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Carbetocin Versus Oxytocin for the Prevention of Postpartum Haemorrhage

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Carbetocin Versus Oxytocin for the Prevention of Postpartum Haemorrhage Faridpur Med. Coll. J. 2015;10(2):76-83 ReviewArticle Carbetocin versus Oxytocin for the Prevention of Postpartum Haemorrhage P Begum1, DR Saha2, Mahabuba3, L Sanjowal4, MK Hasan5 Abstract: Postpartum haemorrhage is the leading cause of maternal mortality worldwide. Total 67-80% of cases are caused by uterine atony. Preventive measures include prophylactic drug use to aid uterine contraction after delivery, thus avoiding severe blood loss and reducing maternal morbidity and mortality. Carbetocin is a synthetic analogue of oxytocin with a long half-life which ensure more effective contraction and less adverse effects. It can be administered as a single dose injection either intravenously or intramuscularly rather than as an infusion over several hours as is the case with oxytocin. Carbetocin is currently indicated for prevention of uterine atony after delivery by caesarean section in spinal or epidural anaesthesia. A reduced need for additional uterotonics was observed with carbetocin vs. oxytocin in high-risk women and carbetocin was at least as effective as syntometrine in low-risk women. Carbetocin is effective treatment for the prevention of postpartum haemorrhage not only following caesarean delivery but also after vaginal delivery in high-risk women and those who suffer from hypertensive disorders in pregnancy. Further research is required to assess whether prophylactic carbetocin is superior to conventional uterotonic agents following vaginal delivery in low-risk women. Key words: Carbetocin, Postpartum Haemorrhage. Introduction: include the prophylactic use of uterotonic agents to enhance natural uterine contraction and retraction The risk of postpartum haemorrhage is much higher for 1,2 following caesarean section and in the third stage of women undergoing caesarean section . particularly in labour for vaginal delivery9,10. Oxytocin is the most developing countries where the majority of operations 3 widely used uterotonic agent, but only has a half-life of are carried out as an emergency procedure . Postpartum 9-11 4 4-10 min . So must be administered as a continuous haemorrhage occurs in up to 15% of vaginal deliveries and represents the most important cause of maternal intravenous infusion to achieve sustained uterotonic morbidity and mortality worldwide5,6. In most cases, activity. Another uterotonic drug frequently used in vaginal deliveries is syntometrine, which contains 5 uterine atony is responsible for the occurrence of 12,13 excessive bleeding during or following childbirth7-9. IU/ml oxytocin and 0.5mg/ml ergometrine . Current strategies for preventing postpartum haemorrhage Syntometrine combines the rapid onset of action of 1. Dr. Poly Begum, MBBS, FCPS (Obs & Gynae), Assistant oxytocin and the prolonged uterotonic effects of an Professor, Department of Obstetrics & Gynaecology, Diabetic ergot alkaloid. Intramuscular syntometrine use in active Association Medical College, Faridpur. management of the third stage of labour is associated 2. Prof. Dr. Dipti Rani Shaha, MBBS, FCPS (Obs & Gynae) w i th a s i g n if i c an t r e d uction in the risk of non-severe Professor & Head, Department of Obstetrics & Gynaecology, postpartum haemorrhage (<1000ml of blood loss) Diabetic Association Medical College, Faridpur. compared with intramuscular oxytocin12,13. Although 3. Dr. Mahbuba MBBS, FCPS (Obs & Gynae), Associate Professor & intramuscular syntometrine is equally effective as Head, Department of Obstetrics & Gynaecology, Faridpur intravenous oxytocin14, gastrointestinal and cardiovascular Medical College, Faridpur. side effects such as maternal nausea, vomiting and raised 4. Dr. Lipika Sanjowal, MBBS, DA, MCPS (Anaesthesia), Associate blood pressure 12-14 are more frequent due to stimulation of Professor, Department of Anaesthesiology, Diabetic Association smooth muscle contraction and vasoconstriction by Medical College, Faridpur. ergometrine15,16. Oral and rectal administration of 5. Dr. Md. Kamrul Hassan, MBBS, DCH (Pediatrics), Junior misoprostol, a synthetic analogue of prostaglandin E1, have Consultant (Pediatrics), Charbhadrasan Upazila Health Complex, demonstrated lower efficacy than injectable uterotonic agents Faridpur. in preventing excessive bleeding following vaginal Address of correspondence : 17,18 delivery and are associated with a high incidence of Dr. Poly Begum, MBBS, FCPS (Obs & Gynae), Assistant Professor, Department of Obstetrics & Gynaecology, Diabetic shivering, fever and a possible risk of severe Association Medical College, Faridpur. Cell: +88-01913-486864, hyperthermia19,20. These factors deem misoprostol E-mail: [email protected] 76 Carbetocin versus Oxytocin for the Prevention of Postpartum Haemorrhage P Begum et al. unsuitable for routine prevention of excessive injection of carbetocin following placental delivery was postpartum bleeding in developed countries, despite at least as effective as a 16-h intravenous infusion of low cost and ease of use20,21. Although injectable 32.5 IU oxytocin in controlling intraoperative blood prostaglandins such as prostaglandin 15-methyl F2α or loss. No significant differences in mean blood loss were sulprostone can prevent excessive bleeding following observed between treatment groups (Table I). However, vaginal delivery, safety concerns and cost limit their significantly fewer women in the carbetocin group suitability for routine use in active management of the (53%) than in the oxytocin group (79%) had blood loss third stage of labour. However, they remain useful of >_ 200 ml (p = 0.041) (Table I). The second study was therapeutic options for postpartum haemorrhage 21 a larger parallel-group, randomised, double-blind, treatment when other interventions prove ineffective . double-dummy, Canadian multi-centre trial, comparing Recent interest has focused on the prophylactic use of 22-29 the efficacy and safety of carbetocin and oxytocin in the oxytocin receptor agonist carbetocin . Here we 694 women undergoing elective caesarean section36. A review the most recent clinical data regarding the single 100 µg intravenous injection of carbetocin was efficacy of carbetocin in the prevention of postpartum more effective at preventing uterine atony than a 5 IU haemorrhage following caesarean section and vaginal intravenous bolus of oxytocin followed by intravenous delivery, and provide an update on the safety and tolerability in comparison to conventional uterotonic infusion of 20 IU over 8h; a significantly lower agents. incidence of additional oxytocic interventions for treatment failure was observed in the carbetocin arm Pharmacology: (Table I). Data from these two studies were pooled to determine overall treatment effect in a recent meta- 29 Carbetocin is a long-acting synthetic analogue of analysis . The risk of postpartum haemorrhage, oxytocin30,31 that can be administered as a single-dose defined as a blood loss >_ 500 ml, was not significantly injection, either intravenously or intramuscularly32. decreased with carbetocin compared with oxytocin Intravenously administered carbetocin has a half-life of (relative risk [RR] = 0.71 and 95% confidence interval approximately 40 min, around 4-10 times longer than [CI] = 0.14-3.53). However, carbetocin significantly that reported for oxytocin. Following intramuscular reduced the need for subsequent interventions with injection, carbetocin reaches peak plasma uterotonic drugs (RR = 0.44, 95% CI = 0.25-0.78) or concentrations in less than 30 min and has 80% uterine massage (RR = 0.38, 95% CI = 0.18-0.80) bioavailability32. The effect of various intravenous and compared with oxytocin. The authors29 also evaluated a intramuscular doses of carbetocin on the postpartum randomised controlled trial published in abstract form37, uterus has been evaluated by tocographic recordings of comparing a single 100 µg intravenous injection of uterine contractions 24-48h after vaginal delivery at carbetocin (n = 62) vs. placebo (n = 57) following 33 term in 40 women . A single intravenous bolus of 8-30 elective caesarean section. Postpartum haemorrhage µg carbetocin or a single intramuscular injection of 10- incidence was not reported as an outcome measure and 70 µg carbetocin produced a tetanic uterine contraction 33 could not be assessed, but the requirement for within 2 min of drug administration . Uterine activity additional oxytocic therapy to prevent haemorrhage persisted for an average of 120 min following was significantly lower with carbetocin vs. placebo intramuscular injection and an average of 60 min 33 (RR = 0.18, 95% CI = 0.09-0.35). Moreover, women in following intravenous injection . Thus, these data the carbetocin group demonstrated a significant show that carbetocin onset of action is rapid increase in uterine tone for 20 min following irrespective of administration route, but duration of administration of study medication compared with action is longer following intramuscular injection. The placebo (p < 0.05). Another study, published in abstract optimal carbetocin dose (intravenous or intramuscular) 36 is 100 µg34. form , investigated the efficacy of carbetocin vs. oxytocin for prevention of uterine atony in high-risk Carbetocin at Caesarean Delivery: women undergoing delivery by caesarean section in Mexico (Table I). Risk factors included fetal Carbetocin is currently approved in 23 countries for macrosomia, polyhydramnios, low placental insertion, prevention of uterine atony and excessive bleeding multiple gestation, prolonged labour, uterine myomas following caesarean delivery in spinal or epidural
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