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Intravenous oxytocin dosing regimens for postpartum hemorrhage prevention at cesarean section: a systematic review and meta-analysis
Phung LC, Farrington EK, Connolly M, Wilson AN, Carvalho B, Homer CSE, Vogel JP
American journal of obstetrics and gynecology. 2021
Abstract
OBJECTIVE To synthesize available evidence on intravenous (IV) oxytocin dosing regimens for the prevention of postpartum hemorrhage (PPH) at cesarean section (CS). DATA SOURCES We searched Medline/OVID, Embase, Global Index Medicus, CINAHL, CENTRAL, ClinicalTrials.gov, and ICTRP for eligible studies published until Feb 2020. STUDY ELIGIBILITY CRITERIA We included any randomized or non-randomized study published in peer-reviewed journals that compared at least two different dosing regimens of IV oxytocin for PPH prevention in women undergoing CS. STUDY APPRAISAL AND SYNTHESIS METHODS Two authors independently assessed eligibility, extracted data, and assessed risk of bias. Primary outcome was incidence of PPH ≥ 1000 mL. Other review outcomes included use of additional uterotonics, blood loss, and adverse maternal events. Data were analyzed based on type of IV administration (bolus only, infusion only, bolus plus infusion) and oxytocin dose. Meta-analysis was performed using randomized trials and reported using risk ratios or mean difference with 95% confidence intervals. GRADE was used to rate the certainty of evidence. Findings from dose-finding trials and non-randomized studies were reported narratively. RESULTS Thirty-five studies (7,333 women) met our inclusion criteria, including 30 randomized trials and five non-randomized studies. There were limited data from trials for most outcomes, and results were not conclusive. Compared to bolus plus infusion regimens, bolus only regimens probably result in slightly higher mean blood loss (MD 52 mL, 95% CI 0.4-104 mL, moderate certainty). Amongst bolus plus infusion regimens, initial bolus doses < 5 IU may reduce nausea (RR 0.26, 95% CI 0.11-0.63, low certainty) as compared to 5-9 IU. Total oxytocin doses 5-9 IU versus 10-19 IU may increase use of additional uterotonics (RR 13.00, 95% CI 1.75-96.37, low certainty). Effects on other outcomes were generally inconclusive. CONCLUSION There are limited data comparing IV oxytocin regimens for PPH prevention at CS. Bolus plus infusion regimens may lead to minor reductions in mean blood loss, and initial bolus doses of < 5 IU may minimize nausea. Bolus only regimens of 10 IU versus 5 IU may decrease use of additional uterotonics, however further comparative trials are required to understand effects on other key outcomes, particularly hypotension.
2.
Cost-effectiveness of uterine tamponade devices for the treatment of postpartum haemorrhage: A systematic review
Vogel JP, Wilson AN, Scott N, Widmer M, Althabe F, Oladapo OT
International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics. 2020
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Abstract
BACKGROUND Uterine tamponade is widely promoted for treating refractory postpartum haemorrhage (PPH), however its cost-effectiveness may vary depending on unit costs and setting. OBJECTIVE To review available data on cost-effectiveness of uterine tamponade devices when used for PPH treatment. SEARCH STRATEGY PubMed and EMBASE were searched (1980 to January 2020), as well as the National Health Services Economic Evaluation database from inception (1995) to March 2015. SELECTION CRITERIA Eligible studies were any type of economic evaluation, or effectiveness studies that provided cost or economic data. DATA COLLECTION AND ANALYSIS Two reviewers independently screened studies, extracted data and assessed quality. MAIN RESULTS Eleven studies using a range of devices (condom catheter, uterine suction devices, Bakri, Inpress, Ellavi) were identified. Cost of condom catheter devices or kits ranged from US$0.64 to US$6, while purpose-designed devices were up to US$400. Two studies that took a health system perspective assessed cost-effectiveness of using uterine balloon tamponade and suggested it was highly cost-effective due to low cost per disability-adjusted life years (DALY) averted, though both used effect estimates from case series. CONCLUSIONS Evidence on the cost-effectiveness of uterine tamponade devices was limited and not generalizable. Rigorous economic evaluations based on updated effect estimates are needed.