies for eligibility and quality and extracted data independently. We contacted authors of the included studies to request more information.
Ten randomised clinical trials (RCTs) with a total of 4052 participants fulfilled our inclusion criteria and were included in this review.
Four RCTs (1881 participants) compared misoprostol with placebo given in addition to conventional uterotonics. Adjunctive use of misoprostol (in the dose of 600 to 1000 mcg) with simultaneous administration of additional uterotonics did not provide additional benefit for our primary outcomes including maternal mortality (risk ratio (RR) 6.16, 95% confidence interval (CI) 0.75 to 50.85), serious maternal morbidity (RR 0.34, 95% CI 0.01 to 8.31), admission to intensive care (RR 0.79, 95% CI 0.30 to 2.11) or hysterectomy (RR 0.93, 95% CI 0.16 to 5.41).
Two RCTs (1787 participants) compared 800 mcg sublingual misoprostol versus oxytocin infusion as primary PPH treatment; one trial included women who had received prophylactic uterotonics, and the other did not. Primary outcomes did not differ between the two groups, although women given sublingual misoprostol were more likely to have additional blood loss of at least 1000 mL (RR 2.65, 95% CI 1.04 to 6.75). Misoprostol was associated with a significant increase in vomiting and shivering.
Two trials attempted to test the effectiveness of estrogen and tranexamic acid, respectively, but were too small for any meaningful comparisons of pre-specified outcomes.
One study compared lower segment compression but was too small to assess impact on primary outcomes.
We did not identify any trials evaluating surgical techniques or radiological interventions for women with primary PPH unresponsive to uterotonics and/or haemostatics.
Clinical trials included in the current review were not adequately powered to assess impact on the primary outcome measures. Compared with misoprostol, oxytocin infusion is more effective and causes fewer side effects when used as first-line therapy for the treatment of primary PPH. When used after prophylactic uterotonics, misoprostol and oxytocin infusion worked similarly. The review suggests that among women who received oxytocin for the treatment of primary PPH, adjunctive use of misoprostol confers no added benefit.
The role of tranexamic acid and compression methods requires further evaluation. Furthermore, future studies should focus on the best way to treat women who fail to respond to uterotonic therapy.