Prevention of postpartum hemorrhage in moderate and high-risk patients: Addition of prophylactic misoprostol.
Academic Article
Overview
abstract
OBJECTIVE: We sought to evaluate the impact of a prospective change in practice to dual pharmacologic prophylaxis with oxytocin and misoprostol for patients at moderate or high risk for postpartum hemorrhage (PPH) based on validated hemorrhage risk assessments on PPH rates, quantitative blood loss (QBL) amounts, and morbidities. METHODS: A quality improvement effort was undertaken with the addition of sublingual misoprostol prophylaxis immediately after birth for patients with moderate or high risk for hemorrhage during pre-birth PPH risk assessment, 200 μg for moderate and 400 μg for high risk. "Oxytocin only" prophylaxis was administered June 2021 to April 2022 and "dual agent" prophylaxis was given April 2022 to April 2023. INCLUSION CRITERIA: deliveries ≥20 weeks' gestation with moderate or high-risk pre-birth PPH risk assessment. EXCLUSION CRITERIA: missing QBL, gestational age <20 weeks or low PPH risk. Primary outcomes were QBL at delivery and total postpartum blood loss (PPBL). Secondary outcomes were PPH rate (≥ 1000 mL) and a composite of maternal morbidity. Data were captured electronically retrospectively for both time periods, with morbidities confirmed by chart review. RESULTS: A total of 2104 (47.9%) patients were treated with oxytocin only prophylaxis and 2293 (52.1%) patients were in the intervention period with dual agent prophylaxis. The cesarean delivery rate for the oxytocin only group was 37.3%, and 39.2% for the dual agent prophylaxis group. Postpartum hemorrhage rate was similar between the two groups, but composite morbidity was significantly lower for the dual agent prophylaxis group (0.4% vs. 1.4% for single agent prophylaxis; P < 0.001). In a subgroup analysis of cesarean delivery, PPH rate and composite morbidity were significantly lower for the dual agent prophylaxis group after adjusting for potential confounders (PPH rate: odds ratio [OR]: 0.76, 95% confidence interval [CI]: 0.60-0.95, P = 0.02; composite morbidity: OR: 0.31, 95% CI: 0.12-0.69, P = 0.004). CONCLUSION: Dual agent prophylaxis with oxytocin and misoprostol immediately after delivery was associated with a significant reduction in total blood loss, PPH rates, and composite morbidity compared to oxytocin only prophylaxis in patients undergoing cesarean birth. Prospective studies are warranted to assess replicability and safety.
