Prophylactic tranexamic acid in Cesarean delivery: an updated meta-analysis with a trial sequential analysis.

PURPOSE: Postpartum hemorrhage (PPH) is a leading cause of maternal mortality worldwide. Although several studies on the prophylactic use of tranexamic acid (TXA) in parturients undergoing Cesarean delivery have been published, conflicting results raise questions regarding its use. Thus, we aimed to investigate the safety and efficacy of PPH prophylaxis with TXA. SOURCE: We searched PubMed®, Embase, Cochrane Central, and ClinicalTrials.gov for randomized controlled trials (RCTs) comparing prophylactic TXA with placebo or no treatment in parturients undergoing Cesarean delivery. Our main outcomes were PPH, any blood transfusion, need for additional uterotonics, and adverse events. We performed a trial sequential analysis (TSA) of all outcomes to investigate the reliability and conclusiveness of findings. PRINCIPAL FINDINGS: We included 38 RCTs including 22,940 parturients, 11,535 (50%) of whom were randomized to receive prophylactic TXA. Patients treated with TXA had significantly fewer cases of PPH (risk ratio [RR], 0.51; 95% confidence interval [CI], 0.38 to 0.69; P < 0.001); less blood transfusion (RR, 0.43; 95% CI, 0.30 to 0.61; P < 0.001), and less use of additional uterotonics (RR, 0.52; 95% CI, 0.40 to 0.68; P < 0.001). No significant differences were found between the groups in terms of adverse effects and thromboembolic events. CONCLUSION: Prophylactic TXA administration for parturients undergoing Cesarean delivery significantly reduced blood loss, without increasing adverse events, supporting its use as a safe and effective strategy for reducing PPH in this population. STUDY REGISTRATION: PROSPERO (CRD42023422188); first submitted 27 April 2023.

RéSUMé: OBJECTIF: L'hémorragie du post-partum (HPP) est l'une des principales causes de mortalité maternelle dans le monde. Bien que plusieurs études sur l'utilisation prophylactique d'acide tranexamique (TXA) chez les personnes parturientes ayant accouché par césarienne aient été publiées, des résultats contradictoires soulèvent des questions quant à son utilisation. Ainsi, nous avons cherché à étudier l'innocuité et l'efficacité de la prophylaxie à base de TXA pour l'HPP. SOURCES: Nous avons fait une recherche sur PubMed®, Embase, Cochrane Central et ClinicalTrials.gov pour en tirer les études randomisées contrôlées (ERC) comparant le TXA prophylactique à un placebo ou à l'absence de traitement chez les personnes parturientes accouchant par césarienne. Nos principaux critères d'évaluation étaient l'HPP, toute transfusion sanguine, la nécessité d'un utérotonique supplémentaire et les événements indésirables. Nous avons effectué une analyse séquentielle des études pour tous les résultats afin d'examiner la fiabilité et le caractère concluant des conclusions. CONSTATATIONS PRINCIPALES: Nous avons inclus 38 ERC comprenant 22 940 personnes parturientes, dont 11 535 (50 %) ont été randomisées pour recevoir du TXA prophylactique. La patientèle traitée par TXA présentait significativement moins de cas d'HPP (risque relatif [RR], 0,51; intervalle de confiance [IC] à 95 %, 0,38 à 0,69; P < 0,001); moins de transfusion sanguine (RR, 0,43; IC 95 %, 0,30 à 0,61; P < 0,001) et moins d'utilisation d'utérotoniques supplémentaires (RR, 0,52; IC 95 %, 0,40 à 0,68; P < 0,001). Aucune différence significative n'a été constatée entre les groupes en termes d'effets indésirables et d'événements thromboemboliques. CONCLUSION: L'administration prophylactique de TXA pour les personnes parturientes accouchant par césarienne a considérablement réduit les pertes de sang sans augmenter les événements indésirables, ce qui soutient son utilisation comme stratégie sécuritaire et efficace pour réduire l'HPP dans cette population. ENREGISTREMENT DE L'éTUDE: PROSPERO (CRD42023422188); première soumission le 27 avril 2023.

Skin-to-Skin Contact in the Third Stage of Labor and Postpartum Hemorrhage Prevention: A Scoping Review.

INTRODUCTION: Literature supports numerous benefits of skin-to-skin contact for neonatal adaptation to extrauterine life and bonding/attachment, but few studies explore the effects of skin-to-skin contact on maternal outcomes. This review aims to map the evidence on skin-to-skin contact in the third stage of labor for postpartum hemorrhage prevention. METHODS: Scoping review, which covered stages recommended by the Institute Joanna Briggs, including studies from the PubMed, EMBASE, CINAHL, LILACS, Web of Science, and Scopus databases, using the descriptors "Postpartum hemorrhage", "Labor stages, third", "Prevention" and "Kangaroo care/Skin-to-skin". RESULTS: 100 publications on the subject found, 13 articles met the inclusion criteria, with 10,169 dyads were assessed in all studies. Publications from 2008 to 2021 were mostly written in English and designed as a randomized controlled trial. Skin-to-skin contact was effective and significant in: reducing the duration of the third stage of labor; placenta delivery; uterine contractility and physiological involution; absence of atony, decreasing blood loss with lower rates of erythrocyte and hemoglobin drop; reducing the need for synthetic oxytocin and/or ergometrine to control bleeding; and reducing changing pads per period and length of stay. DISCUSSION: Skin-to-skin contact was considered an effective, low-cost, and safe strategy, with positive effects already established in the literature for infants and extremely favorable results in postpartum hemorrhage prevention cases, being highly recommended in assistance for the dyad. Open Science Framework Registry ( https://osf.io/n3685 ).

Analysis of the efficacy of prophylactic tranexamic acid in preventing postpartum bleeding: systematic review with meta-analysis of randomized clinical trials.

BACKGROUND: Postpartum Hemorrhage (PPH) is one of the main causes of maternal mortality, mainly in the poorest regions of the world, drawing attention to the need for strategies for preventing it. This study aims to evaluate the efficacy of prophylactic administration of Tranexamic Acid (TXA) in decreasing blood loss in pregnant women in delivery, preventing PPH. METHODS: Systematic review of randomized clinical trials. We searched for publications in PubMed, EMBASE and Cochrane Library databases, with the uniterms "postpartum, puerperal hemorrhage" and "tranexamic acid", published between January of 2004 and January of 2020. The eligibility criteria were trials published in English with pregnant women assessed during and after vaginal or cesarean delivery about the effect of prophylactic use of TXA on bleeding volume. The random-effects model was applied with the DerSimonian-Laird test and the Mean Difference (MD) was calculated for continuous variables together with each 95% CI. This systematic review was previously registered in the PROSPERO platform under the registration n° CRD42020187393. RESULTS: Of the 630 results, 16 trials were selected, including one with two different doses, performing a total of 6731 patients. The intervention group received a TXA dose that varied between 10 mg.kg-1 and 1g (no weight calculation). The TXA use was considered a protective factor for bleeding (MD: -131.07; 95% CI: -170.00 to -92.78; p = 0.000) and hemoglobin variation (MD: -0.417; 95% CI: -0.633 to -0.202; p = 0.000). In the subgroup analysis related to the cesarean pathway, the effect of TXA was even greater. CONCLUSION: The prophylactic use of tranexamic acid is effective in reducing the post-partum bleeding volume. PROSPERO REGISTRATION ID: CRD42020187393.

Analysis of the efficacy of prophylactic tranexamic acid in preventing postpartum bleeding: systematic review with meta-analysis of randomized clinical trials

Abstract Background Postpartum Hemorrhage (PPH) is one of the main causes of maternal mortality, mainly in the poorest regions of the world, drawing attention to the need for strategies for preventing it. This study aims to evaluate the efficacy of prophylactic administration of Tranexamic Acid (TXA) in decreasing blood loss in pregnant women in delivery, preventing PPH. Methods Systematic review of randomized clinical trials. We searched for publications in PubMed, EMBASE and Cochrane Library databases, with the uniterms "postpartum, puerperal hemorrhage" and "tranexamic acid", published between January of 2004 and January of 2020. The eligibility criteria were trials published in English with pregnant women assessed during and after vaginal or cesarean delivery about the effect of prophylactic use of TXA on bleeding volume. The random-effects model was applied with the DerSimonian-Laird test and the Mean Difference (MD) was calculated for continuous variables together with each 95% CI. This systematic review was previously registered in the PROSPERO platform under the registration n° CRD42020187393. Results Of the 630 results, 16 trials were selected, including one with two different doses, performing a total of 6731 patients. The intervention group received a TXA dose that varied between 10 mg.kg−1 and 1g (no weight calculation). The TXA use was considered a protective factor for bleeding (MD: -131.07; 95% CI: -170.00 to -92.78; p= 0.000) and hemoglobin variation (MD: -0.417; 95% CI: -0.633 to -0.202; p= 0.000). In the subgroup analysis related to the cesarean pathway, the effect of TXA was even greater. Conclusion The prophylactic use of tranexamic acid is effective in reducing the post-partum bleeding volume. PROSPERO registration ID CRD42020187393.

Protocolo assistencial multidisciplinar manejo na hemorragia pós-parto / Multidisciplinary care protocol management of postpartum hemorrhage

A hemorragia pós-parto (HPP) é a segunda causa morte materna no Brasil. Além disso, a HPP pode levar a complicações secundárias como necessidade de transfusões de hemoderivados, coagulação intravascular disseminada (CIVD), admissão em unidades de terapia intensiva, choque hipovolêmico/hemorrágico, infecção, histerectomia, falência renal aguda e síndrome de Sheehan. Visto isto, esse protocolo tem como objetivo treinar as equipes assistenciais para diagnóstico precoce e ações de resposta rápida, diminuindo desta forma a morbimortalidade deste evento hemorrágico. (Au)

Evidence-based labor management: third stage of labor (part 5).

During the third stage of labor, oxytocin and tranexamic acid, oxytocin and misoprostol, oxytocin and methylergometrine, or carbetocin is recommended for the prevention of postpartum hemorrhage after vaginal delivery. Intravenous oxytocin (10 IU) immediately after delivery of the neonate (after either anterior shoulder or whole-body delivery) and before delivery of the placenta is recommended. If oxytocin and tranexamic acid combination is chosen, intravenous tranexamic acid (1 g) in addition to intravenous oxytocin (10 IU) immediately after delivery of the neonate and before placental delivery is recommended. If oxytocin and misoprostol combination is chosen, sublingual misoprostol (400 µg) in addition to intravenous oxytocin (10 IU) immediately after delivery of the neonate is recommended. If there is no intravenous access or if in low-resource settings, sublingual misoprostol (400 µg) and intramuscular oxytocin (10 IU) are recommended. If oxytocin and methylergometrine combination is chosen, intramuscular methylergometrine (0.2 mg) and intravenous oxytocin (10 IU) immediately after delivery of the neonate are recommended. Single-dose intravenous or intramuscular carbetocin (100 µg) immediately after delivery of the neonate is recommended. Controlled cord traction and delayed cord clamping for approximately 60 seconds is recommended. There is insufficient evidence to support or refute umbilical cord milking, uterine massage, or nipple stimulation for the prevention of postpartum hemorrhage. Repair of first- and second-degree lacerations with continuous synthetic suture technique is recommended. No repair of first-degree lacerations if hemostatic and normal cosmesis can be considered. Repair of third-degree lacerations with end-to-end or overlap continuous synthetic suture technique is recommended. Repair of fourth-degree lacerations with delayed absorbable 4-0 or 3-0 polyglactin or chromic suture in a running fashion is recommended. The use of single-dose second-generation cephalosporin at the time of third- or fourth-degree laceration repairs can be considered. Skin-to-skin contact after delivery is recommended. There is insufficient evidence to support or refute routine cord blood gas sampling after delivery. Public cord blood banking is recommended.

Investigación de incidencia y complicaciones de histerectomía de emergencia en periparto / Investigation of Incidence and Complications of Emergency peripartum hysterectomy

Introducción: La histerectomía periparto de emergencia es una cirugía de alto riesgo, que se realiza mayoritariamente después de un parto vaginal o cesárea. Dada la importancia de las complicaciones y la mortalidad de las embarazadas para el sistema de salud, el presente estudio tuvo como objetivo investigar la incidencia y las complicaciones de la histerectomía periparto de emergencia en los hospitales generales y docentes de la Universidad de Ciencias Médicas de Zahedan. Materiales y Métodos: En este estudio descriptivo-analítico transversal, luego de obtener la aprobación del Comité de Ética, se investigó la historia clínica de las pacientes con histerectomía periparto de emergencia ingresadas en el hospital Ali ibn Abitaleb de Zahedan para la interrupción del embarazo durante 2017-2018. fueron estudiados. Después de evaluar las características demográficas, incluida la edad, la educación y la ocupación, se investigaron las causas y las complicaciones de la histerectomía de emergencia. Finalmente, los datos fueron analizados por el software SPSS.Resultados: De 2438 casos, se investigaron 50 casos de histerectomía. La edad media de las madres y el número medio de embarazos fue de 31,06 ± 5,21 y 5,72 ± 2,31, respectivamente. En este estudio, se registraron 35 cesáreas (70%) y 15 partos vaginales normales (30%), y solo el 2% condujo a una histerectomía de emergencia. Las causas más comunes de histerectomía de emergencia incluyeron placenta accreta (28%), atonía uterina (24%) y rotura uterina (20%). Las complicaciones también incluyeron fiebre (24%), coagulopatía (14%) e infección de la herida (12%). Conclusión: la placenta accreta y la atonía uterina son las causas más importantes de histerectomía. Las complicaciones más comunes de la histerectomía de emergencia son fiebre, coagulopatía e infecciones de heridas. Una disminución en el parto por cesárea electiva y un mayor fomento del parto vaginal natural podrían reducir significativamente la incidencia de histerectomía periparto y la mortalidad materna

Introduction: The emergency peripartum hysterectomy is a high-risk surgery, which is mostly performed after vaginal delivery or Caesarean section. Given the importance of complications and mortality of pregnant mothers for the health system, the present study aimed to investigate the incidence and complications of emergency peripartum hysterectomy in general and teaching hospitals of Zahedan University of Medical Sciences. Materials and Methods: In this cross-sectional descriptive-analytic study, after obtaining the Ethics Committee approval, the medical record of patients with emergency peripartum hysterectomy admitted to Ali ibn Abitaleb hospital of Zahedan for pregnancy termination during 2017-2018 were investigated. were studied. After evaluating demographic characteristics, including age, education, and occupation, causes, and complications of emergency hysterectomy were investigated. Finally, data were analyzed by SPSS software. Results: Out of 2438 cases, 50 cases of hysterectomy were investigated. The mean age of mothers and the average number of pregnancies was 31.06±5.21 and 5.72±2.31, respectively. In this study, 35 caesarean sections (70%) and 15 normal vaginal delivery (30%) were recorded, with only 2% leading to emergency hysterectomy. The most common causes of emergency hysterectomy included placenta accreta (28%), uterine atony (24%), and uterine rupture (20%). The complications also included fever (24%), coagulopathy (14%), and wound infection (12%). Conclusion: Placenta accreta and uterine atony are the most important causes of hysterectomy. The most common complications of emergency hysterectomy are fever, coagulopathy, and wound infections. A decrease in elective caesarean delivery and further encouraging to natural vaginal delivery could significantly reduce the incidence of peripartum hysterectomy and maternal mortality

Route of oxytocin administration for preventing blood loss at caesarean section: a systematic review with meta-analysis.

OBJECTIVES: Assess the effects of different routes of prophylactic oxytocin administration for preventing blood loss at caesarean section (CS). DESIGN: Systematic review and meta-analysis. METHODS: Medline, EMBASE, CINAHL, Cochrane Library, BVS, SciELO and Global Index Medicus were searched through 24 May 2020 for randomised controlled trials (RCTs) comparing different routes of prophylactic oxytocin administration during CS. Study selection, data extraction and quality assessment were conducted by two investigators independently. We pooled results in fixed effects meta-analyses and calculated average risk ratio (RR), mean difference (MD) and 95% CI. We used GRADE to assess the overall quality of evidence for each outcome. RESULTS: Three trials (180 women) were included in the review. All studies compared intramyometrial (IMY) versus intravenous oxytocin in women having prelabour CS. IMY compared with intravenous oxytocin administration may result in little or no difference in the incidence of postpartum haemorrhage (RR 0.14, 95% CI 0.01 to 2.70; N=100 participants; 1 RCT), hypotension (RR 1.00, 95% CI 0.29 to 3.45; N=40; 1 RCT), headache (RR 3.00, 95% CI 0.13 to 69.52; N=40; 1 RCT) or facial flushing (RR 0.50, 95% CI 0.05 to 5.08; N=40; 1 RCT); IMY oxytocin may reduce nausea/vomiting (RR 0.13, 95% CI 0.02 to 0.69; N=140; 2 RCTs). We are very uncertain about the effect IMY versus intravenous oxytocin on the need for additional uterotonics (RR 0.82; 95% CI 0.25 to 2.69; N=140; 2 RCTs). IMY oxytocin may reduce blood loss slightly (MD -57.40 mL, 95% CI -101.71 to -13.09; N=40; 1 RCT). CONCLUSIONS: There is limited, low to very low certainty evidence on the effects of IMY versus intravenous oxytocin at CS for preventing blood loss. The evidence is insufficient to support choosing one route over another. More trials, including studies that assess intramuscular oxytocin administration, are needed on this relevant question. PROSPERO REGISTRATION NUMBER: CRD42020186797.

Postpartum hemorrhage in Suriname: A national descriptive study of hospital births and an audit of case management.

BACKGROUND: Postpartum hemorrhage (PPH) is the leading cause of direct maternal mortality globally and in Suriname. We aimed to study the prevalence, risk indicators, causes, and management of PPH to identify opportunities for PPH reduction. METHODS: A nationwide retrospective descriptive study of all hospital deliveries in Suriname in 2017 was performed. Logistic regression analysis was applied to identify risk indicators for PPH (≥ 500ml blood loss). Management of severe PPH (blood loss ≥1,000ml or ≥500ml with hypotension or at least three transfusions) was evaluated via a criteria-based audit using the national guideline. RESULTS: In 2017, the prevalence of PPH and severe PPH in Suriname was 9.2% (n = 808/8,747) and 2.5% (n = 220/8,747), respectively. PPH varied from 5.8% to 15.8% across the hospitals. Risk indicators associated with severe PPH included being of African descent (Maroon aOR 2.1[95%CI 1.3-3.3], Creole aOR 1.8[95%CI 1.1-3.0]), multiple pregnancy (aOR 3.4[95%CI 1.7-7.1]), delivery in Hospital D (aOR 2.4[95%CI 1.7-3.4]), cesarean section (aOR 3.9[95%CI 2.9-5.3]), stillbirth (aOR 6.4 [95%CI 3.4-12.2]), preterm birth (aOR 2.1[95%CI 1.3-3.2]), and macrosomia (aOR 2.8 [95%CI 1.5-5.0]). Uterine atony (56.7%, n = 102/180[missing 40]) and retained placenta (19.4%, n = 35/180[missing 40]), were the main causes of severe PPH. A criteria-based audit revealed that women with severe PPH received prophylactic oxytocin in 61.3% (n = 95/155[missing 65]), oxytocin treatment in 68.8% (n = 106/154[missing 66]), and tranexamic acid in 4.9% (n = 5/103[missing 117]). CONCLUSIONS: PPH prevalence and risk indicators in Suriname were similar to international and regional reports. Inconsistent blood loss measurement, varied maternal and perinatal characteristics, and variable guideline adherence contributed to interhospital prevalence variation. PPH reduction in Suriname can be achieved through prevention by practicing active management of the third stage of labor in every birth and considering risk factors, early recognition by objective and consistent blood loss measurement, and prompt treatment by adequate administration of oxytocin and tranexamic acid according to national guidelines.

Recombinant vs plasma-derived von Willebrand factor to prevent postpartum hemorrhage in von Willebrand disease.

von Willebrand disease (VWD) is a congenital bleeding disorder characterized by deficient or defective von Willebrand factor (VWF). Among women with VWD, postpartum hemorrhage (PPH) is common. Treatment options at delivery include plasma-derived VWF (pdVWF) and recombinant VWF (rVWF). However, limited data are available regarding their efficacy. We conducted a retrospective observational study comparing PPH in women with VWD treated at the Hemophilia Center of Western Pennsylvania between 1 February 2017 and 31 January 2018 with either rVWF or pdVWF. We compared postpartum outcomes, including PPH frequency and estimated blood loss (EBL) at delivery. There were a total of 12 deliveries, 7 vaginal and 5 cesarean. At delivery and for 3 days postpartum, 6 women received 80 IU/kg of rVWF and 6 received 80 IU/kg of pdVWF, based on prepregnancy weight, insurance, and/or patient choice. Treatment groups had similar demographics, including median age (32.0 vs 27.0 years; P = .075), bleeding scores (3.0 vs 3.5; P = .734), and prepregnancy body mass index (29.0 vs 29.2 kg/m2; P = .691). PPH occurred in 3 (25.0%) of 12 deliveries, with no difference by treatment group (2 of 6 rVWF vs 1 of 6 pdVWF; P = 1.000) and no difference in EBL by treatment group (685 vs 462 mL; P = .384) or delivery type (vaginal, P = .722 vs cesarean, P = .531). In summary, PPH occurred in one-fourth of the deliveries in women with VWD, despite a higher dose (80 IU/kg) of rVWF or pdVWF. Future trials are needed to develop and assess novel strategies to prevent PPH in VWD.

Access and use of oxytocin for postpartum haemorrhage prevention: a pre-post study targeting the poorest in six Mesoamerican countries.

OBJECTIVES: Haemorrhage remains the leading cause of maternal mortality in Central America. The Salud Mesoamérica Initiative aims to reduce such mortality via performance indicators. Our objective was to assess the availability and administration of oxytocin, before and after applying Salud Mesoamérica Initiative interventions in the poorest health facilities across Central America. DESIGN: Pre-post study. SETTING: 166 basic-level and comprehensive-level health facilities in Belize, Guatemala, Honduras, Mexico, Nicaragua and Panama. PARTICIPANTS: A random sample of medical records for uncomplicated full-term deliveries (n=2470) per International Classification of Diseases coding at baseline (July 2011 to August 2013) and at first-phase follow-up (January 2014 to October 2014). INTERVENTIONS: A year of intervention implementation prior to first-phase follow-up data collection focused on improving access to oxytocin by strengthening supply chains, procurement, storage practices and pharmacy inventory monitoring, using a results-based financing model. PRIMARY AND SECONDARY OUTCOME MEASURES: Oxytocin availability (primary outcome) and administration (secondary outcome) for postpartum haemorrhage prevention. RESULTS: Availability of oxytocin increased from 82.9% to 97.6%. Oxytocin administration increased from 83.6% to 88.4%. Significant improvements were seen for availability of oxytocin (adjusted OR (aOR)=8.41, 95% CI 1.50 to 47.30). Administration of oxytocin was found to be significantly higher in Honduras (aOR=2.96; 95% CI 1.00 to 8.76) in reference to Guatemala at follow-up. CONCLUSION: After interventions to increase health facility supplies, the study showed a significant improvement in availability but not administration of oxytocin in poor communities within Mesoamerica. Efforts are needed to improve the use of oxytocin.

Postpartum use of oxytocin and volume of placental transfusion: a randomised controlled trial.

OBJECTIVE: To assess whether oxytocin administered before clamping the umbilical cord modifies the volume of placental transfusion. DESIGN: Randomised controlled trial. METHODS: Mothers of term infants born vigorous by vaginal delivery with informed consent provided in early labour were randomly assigned to oxytocin (10 IU) given intravenously within 15 s of birth (group 1) or after clamping the umbilical cord 3 min after delivery (group 2). Soon after birth, all infants were weighed using a 1 g precision scale and subsequently placed on the mother's abdomen or chest. At 3 min, in both groups, the cord was clamped and cut, and the weight was again obtained. The primary outcome (volume of placental transfusion) was estimated by the difference in weights. RESULTS: 144 patients were included. There were no differences in the primary outcome: infants in group 1 (n=70) gained a mean weight of 85.9 g (SD 48.3), and in group 2 (n=74) 86.7 g (SD 49.6) (p=0.92). No differences were found in secondary outcomes, including newborns' haematocrit and bilirubin concentrations and severe maternal postpartum haemorrhage. On the advice of the Data and Safety Monitoring Committee, the trial was stopped due to futility at 25% of the planned sample size. CONCLUSIONS: When umbilical cord clamping is delayed for 3 min, term newborn infants born vigorous receive a clinically significant placental transfusion which is not modified by the administration of intravenous oxytocin immediately after birth. TRIAL REGISTRATION NUMBER: NCT02618499.

Guía de práctica clínica para el uso de uterotónicos en la prevención de la hemorragia posparto / Clinical practice guide for the use of uterotonics in postpartum hemorrhage prevention

Objetivo: Proveer recomendaciones para mejorar la calidad del cuidado y desenlaces para mujeres que reciben atención del parto, en relación a la prevención de la hemorragia posparto (HPP) por atonía uterina en El Salvador. Métodos: La presente guía fue desarrollada siguiendo los lineamientos del Manual para la elaboración de guías de la Organización Mundial de la Salud1. De forma general, se creó un grupo para la elaboración con enfoque multidisciplinario compuesto por expertos sobre el tema, epidemiólogos, metodólogos y pacientes. Con base en la evidencia proveniente de la guía para el uso de uterotónicos para la prevención de hemorragia posparto, se desarrolló una adaptación para el contexto del sistema de salud de El Salvador2. Se realizó inclusión de evidencia local y la contextualización de sus recomendaciones. Las recomendaciones fueron graduadas en un panel de expertos conformado por profesionales en estadística, enfermería, materno infantil, médicos generales y especialistas en ginecología y obstetricia, perinatología, anestesiología, medicina familiar, economía de la salud, epidemiología, además se incluyó la participación de pacientes siguiendo el enfoque GRADE. Adicionalmente, la guía fue evaluada por pares temáticos y metodológicos. Todos los participantes del panel y del grupo desarrollador firmaron un formato de conflicto de intereses que analizaron los coordinadores de la guía.

Care technologies to prevent and control hemorrhage in the third stage of labor: a systematic review. / Tecnologias de cuidado para prevenção e controle da hemorragia no terceiro estágio do parto: revisão sistemática.

OBJECTIVE: to identify evidence concerning the contribution of health technologies used to prevent and control hemorrhaging in the third stage of labor. METHOD: systematic review with database searches. First, two researchers independently selected the papers and, at a second point in time, held a reconciliation meeting. The Kappa coefficient was used to assess agreement, while the Grading of Recommendations, Assessment, Development and Evaluation was adopted to assess risk of bias and classify level of evidence. RESULTS: in this review, 42 papers were included, 34 of which addressed product technologies, most referred to pharmacological products, while two papers addressed the use of blood transparent plastic bags collector and the contribution of birth spacing and prenatal care. The eight papers addressing process technologies included the active management of the third stage of labor, controlled cord traction, uterine massage, and educational interventions. CONCLUSION: product and process technologies presented high and moderate evidence confirmed in 61.90% of the papers. The levels of evidence confirm the contribution of technologies to prevent and control hemorrhaging. Clinical nurses should provide scientific-based care and develop protocols addressing nursing care actions.

Prevention and management of primary postpartum hemorrhage among puerperae in a teaching hospital in São Paulo, Brazil: a best practice implementation project.

OBJECTIVES: The aim of this project was to develop and implement strategies to promote standardization and formal documentation of increased bleeding within the first 24 h after birth, in compliance with best practice. INTRODUCTION: Official data from Brazil shows a maternal mortality rate of around 52 to 75 deaths per 100,000 live births, 8% of which are caused by hemorrhage. Early diagnosis is promoted through standardization and formal documentation of the first signs of hemorrhage. METHODS: The current implementation project used the Joanna Briggs Institute Practical Application of Clinical Evidence System, a baseline audit was conducted on a sample size of 108 patients and 67 nursing staff. Based on the results of the baseline audit, strategies to address non-compliance were developed and implemented. A follow-up audit was conducted on a sample size of 110 patients and 68 nursing staff, using the same audit criteria. RESULTS: The baseline audit showed poor compliance with evidence-based best practice in every criterion. The implemented protocol for postpartum hemorrhage was well received by the nursing staff, promoting early diagnosis of increased bleeding within 24 h after birth and providing support for further medical treatment. There were significant improvements in every best practice criterion in the follow-up audit. CONCLUSION: The current implementation project managed to improve the nursing staff professional practice, reducing the absence of records while promoting greater awareness of the first signs of primary postpartum hemorrhage.

Tecnologias de cuidado para prevenção e controle da hemorragia no terceiro estágio do parto: revisão sistemática / Care technologies to prevent and control hemorrhage in the third stage of labor: a systematic review / Tecnologías de cuidado para prevención y control de la hemorragia en la tercera etapa del parto: revisión sistemática

Objetivo identificar evidências acerca das contribuições das tecnologias de cuidado usadas para prevenção e controle da hemorragia no terceiro estágio do parto. Método revisão sistemática com busca em bases de dados. Dois investigadores selecionaram os textos de forma independente na primeira etapa e, na segunda, em reunião de conciliação. Para avaliação da concordância, aplicou-se o coeficiente Kappa; para avaliação do risco de viés e classificação dos níveis de evidência, adotou-se o Grading of Recommendations, Assessment, Development and Evaluation. Resultados incluíram-se 42 artigos; desses, 34 classificados como tecnologias de produto, sendo a maioria produtos farmacológicos; dois referentes ao uso do saco plástico transparente para a coleta de sangue e contribuição do intervalo de nascimento e dos cuidados pré-natais. Os oito artigos classificados como tecnologias de processo se referiam a manejo ativo do terceiro estágio do parto, tração controlada de cordão, massagem uterina e intervenções educacionais. Conclusão as tecnologias de produto e de processo apresentaram evidência alta e moderada confirmada em 61,90% dos artigos. Os níveis de evidência demonstram contribuições das tecnologias para prevenção e controle da hemorragia. Na prática clínica, o enfermeiro deve oferecer cuidados à mulher fundamentados em evidências científicas e construir protocolos sobre as ações de cuidado da enfermagem.

Objective to identify evidence concerning the contribution of health technologies used to prevent and control hemorrhaging in the third stage of labor. Method systematic review with database searches. First, two researchers independently selected the papers and, at a second point in time, held a reconciliation meeting. The Kappa coefficient was used to assess agreement, while the Grading of Recommendations, Assessment, Development and Evaluation was adopted to assess risk of bias and classify level of evidence. Results in this review, 42 papers were included, 34 of which addressed product technologies, most referred to pharmacological products, while two papers addressed the use of blood transparent plastic bags collector and the contribution of birth spacing and prenatal care. The eight papers addressing process technologies included the active management of the third stage of labor, controlled cord traction, uterine massage, and educational interventions. Conclusion product and process technologies presented high and moderate evidence confirmed in 61.90% of the papers. The levels of evidence confirm the contribution of technologies to prevent and control hemorrhaging. Clinical nurses should provide scientific-based care and develop protocols addressing nursing care actions.

Objetivo identificar las evidencias acerca de las contribuciones de las tecnologías de cuidado usadas para la prevención y el control de la hemorragia en la tercera etapa del parto. Método revisión sistemática con búsqueda en bases de datos. Dos investigadores seleccionaron los textos, de forma independiente, en la primera etapa; y, en la segunda en reunión de conciliación. Para evaluación de la concordancia fue aplicado el coeficiente Kappa; para evaluación del riesgo de sesgo y clasificación de los niveles de evidencia, se adoptó el Grading of Recommendations, Assessment, Development and Evaluation. Resultados fueron incluidos 42 artículos; de estos, 34 fueron clasificados como: tecnologías de producto (siendo la mayoría productos farmacológicos), dos referentes a la contribución del saco plástico transparente recolector de sangre y del intervalo de nacimiento y de los cuidados prenatales. Los ocho artículos clasificados como tecnologías de proceso se referían al manejo activo de la tercera etapa del parto, a la tracción controlada del cordón, al masaje uterino y a intervenciones educacionales. Conclusión las tecnologías de producto y de proceso presentaron evidencia alta y moderada, lo que fue confirmado en 61,90% de los artículos. Los niveles de evidencia demuestran las contribuciones de las tecnologías para la prevención y el control de la hemorragia. En la práctica clínica, el enfermero debe ofrecer cuidados a la mujer fundamentados en evidencias científicas y construir protocolos sobre las acciones de cuidado de la enfermería.

Eficacia y seguridad de carbetocina endovenosa en la prevención de hemorragia postparto en gestantes con factores de riesgo para sobre-distensión uterina que requiriesen parto por cesárea / Efficacy and safety of intravenous carbetocin in the prevention of postpartum hemorrhage in pregnant women with risk factors for uterine over-distention that require cesarean delivery

INTRODUCCIÓN: El presente dictamen expone la evaluación de la eficacia y seguridad de la carbetocina 100 µg administrada vía endovenosa (EV) para la prevención de la hemorragia postparto (HPP) en gestantes con factores de riesgo para sobre-distensión uterina que requiriesen parto por cesárea. El American College of Obstetricians and Gynecologists define hemorragia postparto (HPP) como la pérdida de 1000 mL o más de sangre o la pérdida de sangre acompañada de signos y síntomas de hipovolemia dentro de las 24 horas postparto; independiente de la vía de nacimiento (i.e., vaginal o cesárea). En Perú, la HPP es la segunda causa de muerte materna durante el puerperio (21% de las muertes). Aproximadamente, el 80% de las HPP se deben a atonía uterina. Una de las principales causas de atonía es la distensión uterina. Los factores asociados a tal distensión incluyen: alta paridad, gestación múltiple, polihidramnios y macrosomía fetal. El presente dictamen preliminar expone la evaluación de la eficacia y seguridad de carbetocina 100 µg, EV, frente a la oxitocina, para la prevención de HPP en gestantes con factores de riesgo para sobre-distensión uterina, que requiriesen parto por cesárea. Los desenlaces de interés incluyen: frecuencia de sangrado de 1000 mL o más, histerectomía, eventos adversos, mortalidad, uso de fármacos uterotónicos y calidad de vida. TECNOLOGÍA SANITARIA DE INTERÉS: La tecnología a evaluarse es el uso de carbetocina 100 µg EV, dosis única, para la prevención de HPP en gestantes con riesgo de sobre-distensión uterina que requiriesen parto por cesárea. Carbetocina (1-deamino-1-monocarbo-[2-0-metiltirosina]-oxitocina) es un análogo sintético de oxitocina. Al igual que esta, se une a los receptores de oxitocina del tejido muscular liso del útero, para producir contracciones rítmicas. Así, se incrementa la frecuencia de las contracciones existentes y la tonicidad del útero controlando el sangrado. Los receptores de oxitocina son escasos en mujeres no gestantes pero se incrementan durante el embarazo y alcanzan su pico al momento del parto (National Center for Biotechnology Information) . La acción uterotónica de carbetocina EV, en gestantes, tiene una duración promedio de 60 ± 18 minutos (Hunter, Schulz, and Wassenaar 1992). METODOLOGÍA: Se llevó a cabo una búsqueda sistemática de la literatura con respecto a la eficacia y seguridad de carbetocina, comparado con oxitocina, para prevenir la hemorragia postparto en gestantes con factores de riesgo para sobre-distensión uterina y que requiriesen parto por cesárea. RESULTADOS: La búsqueda bibliográfica se realizó en tres etapas. Primero se realizó la búsqueda sistemática de evidencia sobre la eficacia y seguridad de carbetocina 100 µg EV, comparado con placebo; de acuerdo con la pregunta PICO validada con los especialistas. Sin embargo, la bibliografía mostró que oxitocina sería el comparador apropiado para la presente evaluación; dado que: (i) oxitocina es recomendada por la Organización Mundial de la Salud (OMS) y diversas guías de práctica clínica (GPC) internacionales para prevenir la HPP, (ii) en Perú, la Dirección General de Medicamentos, Insumos y Drogas señala que oxitocina es utilizada para el control (el cual incluye prevención) del sangrado uterino postparto, y (iii) se encuentra disponible en EsSalud para el manejo de HPP. Frente a ello, en la segunda etapa, se ampliaron los criterios de elegibilidad para incluir evidencia que compare carbetocina versus oxitocina. Sin embargo, la evidencia disponible para la población de interés de este dictamen (gestantes con factores de riesgo para sobre-distensión uterina) fue escasa. Por lo tanto, en la tercera etapa se ampliaron los criterios de elegibilidad para incluir toda GPC, ETS y RS que compare carbetocina y oxitocina en la población general de gestantes que tuvieron parto por cesárea. Al ser una población más amplia, se espera que la población de interés del presente dictamen esté incluida en estos estudios. CONCLUSIONES: Tras la búsqueda sistemática de literatura, solo se identificaron dos estudios observacionales que compararon la eficacia y seguridad de carbetocina y oxitocina en la población de interés (gestantes con factores de riesgo para sobre-distensión uterina que requirieron parto por cesárea). Ambos estudios sugieren que carbetocina y oxitocina son similares en eficacia y seguridad; sin embargo, los estudios observacionales no son suficientemente sólidos para determinar la eficacia comparativa de carbetocina frente a oxitocina, en la población de interés del presente dictamen. También se incluyeron dos GPC, dos ETS y dos RS con MA que respondían a la pregunta PICO en una población más amplia (gestantes que tuvieron parto de por cesárea). Esta evidencia indirecta coincide en que carbetocina y oxitocina son similares en eficacia (incidencia de HPP, control de sangrado) y seguridad (incidencia de eventos adversos). Carbetocina solo sería más eficaz en reducir la proporción de pacientes que requieren de tratamiento uterotónico adicional. Sin embargo, esta diferencia no conduce a una diferencia de relevancia clínica o una diferencia económicamente favorable. Con la evidencia disponible a la fecha, no se cuenta con argumentos técnicos que permitan concluir que carbetocina sea más eficaz o segura que oxitocina en la prevención de HPP en gestantes con factores de riesgo para sobre-distensión uterina. Siendo que carbetocina no ha probado ofrecer beneficios adicionales a oxitocina (alternativa disponible en el petitorio) ni en términos de eficacia, ni de seguridad o costos, oxitocina sigue siendo la mejor alternativa disponible para la prevención de HPP en la población mencionada. El Instituto de Tecnologías en Salud e Investigación - IETSI, no aprueba el uso de carbetocina 100 µg EV para la prevención de HPP en gestantes con factores de riesgo para sobre-distensión uterina que requiriesen parto por cesárea.