who recommendations for the prevention & management of postpartum haemorrhage matthews mathai

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Africa Regional Meeting on Interventions for Impact in Essential Maternal and Newborn Care, Addis Ababa, Feb 21, 2011

WHO Recommendations for the Prevention & Management of

Postpartum Haemorrhage

Matthews Mathai

WHO Recommendations for the Prevention & Management of

Postpartum Haemorrhage

Matthews Mathai

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Haemorrhage is the major cause of maternal death

Haemorrhage is the major cause of maternal death

Haemorrhage, 33.9

Hypertensive Disorders, 9.1

Sepsis/Infections, 9.7Abortion, 3.9

Obstructed Labour, 4.1

Ectopic Pregnancy, 0.5

Embolism, 2.0

Other Direct, 4.9

HIV/AIDS, 6.2

Anaemia, 3.7

Other Indirect Deaths, 16.7

Unclassified Deaths, 5.4Africa

WHO analysis of causes of maternal death: a systematic reviewLancet 367: 1066-1074, 2006

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ContextContext

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

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PPH prevention (2007)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

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Prevention of PPH – Summary 1Prevention 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

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Prevention of PPH – Summary 2Prevention 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

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Guidelines: PPH Management (2009)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

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Which uterotonic for atonic PPH?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

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Misoprostol as an adjunctMisoprostol 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)

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Misoprostol for treatmentMisoprostol 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)

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Additional pointsAdditional 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

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Other interventions - 1Other 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

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Other interventions - 2Other 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

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WHO position on misoprostol for PPH prevention and treatment

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

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UpdatesUpdates

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

who recommendations for the prevention & management of postpartum haemorrhage matthews mathai

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