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WHO Recommendations for the Prevention & Management of Postpartum Haemorrhage Matthews Mathai

WHO Recommendations for the Prevention & Management of Postpartum Haemorrhage Matthews Mathai. Haemorrhage is the major cause of maternal death. Africa. WHO analysis of causes of maternal death: a systematic review Lancet 367: 1066-1074, 2006. Context.

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WHO Recommendations for the Prevention & Management of Postpartum Haemorrhage Matthews Mathai

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  1. WHO Recommendations for the Prevention & Management of Postpartum HaemorrhageMatthews Mathai

  2. Haemorrhage is the major cause of maternal death Africa WHO analysis of causes of maternal death: a systematic reviewLancet 367: 1066-1074, 2006

  3. Context • Increasing demands on countries to move to misoprostol for PPH prevention • WHO requested for guidance on best practices for prevention of PPH by • Member states • Developmental partners • Two meetings convened • Prevention of PPH Oct 2006 • Management of PPH Nov 2008

  4. PPH prevention (2007) 9 questions related to management of the 3rd stage of labour 3 critical outcomes Maternal death Blood loss ≥ 1000 ml Blood transfusion Subgroup by skilled and non-skilled attendants GRADE system for quality of evidence and strength of recommendations

  5. Prevention of PPH – Summary 1 • Active management of third stage of labour should be offered by skilled attendants to all women • Oxytocin is the preferred uterotonic • Ergometrine has similar beneficial effects but more adverse effects • Ergometrine may be used if oxytocin is not available but should be avoided in women with hypertension and heart disease • Misoprostol is less effective than oxytocin and has more adverse effects

  6. Prevention of PPH – Summary 2 • In the absence of active management of third stage of labour, a uterotonic should be offered to all women by a health care worker trained in its use • Late clamping of the cord has beneficial effects for the infant but the effects on the mother of timing of cord clamping are not known

  7. Guidelines: PPH Management (2009) 39 questions in 6 domains related to management of PPH Critical outcomes Additional blood loss ≥ 500/1000 ml Additional uterotonics Additional non-surgical and surgical interventions Blood transfusion Severe morbidity including procedure related complications Maternal temp > 40oC

  8. Which uterotonic for atonic PPH? Mostly indirect evidence from PPH prevention studies • Oxytocin should be preferred over other uterotonics • If oxytocin is not available or if bleeding continues • Offer ergometrine or FDC of oxytocin and ergometrine • If 2nd line treatment not available or if bleeding continues • Offer a prostaglandin as third line treatment

  9. Misoprostol as an adjunct • Four trials – over 1800 women who had AMTSL with oxytocin - 600 – 1000 mcg • Outcomes • Addl blood loss > 500 ml (RR 0.83; 95% CI 0.64-1.07) • Addl blood loss > 1 L (RR 0.76; 95% CI 0.43-1-34) • Blood transfusion (RR 0.96; 95% CI 0.77-1.19) • Recommendations: • No added benefit of misoprostol as adjunct treatment in women who have received oxytocin during third stage of labour. Oxytocin alone should be used(Moderate-high quality; strong)

  10. Misoprostol for treatment • One large trial – unpublished – 800 mcg misoprostol compared to 40 IU oxytocin – NO AMTSL • Misoprostol associated with • Addl blood loss > 500 ml (RR 2.66; 95% CI 1.62-4.38) • Receiving addl uterotonics (RR 1.79; 95% CI 1.19-2.69) • Temp > 40o C over 13% of women; none in oxytocin • Recommendation: • In women who have not received oxytocin for PPH prevention, oxytocin alone should be offered for treatment(Moderate-high quality; strong)

  11. Additional points • Oxytocin – higher effectiveness with fewer side effects • Make oxytocin available where not currently available • Misoprostol may be used if no other uterotonic is available but safest dose not clear

  12. Other interventions - 1 • Uterine massage: start when PPH is diagnosed • Bimanual uterine compression and external aortic compression as temporizing measures • Uterine packing not recommended • Intrauterine balloon/condom tamponade – if no response to uterotonics or if uterotonics are not available

  13. Other interventions - 2 • Non-pneumatic anti-shock garment • No recommendation pending results of ongoing research • Uterine artery embolization – consider if other measures have failed • If no response to other interventions, initiate surgical interventions starting with conservative approaches first

  14. WHO position on misoprostol for PPH prevention and treatment • Active management of third stage of labour (AMTSL) with oxytocin recommended for PPH prevention • In the absence of personnel to offer AMTSL, trained health worker should offer 600 mcg misoprostol orally immediately after birth of baby. In such cases no active intervention to deliver placenta should be carried out • WHO does not recommend distribution of misoprostol to community level health workers or women and their families for routine or emergency use • WHO recommends research at the community-level to investigate how PPH can be managed effectively at this level

  15. Updates • Application for inclusion of misoprostol for PPH prevention and treatment in WHO Model List will be reviewed by Expert Committee in March 2011 • Next update of WHO guidance on PPH prevention and treatment planned for 2012

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