Risk Factors for Carbetocin Failure after a Cesarean Section: Is Obesity One of Them?

Obese pregnant women have increased rates of fetal macrosomia, long labor, and cesarean sections, which lead to an increased risk of postpartum hemorrhage (PPH). Carbetocin is useful for the prevention of PPH after a cesarean section. Our study aimed to investigate predictors of carbetocin failure after a cesarean section, and specifically whether obesity is associated with carbetocin failure. We retrospectively analyzed all women who received carbetocin after a cesarean section. Carbetocin failure was defined as changes in hematocrit and hemoglobin, blood loss ≥ 1000 mL, and the need for an additional uterotonic agent or second-line therapies for persistent PPH. Univariate and multivariate analyses were performed to investigate predictors of carbetocin failure. The study included 600 women, with 131 (21.8%) obese women. Overall, 44 (7.3%) carbetocin failures were reported, and rates of obese women were similar between groups (carbetocin failure, 11.4% vs. 22.9%; p = 0.08). Previous PPH (p < 0.001), a cesarean section during labor (p = 0.01), cervical ripening (p = 0.02), and birthweight (p = 0.01) were significantly different between groups. In the multivariable logistic regression analysis adjusted for potential confounders, cervical ripening (adjusted odds ratio (OR) 2.23, 95% confidence interval (CI) 1.01–4.80), compared with spontaneous labor, was significantly associated with carbetocin failure. Obesity was not associated with carbetocin failure after cesarean sections.

Hemodynamic effects of carbetocin administered as an intravenous bolus or infusion during cesarean delivery

Background: Postpartum hemorrhage is the leading cause of maternal mortality. Oxytocin being the most popular uterotonic agent, has been routinely administered after both vaginal delivery and cesarean section. Carbetocin is a newer uterotonic agent and provides the benefit of a longer duration of action without additional administration post-delivery.Methods: We recruited 34 women undergoing elective cesarean section under spinal anesthesia. All patient was received spinal anesthesia using 0.5% hyperbaric Marcaine 8–10 mg in conjugation with fentanyl 20 μg in the left lateral decubitus position. Hartmann’s solution 10–15 ml/kg was administered before carbetocin. The operation started as soon as sensory block at level T4–T6 was confirmed. A non-invasive hemodynamic monitoring cuff (Finometer®) was attached to the patient’s finger soon after the induction of spinal anesthesia. Using the Finometer, we recorded the heart rate and mean arterial pressure at every 15 s, starting from 15 s before the administration of carbetocin to 5 min after. After the removal of the placenta, the bolus group was administered intravenous bolus injection of carbetocin 100 μg and the infusion group was administered carbetocin 100 μg diluted in 50 ml normal saline, over 5 min using an infusion pump.Results: The demographic data showed no significant difference between the two groups. Furthermore, there were no significant hemodynamic differences between the two groups.Conclusions: The method of administration of carbetocin does not influence its hemodynamic effects.

Induction of labor in twin gestation: can we predict success?

Objective: To identify factors associated with a successful induction of labor in twin pregnancies and associated maternal morbidity. Study design: This was a retrospective review of twin pregnancies ≥24 weeks’ gestation undergoing labor induction from 2011 to 2016. The primary outcome was a successful induction of labor. The secondary outcome was a composite of maternal morbidity, including ≥1 of the following: estimated blood loss (EBL) >1500 ml, blood transfusion, hysterectomy, intensive care unit (ICU) admission or maternal death. Results: Of 104 twin pregnancies undergoing labor induction, 64 (61.5%) had a vaginal delivery of both twins. Multiparity [odds ratio (OR) 12.3, 95% confidence interval (CI) 3.9–38.8, P≤0.005] and maternal age <35 years (OR 2.33, 95% CI 1.1–5.2, P=0.038) were independently associated with vaginal delivery. The overall rate of composite maternal morbidity was 7.7%. Cesarean delivery (CD) was associated with an increased rate of composite maternal morbidity compared to the successful induction group (17.5% vs. 1.6%, P≤0.005). An EBL >1500 ml, uterine atony and the use of ≥1 uterotonic agent were more frequent in the CD group. Conclusions: Multiparous women and those <35 years of age were more likely to have a vaginal delivery. Maternal morbidity is increased in women who required a CD after labor induction compared to those who achieved a vaginal delivery.

Randomized controlled trial of rectal misoprostal and intramuscular oxytocin in the prevention of PPH

Background: PPH accounts for merely 23% of maternal mortality in developing countries. Misoprostol is a uterotonic agent and is a PGE analogue commonly used in management of PPH. Oxytocin is another uterotonic agent which is now been introduced as intramuscularly effective agent to prevent PPH.This study aims to compare rectal misoprostol with intramuscular oxytocin in reducing blood loss in third stage of labor to prevent PPH. Objective of present study is to compare the clinical effect of rectal misoprostol with intramuscular oxytocin in prevention of PPH.Methods: A randomized study was conducted over duration of 3 months, at Department of OBG, BRIMS, Bidar, Karnataka, India. Patients with singleton pregnancy with the history of one previous LSCS and opting for elective LSCS were included in the study. Patients with risk pregnancy, such as pre eclampsia, cardiac disease and asthma or grand multipara were excluded from the study. Immediately after spinal anesthesia rectal misoprostol was given while oxytocin was administered after delivery of the baby. Incidence of PPH and amount of blood loss was observed and compared.Results: The difference in both the groups with regard to mean amount of blood loss, mean duration of the third stage of labor, and mean amount of fall in hemoglobin level was not statistically significant as P value was >0.05. The incidence of PPH and the need for additional oxytocic are slightly more in the misoprostol group. The incidence of shivering and pyrexia was more in the misoprostol group, but not so disturbing so as to lead to disuse of this drug.Conclusions: Oral misoprostol, though not a replacement of parenterally administered oxytocin, can be used safely in all deliveries for the prevention of postpartum hemorrhage.

MANAGEMENT OF THIRD STAGE OF LABOUR;

The routine prophylactic administration of an uterotonic agent is an integralpart of active management of the third stage of labor, helping to prevent postpartum haemorrhage (PPH). The two mostwidely used uterotonic agents are: ergometrine-oxytocin (Syntometrine ®) (a combination of oxytocin, 5 internationalunits (iu) and ergometrine, 0.5 mg) and oxytocin, (Syntocinon ®) 10 international units (iu). Objective: To compare theefficacy and safety of intravenous oxytocin, with intramuscularly syntometrine in the management of third stage of labor.Study design: Experimental study. Setting: Department of obstetrics and gynaecology Combined Military HospitalPeshawar. Period: Over one year period from March 2005 to March 2006. Methods: A total 200 women havingsingleton pregnancy and vaginal delivery admitted in maternity ward were divided in two treatment groups by simplerandom sampling using random number tables, 100 patients received 2 ml Syntometrine, (a combination of oxytocin,5iu and ergometrine meleate 0.5mg) intramuscularly and 100 patients received 10iu of intravenous syntocinon at thedelivery of anterior shoulder of the fetus. Results: The use of intravenous oxytocin,, was associated with a reductionin postpartum blood loss (P<0.001) but there was no difference in the risk of post partum hemorrhage, in the need forrepeated oxytocin injections and the drop in peripartum hemoglobin level between the two groups, and need for bloodtransfusion. There was also no difference in the risk of prolonged third stage, or manual removal placenta. The useof syntometrine was associated with a higher risk of hypertension (RR 2.39, 95% Cl 1.00-5.70) other side effects weremild in nature with no differences between the two groups. Conclusions: There are no important clinical differencesin the effectiveness of intramuscular syntometrine and. Intravenous oxytocin for the prevention of post partum bloodloss. Intravenous oxytocin is less likely to cause hypertension and other side effect profiles are low

Oxytocin in human intrauterine tissues at parturition

The recent detection of oxytocin (OT) mRNA in human gestational tissues suggests that OT may be locally synthesized and released to act on the uterus as a local mediator in the mechanism of parturition. In order to investigate this possibility the OT immunoreactive (I.R.) content was examined directly in placental decidua and amniochorial membranes after term and preterm delivery and in their culture media at term gestation. I.R.OT concentrations were also measured in maternal, retroplacental and umbilical plasma as well as in amniotic fluid in the presence or the absence of labour. Low I.R.OT concentrations (below 15 fmol g-1 wet tissue) were found in both amniochorial membranes and placental decidua. Moreover, whereas in amniochorion they were higher (P < 0.05) after preterm than term spontaneous parturition, in decidua they were higher (P < 0.05) after term than preterm vaginal delivery. Detectable amounts (below 15 fmol g-1 wet tissue per h) of I.R.OT were also found in culture media from explants of the above tissues. Among all the examined maternal and fetal fluids a rise in I.R.OT content at parturition was detected only in the amniotic liquor (P < 0.05). These findings suggest that I.R.OT concentrations in intrauterine tissues are very low; however, considering that OT is the most potent endogenous uterotonic agent, OT as such concentrations might play a paracrine function in the biochemical events leading to human parturition. Therefore, a role for amniotic OT in parturition can not be excluded.