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