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WHO Recommendations Uterotonics for the Prevention of Postpartum Haemorrhage PowerPoint Presentation

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Description : Check out this medical presentation on Obstetrics & Gynecology, which is titled "WHO Recommendations - Uterotonics for the Prevention of Postpartum Haemorrhage", to know about WHO recommendations on uterotonics for the prevention of postpartum haemorrhage.

Tags : Obstetrics, Gynecology, WHO, Recommendations, Uterotonics, Prevention, Postpartum Haemorrhage

Published on : Jul 18, 2021 | Views : 2394 | Downloads : 4

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The global burden of postpartum haemorrhage 01 table of contents Uterotonics for PPH prevention 02 How were the WHO recommendations updated? 03 What are the updated WHO recommendations? 04 So what’s new? 05 06 Implementing the WHO recommendations
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What is postpartum haemorrhage? Postpartum haemorrhage (PPH) is the leading cause of maternal death worldwide. Postpartum haemorrhage (PPH) is commonly defined as a blood loss of 500 ml or more within 24 hours after birth. It affects about 5% of all women giving birth around the world. Globally, nearly one quarter of all maternal deaths are associated with PPH. In most low-income countries, it is the main cause of maternal mortality. The majority of PPH-associated deaths could be avoided by the use of prophylactic uterotonics during the third stage of labour and appropriate treatment. Improving health care for women during childbirth to prevent and treat PPH is a necessary step towards achievement of the health targets of the Sustainable Development Goals (SDGs). 1. the global burden of postpartum haemorrhage section 01 99% of all maternal deaths occur in low- and middle-income countries (LMICs).
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New findings on uterotonics for PPH prevention 2. Uterotonics for PPH prevention section 02 196 trials (135 559 women) across 53 countries Any trial comparing a uterotonic vs placebo, no uterotonic or another uterotonic Single agents (oxytocin, carbetocin, misoprostol, ergometrine) or combination agents (oxytocin plus ergometrine, oxytocin plus misoprostol) A Cochrane systematic review and network meta-analysis compared uterotonic options with no uterotonic and other uterotonic options. Gallos et al. Uterotonic agents for preventing postpartum haemorrhage: a network meta‐analysis. Cochrane Database Syst Rev. CD011689.
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New findings on uterotonics for PPH prevention 2. Uterotonics for PPH prevention section 02 196 trials (135 559 women) across 53 countries Any trial comparing a uterotonic vs placebo, no treatment or another uterotonic Single agents (oxytocin, carbetocin, misoprostol, ergometrine) or combination agents (oxytocin plus ergometrine, oxytocin plus misoprostol) A Cochrane systematic review and network meta-analysis compared all uterotonic options and placebo or no treatment. In light of this new evidence, the WHO recommendations on uterotonics for PPH prevention have been updated The WHO PPH recommendations were first published in 2012. These updated recommendations (2018) supersede the previous recommendations on uterotonics for PPH prevention.
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A systematic approach The recommendations were updated according to the standards of the WHO handbook on guideline development 3. how were the WHO recommendations updated? section 03 Updating involves: WHO Steering Group Guideline Development Group (GDG) Executive Guideline Steering Group (GSG) External Review Group Systematic review team External partners and observers
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GDG formulates the recommendations The Guideline Development Group (GDG) convened in September & October 2018 The GDG comprised 18 external experts and relevant stakeholders with expertise in research, guideline development, policy and programmes on PPH prevention and treatment. 3. how were the WHO recommendations updated? section 03 GDG members considered: Balance between desirable and undesirable effects Overall quality of supporting evidence Values and preferences of stakeholders Resource requirements Cost-effectiveness Acceptability Feasibility Equity
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What works? Efficacy and safety of uterotonics for PPH prevention uterotonic options vs placebo or no treatment 4. What are the updated WHO recommendations? section 04 Which one? Choice of uterotonics for PPH prevention uterotonic options vs other uterotonic options
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Recommendation 1. The use of an effective uterotonic for the prevention of PPH during the third stage of labour is recommended for all births. To effectively prevent PPH, only one of the following uterotonics should be used: Oxytocin Carbetocin Misoprostol Ergometrine/methylergometrine Oxytocin and ergometrine fixed-dose combination 4. What works: efficacy and safety of uterotonics for PPH prevention section 04
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Recommendation 1. The use of an effective uterotonic for the prevention of PPH during the third stage of labour is recommended for all births. To effectively prevent PPH, only one of the following uterotonics should be used: Oxytocin Carbetocin Misoprostol Ergometrine/methylergometrine Oxytocin and ergometrine fixed-dose combination 4. What works: efficacy and safety of uterotonics for PPH prevention section 04 Recommendation 1.1 The use of oxytocin (10 IU, IM/IV) is recommended for the prevention of PPH for all births. Vaginal birth or caesarean section Skilled health personnel required to administer At caesarean section: consider dividing doses and avoid a rapid IV bolus
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Recommendation 1. The use of an effective uterotonic for the prevention of PPH during the third stage of labour is recommended for all births. To effectively prevent PPH, only one of the following uterotonics should be used: Oxytocin Carbetocin Misoprostol Ergometrine/methylergometrine Oxytocin and ergometrine fixed-dose combination 4. What works: efficacy and safety of uterotonics for PPH prevention section 04 Recommendation 1.2 The use of carbetocin (100 µg, IM/IV) is recommended for the prevention of PPH for all births in contexts where its cost is comparable to other effective uterotonics. Vaginal birth or caesarean section Skilled health personnel required to administer For PPH prevention only
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Recommendation 1. The use of an effective uterotonic for the prevention of PPH during the third stage of labour is recommended for all births. To effectively prevent PPH, only one of the following uterotonics should be used: Oxytocin Carbetocin Misoprostol Ergometrine/methylergometrine Oxytocin and ergometrine fixed-dose combination 4. What works: efficacy and safety of uterotonics for PPH prevention section 04 Recommendation 1.3 The use of misoprostol (either 400 µg or 600 µg PO) is recommended for the prevention of PPH for all births. Alternative routes may be needed at caesarean section, but oral route is preferred by women No clear evidence of which dose is superior, but higher doses have more side effects Inform women of possible adverse effects Can be used in hospital or community
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Recommendation 1. The use of an effective uterotonic for the prevention of PPH during the third stage of labour is recommended for all births. To effectively prevent PPH, only one of the following uterotonics should be used: Oxytocin Carbetocin Misoprostol Ergometrine/methylergometrine Oxytocin and ergometrine fixed-dose combination 4. What works: efficacy and safety of uterotonics for PPH prevention section 04 Recommendation 1.4 The use of ergometrine (200 µg, IM/IV) is recommended for the prevention of PPH in contexts where hypertensive disorders can be safely excluded prior to its use Vaginal birth or caesarean section Skilled health personnel are required Inform women of possible side effects - other options may have better side effect profile
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Recommendation 1. The use of an effective uterotonic for the prevention of PPH during the third stage of labour is recommended for all births. To effectively prevent PPH, only one of the following uterotonics should be used: Oxytocin Carbetocin Misoprostol Ergometrine/methylergometrine Oxytocin and ergometrine fixed-dose combination 4. What works: efficacy and safety of uterotonics for PPH prevention section 04 Recommendation 1.5 The use of oxytocin and ergometrine fixed-dose combination (5 IU/500 µg IM) is recommended for the prevention of PPH in contexts where hypertensive disorders can be safely excluded prior to its use. Vaginal birth or caesarean section Skilled health personnel are required
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Recommendation 1. The use of an effective uterotonic for the prevention of PPH during the third stage of labour is recommended for all births. To effectively prevent PPH, only one of the following uterotonics should be used: Oxytocin Carbetocin Misoprostol Ergometrine/methylergometrine Oxytocin and ergometrine fixed-dose combination Injectable prostaglandins 4. What works: efficacy and safety of uterotonics for PPH prevention section 04 Recommendation 1.6 Injectable prostaglandins (carboprost or sulprostone) are not recommended for the prevention of PPH
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How do we compare uterotonics to one another? 4. Which one: identifying a uterotonic of choice section 04 Comparing uterotonics through oxytocin as a common comparator Oxytocin is current standard of care Largest number of trials in the network meta-analysis The natural sequence for introducing a new uterotonic option is to evaluate efficacy with the “gold standard” option section 04 Oxytocin
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Desirable outcomes How do the effects of carbetocin compare to oxytocin for these outcomes?
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4. Which one: Summary of judgements comparing uterotonics to oxytocin (reference) These criteria were considered by the GDG for each uterotonic option
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4. Which one: Summary of judgements comparing uterotonics to oxytocin (reference) Oxytocin is the reference comparator
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4. Which one: Summary of judgements comparing uterotonics to oxytocin (reference) Carbetocin compared to oxytocin Similar desirable effects, and carbetocin likely superior in reducing PPH (≥ 500 ml) (41 fewer events per 1000 women), use of additional uterotonics (74 fewer per 1000) and blood loss after birth (81 ml less on average). No clear difference in undesirable effects While balance of effects probably favours carbetocin, the supply cost of carbetocin is approximately 20 times more than oxytocin Uncertain whether the additional benefits justify the additional cost of routinely implementing carbetocin at the current unit price Acceptability among stakeholders and impact on health equity would vary across settings compared with oxytocin.
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4. Which one: Summary of judgements comparing uterotonics to oxytocin (reference) Misoprostol compared to oxytocin Misoprostol has similar desirable effects to oxytocin, but it is less effective for reducing severe PPH (≥ 1000 ml) (7 more events per 1000 women). Causes more undesirable effects (including nausea, vomiting, shivering, fever and diarrhoea). Misoprostol is cheaper, heat-stable, can be used orally, and is probably acceptable and feasible to use. Lower effectiveness for severe PPH and greater undesirable effects may increase costs (these costs may vary according to the setting). Can be task-shifted to lay health workers and community health workers.
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4. Which one: Summary of judgements comparing uterotonics to oxytocin (reference) Ergometrine / methylergometrine compared to oxytocin No clear evidence of difference in desirable effects. However, women are more likely to experience nausea, vomiting, headache, hypertension and diarrhoea with ergometrine. Costs associated with managing undesirable effects, as well as the need to screen for high blood pressure, implies that oxytocin is probably more cost-effective. Ergometrine may have negative effects on health equity in settings with high rates of – or lack of screening for – hypertensive disorders.
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4. Which one: Summary of judgements comparing uterotonics to oxytocin (reference) Oxytocin plus ergometrine compared to oxytocin Similar to oxytocin in terms of desirable outcomes, though it is possibly more effective in preventing PPH (≥ 500 ml) (44 fewer events per 1000 women). More undesirable effects than oxytocin, including nausea, vomiting and diarrhoea. Balance of effects clearly favours oxytocin. Costs related to undesirable effects, as well as the need to screen for women with hypertensive disorders, imply that oxytocin is probably more cost-effective. May have a negative impact on health equity, particularly in settings with limited capacity and capability to routinely screening for hypertensive disorders of pregnancy.
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4. Which one: Summary of judgements comparing uterotonics to oxytocin (reference) Misoprostol plus oxytocin compared to oxytocin Probably superior to oxytocin for blood transfusion (11 fewer events per 1000 women), additional uterotonic use (58 fewer per 1000) and blood loss (88 ml less on average). May possibly prevent more PPH (≥ 500 ml) (44 fewer per 1000) and result in a smaller mean change in haemoglobin level (before versus after birth). Associated with more undesirable effects including nausea, vomiting, diarrhoea, shivering and fever. Balance of effects favours oxytocin. Cost-effectiveness may vary in different settings. Feasibility is limited due to the complexity of using two separate medications through different routes of administration.
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Recommendation 2. In settings where multiple uterotonic options are available, oxytocin (10 IU, IM/IV) is the recommended uterotonic agent for the prevention of PPH for all births. Vaginal birth or caesarean section Skilled health personnel are required 4. Which one: Choice of uterotonics for PPH prevention section 04 Combination of misoprostol and oxytocin may be more effective than oxytocin alone for some priority outcomes, however: increases side effects not available as a fixed dose combination requires parenteral and oral administration section 04
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Recommendation 3. In settings where oxytocin is unavailable (or its quality cannot be guaranteed), the use of other injectable uterotonics (carbetocin, or if appropriate ergometrine/methylergometrine or oxytocin and ergometrine fixed-dose combination) or oral misoprostol is recommended. Vaginal birth or caesarean section Skilled health personnel are required 4. Which one: Choice of uterotonics for PPH prevention section 04
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Recommendation 4. In settings where skilled health personnel are not present to administer injectable uterotonics, the administration of misoprostol (either 400 µg or 600 µg PO) by community health care workers and lay health workers is recommended for the prevention of PPH. If skilled health personnel are not present or have not been trained to administer injectable uterotonics, oral misoprostol is preferred 4. Which one: Choice of uterotonics for PPH prevention section 04
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5. What’s new: wider scope, more evidence section 05
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5. So what’s new: More recommendations, greater specificity section 05 * Context specific recommendation
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6. implementing the updated WHO recommendations Is oxytocin available? Use oxytocin (10 IU, IV or IM) Oxytocin is not available, or its quality cannot be guaranteed Misoprostol (400 µg or 600 µg PO) Are skilled health personnel who can administer injectable uterotonics available? Trained community health workers and lay health workers can administer misoprostol (400 µg or 600 µg PO) No No Yes Is oxytocin of sufficient quality? No Heat-stable carbetocin (100 µg, IM/IV), in contexts where its cost is comparable to other effective uterotonics. Ergometrine / methylergometrine (200 µg, IM/IV), in contexts where hypertensive disorders can be safely excluded prior to its use. Fixed-dose combination of oxytocin and ergometrine, in contexts where hypertensive disorders can be safely excluded prior to its use. OR OR OR Yes Yes section 06
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Implementation considerations Update clinical guidance Develop or revise existing clinical guidelines, protocols or job aids 6. implementing the updated WHO recommendations Equip health facilities Ensure necessary supplies, equipment and staff to use uterotonics safely Support behaviour change Obtain technical support for implementation, engage stakeholders and partners, and provide training section 06
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Implementation considerations Quality-certified uterotonics Regulatory, procurement and logistics processes that work 6. implementing the updated WHO recommendations Cold-chain transport & storage For heat-sensitive uterotonics (oxytocin, ergometrine) Effective communication Ensure women are informed of risks, benefits and alternatives section 06
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