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Reproductive Health Oct 2017Around 303,000 maternal deaths occur every year; most of these are preventable (World Health Organization), ICD-10: International classification of diseases and related... (Review)
Review
BACKGROUND
Around 303,000 maternal deaths occur every year; most of these are preventable (World Health Organization), ICD-10: International classification of diseases and related health problems, 10th revision. Volume 2: Instruction manual, 2010). Ninety-nine percent of these maternal deaths occur in developing countries. PPH contributed 35 % (35%) of total maternal. Several interventions being done to reduce the number of maternal deaths. It has been noted that a simple low cost intervention of providing misoprostol timely could prevent these deaths.
OBJECTIVES
The objectives of this systematic review was to identify barriers/gaps in the implementation of misoprostol use for prevention of postpartum hemorrhage and management of Post-abortion care services in developing countries.
METHODS
This study was a systematic review of published qualitative and quantitative literature on misoprostol in developing countries. Documents included were local and international peer reviewed articles and program reports on misoprostol implementation. PubMed, Google Scholars and Science direct databases were used along with Grey literature and manual search using terms "implementation gaps", "misoprostol use", "postpartum hemorrhage", "post-abortion care" and "developing countries".
RESULTS
Gaps or barriers in misoprostol use identified through systematic review can be categorized into six broader thematic areas including: inconsistency in supplies and its distribution; inadequate staffing; lack of knowledge of providers and end users, absence of the registration of drug and fear and apprehensions related to its use at provider and policy level.
CONCLUSION
It is concluded that barriers and gaps can be addressed through providing enabling environment through supportive policies, designing a formal plan for supplies, task shifting strategies and use of guidelines and protocols for successful implementation.
Topics: Developing Countries; Female; Humans; Maternal Death; Misoprostol; Oxytocics; Postpartum Hemorrhage; Postpartum Period; Pregnancy
PubMed: 29078777
DOI: 10.1186/s12978-017-0383-5 -
Proceedings of the National Academy of... Jun 2014Recent evidence suggests that enduring social bonds have fitness benefits. However, very little is known about the neural circuitry and neurochemistry underlying the...
Recent evidence suggests that enduring social bonds have fitness benefits. However, very little is known about the neural circuitry and neurochemistry underlying the formation and maintenance of stable social bonds outside reproductive contexts. Oxytocin (OT), a neuropeptide synthetized by the hypothalamus in mammals, regulates many complex forms of social behavior and cognition in both human and nonhuman animals. Animal research, however, has concentrated on monogamous mammals, and it remains unknown whether OT also modulates social bonds in nonreproductive contexts. In this study we provide behavioral evidence that exogenous OT promotes positive social behaviors in the domestic dog toward not only conspecifics but also human partners. Specifically, when sprayed with OT, dogs showed higher social orientation and affiliation toward their owners and higher affiliation and approach behaviors toward dog partners than when sprayed with placebo. Additionally, the exchange of socio-positive behaviors with dog partners triggered the release of endogenous OT, highlighting the involvement of OT in the development of social relationships in the domestic dog. These data provide new insight into the mechanisms that facilitate the maintenance of close social bonds beyond immediate reproductive interest or genetic ties and complement a growing body of evidence that identifies OT as one of the neurochemical foundations of sociality in mammalian species.
Topics: Animals; Behavior, Animal; Dogs; Female; Humans; Male; Oxytocics; Oxytocin; Social Behavior
PubMed: 24927552
DOI: 10.1073/pnas.1322868111 -
International Journal of Gynaecology... Jan 2013Little is known about the use of traditional preparations for uterotonic effects at or near delivery in Sub-Saharan Africa. (Review)
Review
BACKGROUND
Little is known about the use of traditional preparations for uterotonic effects at or near delivery in Sub-Saharan Africa.
OBJECTIVE
To describe (1) use of traditional preparations in Sub-Saharan Africa intended to have uterotonic effects at or near birth; and (2) results of pharmacologic investigations of the uterotonic properties of such preparations.
SEARCH STRATEGY
Structured review of 13 databases.
SELECTION CRITERIA
Articles describing use of traditional preparations in Sub-Saharan Africa with primary data, published in English between January 1, 1980 and June 30, 2010.
DATA COLLECTION AND ANALYSIS
Full-text review using standard spreadsheet templates.
MAIN RESULTS
Objective 1 analysis identified 208 plant species used for uterotonic effects at or near delivery. The most common use was labor induction/augmentation (n=185). Other uses were to expel the placenta, shorten the third stage of labor, manage retained placenta (n=61), and prevent/manage postpartum hemorrhage (n=20). Objective 2 analysis identified 82 species with uterotonic activity confirmed through pharmacologic evaluation. Studies also identified potentiating/inhibiting effects of extracts on pharmaceutical uterotonics.
CONCLUSION
Numerous plants are used for uterotonic effects in Sub-Saharan Africa; uterotonic activity has been confirmed in many through pharmacologic evaluation. Such use may increase the risk of adverse outcomes. Further research is needed on the uterotonic efficacy of traditional preparations and on interventions to address use during labor.
Topics: Africa South of the Sahara; Animals; Delivery, Obstetric; Female; Humans; Labor, Obstetric; Medicine, African Traditional; Oxytocics; Plant Extracts; Plants, Medicinal; Pregnancy; Uterine Contraction
PubMed: 23021290
DOI: 10.1016/j.ijgo.2012.06.020 -
BMC Pregnancy and Childbirth Nov 2017Postpartum haemorrhage (PPH) is a major cause of maternal mortality and morbidity worldwide. Experimental and clinical studies indicate that prolonged oxytocin exposure... (Review)
Review
BACKGROUND
Postpartum haemorrhage (PPH) is a major cause of maternal mortality and morbidity worldwide. Experimental and clinical studies indicate that prolonged oxytocin exposure in the first or second stage of labour may be associated with impaired uterine contractility and an increased risk of atonic PPH. Therefore, particularly labouring women requiring cesarean delivery constitute a subset of patients that may exhibit an unpredictable response to oxytocin. We mapped the evidence for comparative studies investigating the hypothesis whether the risk for PPH is increased in women requiring cesarean section after induction or augmentation of labour.
METHODS
We performed a systematic literature search for clinical trials in Medline, Embase, Web of Science, and the Cochrane Library (May 2016). Additionally we searched for ongoing or unpublished trials in clinicaltrials.gov and the WHO registry platform. We identified a total of 36 controlled trials investigating the exogenous use of oxytocin in cesarean section. Data were extracted for study key characteristics and the current literature literature was described narratively.
RESULTS
Our evidence map shows that the majority of studies investigating the outcome PPH focused on prophylactic oxytocin use compared to other uterotonic agents in the third stage of labour. Only 2 dose-response studies investigated the required oxytocin dose to prevent uterine atony after cesarean delivery for labour arrest. These studies support the hypotheses that labouring women exposed to exogenous oxytocin require a higher oxytocin dose after delivery than non-labouring women to prevent uterine atony after cesarean section. However, the study findings are flawed by limitations of the study design as well as the outcome selection. No clinical trial was identified that directly compared exogenous oxytocin versus no oxytocin application before intrapartum cesarean delivery.
CONCLUSION
Despite some evidence from dose-response studies that the use of oxytocin may increase the risk for PPH in intrapartum cesarean delivery, current research has not investigated the prepartal application of oxytocin in well controlled clinical trials. It was striking that most studies on exogenous oxytocin are focused on PPH prophylaxis in the third stage of labour without differing between the indications of cesarean section and hence the prepartal oxytocin status.
Topics: Adult; Cesarean Section; Female; Humans; Labor, Induced; Maternal Mortality; Oxytocics; Oxytocin; Postpartum Hemorrhage; Pregnancy; Risk Factors; Trial of Labor; Uterine Inertia; Young Adult
PubMed: 29187156
DOI: 10.1186/s12884-017-1584-1 -
The Cochrane Database of Systematic... Sep 2013Labour dystocia is associated with a number of adverse maternal and neonatal outcomes. Augmentation of labour is a commonly used intervention in cases of labour... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Labour dystocia is associated with a number of adverse maternal and neonatal outcomes. Augmentation of labour is a commonly used intervention in cases of labour dystocia. Misoprostol is an inexpensive and stable prostaglandin E1 analogue that can be administered orally, vaginally, sublingually or rectally. Misoprostol has proven to be effective at stimulating uterine contractions although it can have serious, and even life-threatening side-effects. Titration refers to the process of adjusting the dose, frequency, or both, of a medication on the basis of frequent review to achieve optimal outcomes. Studies have reported on a range of misoprostol titration regimens used for labour induction and titrated misoprostol may potentially be effective and safe for augmentation of labour.
OBJECTIVES
To examine the effects and safety of titrated oral misoprostol compared with placebo, oxytocin, other interventions, or no active treatment, in women with labour dystocia.
SEARCH METHODS
The Trials Search Co-ordinator of the Cochrane Pregnancy and Childbirth Group searched the Cochrane Pregnancy and Childbirth Group's Trials Register; date of search: 29 May 2013. We also searched the reference lists of retrieved studies
SELECTION CRITERIA
Randomised trials (including quasi-randomised and cluster-randomised trials) comparing titrated oral misoprostol with placebo, other interventions (e.g. oxytocin, other prostaglandins), or no treatment in women requiring augmentation of labour were eligible for inclusion.
DATA COLLECTION AND ANALYSIS
Two review authors independently assessed eligibility for inclusion, carried out data extraction and assessed risk of bias in included studies. Data were entered by one author and checked for accuracy.
MAIN RESULTS
We included two randomised trials with a total of 581 women each comparing different regimens of titrated oral misoprostol with intravenous oxytocin. One study compared 20 mcg doses of misoprostol dissolved in water (repeated every hour up to four hours, after which the dose was increased to 40 mcg per hour up to a maximum total dose of 1600 mcg), while the second study gave women 75 mcg doses (repeated after four hours provided there were no adverse effects observed).Neither trial reported maternal death, severe maternal morbidity, or fetal/neonatal mortality outcomes, and only a few fetal/neonatal morbidity outcomes were considered, none of which were significantly different between groups. For several outcomes (such as maternal side-effects, instrumental birth, maternal blood transfusion for hypovolaemia and epidural analgesia), the number of events was generally too low for sufficient statistical power to be achieved. Maternal satisfaction was not reported in either trial. One trial reported a slight reduction in the median duration of labour from the start of augmentation to vaginal delivery in the oxytocin group.Neither trial reported significantly higher rates of caesarean section (CS) in the oral misoprostol group. Rates of vaginal delivery within 12 and 24 hours of commencing augmentation were not significantly different in the trial using a 20 mcg misoprostol dose. Neither trial had significantly higher rates of uterine hyperstimulation with fetal heart rate changes in the titrated oral misoprostol group. However, the rates of this outcome varied so greatly between the two studies as to suggest that other factors were at play. The only significant differences between groups related to uterine hyperstimulation (without fetal heart rate changes), and results were not consistent in the two trials. In the trial examining the higher dose of misoprostol, more women in the misoprostol group experienced hyperstimulation of labour measured over a 10-minute period compared with those receiving oxytocin (risk ratio (RR) 1.17, 95% confidence interval (CI) 1.02 to 1.35, 350 women). In the study examining the lower titrated dose of misoprostol, there was a lower incidence of tachysystole when labour was augmented with titrated oral misoprostol than with oxytocin (RR 0.39, 95% CI 0.17 to 0.91, 231 women) with no occurrences of hypertonus in either group of women.
AUTHORS' CONCLUSIONS
Important uncertainties still exist on the safety and acceptability of titrated oral misoprostol compared with intravenous oxytocin regimens in women with dystocia following spontaneous onset of labour. Although in facilities where electronic oxytocin infusion is not available, low-dose titrated misoprostol may offer a better alternative to an uncontrolled oxytocin infusion to avoid hyperstimulation. Further research is needed in both high- and low-resource settings More trials should be conducted to evaluate the effect of a standard titration oral misoprostol regimen, both following spontaneous labour and labour induction. Comparisons with other augmentation methods are also warranted, as are any effects on women's birth experiences.
Topics: Administration, Oral; Cervical Ripening; Delivery, Obstetric; Female; Humans; Injections, Intravenous; Misoprostol; Oxytocics; Oxytocin; Pregnancy; Pregnancy Outcome; Randomized Controlled Trials as Topic
PubMed: 24058051
DOI: 10.1002/14651858.CD010648.pub2 -
American Family Physician Jul 2000
Review
Topics: Dinoprostone; Drug Costs; Female; Health Care Costs; Humans; Labor, Induced; Misoprostol; Oxytocics; Practice Guidelines as Topic; Pregnancy
PubMed: 10929705
DOI: No ID Found -
European Journal of Obstetrics,... Oct 2017The most commonly used approved indications for mifepristone in obstetrics include: termination of early pregnancy, cervical dilatation prior to abortion, labour... (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVE
The most commonly used approved indications for mifepristone in obstetrics include: termination of early pregnancy, cervical dilatation prior to abortion, labour induction in case of fetal death in utero. Fewer studies have been conducted on the effect of mifepristone on cervical ripening and induction of labour in term pregnancy with a live fetus. The aim of our study was to evaluate efficacy and safety of mifepristone use for cervical ripening and induction of labour versus expectant management in full-term pregnancy.
STUDY DESIGN
Randomized controlled trial. 149 women were randomized, 74 for cervical ripening and induction with mifepristone (200mg orally at the moment of enrollment and, if applicable, second dose after 24h), 75 - expectant management. Primary outcomes: gain in Bishop Score within 24 and 48-h of mifepristone; number of women going into spontaneous labor within 24, 48 and 72-h of mifepristone; rate of failed induction or expectant management.
SECONDARY OUTCOMES
enrollment-induction to delivery interval; mode of delivery; requirement of oxytocin augmentation, neonatal outcomes.
RESULTS
After 48h from enrollment mean gain in Bishop score was 2.58±1.33 in the induction group and 1.15±0.97 in the expectant group (<0.001). Failed management rate was 5.41% and 2.67%, respectively. Significantly more mifepristone treated women had labour within 24, 48 and 72h from enrollment (RR 15.20 CI 95% 2.06-112.18; RR 6.08 CI 95% 2.73-13.57; RR 2.14 CI 95% 1.04-4.42) (p<0.05). Enrollment-induction to delivery interval was significantly shorter in mifepristone group: 2.69±2.06 vs 3.77±1.86days (p<0.001). Premature rupture of membranes, meconium-stained amniotic fluid were more common in expectant management, but regional analgesia and cephalopelvic disproportion - in induction group. There were no differences in mode of delivery, requirement of oxytocin augmentation and main neonatal outcomes.
CONCLUSION
Mifepristone was efficient on inducing cervical ripening and labour in full-term pregnancy. There were no significant difference in main maternal and neonatal outcomes between mifepristone use and expectant management. There were no serious adverse side effects of mifepristone, but there were some features of the course of labor, like more painful uterine contractions and trend of higher rate of cephalopelvic disproportion, that might be directly related to the mifepristone action.
Topics: Cervical Ripening; Delivery, Obstetric; Female; Humans; Labor, Induced; Mifepristone; Oxytocics; Oxytocin; Pregnancy; Term Birth; Treatment Outcome; Uterine Contraction
PubMed: 28898687
DOI: 10.1016/j.ejogrb.2017.08.038 -
Journal of the Royal Society of Medicine Aug 2012This article describes and critically appraises clinical trials assessing misoprostol effectiveness in preventing primary postpartum haemorrhage (PPH) in home and... (Review)
Review
This article describes and critically appraises clinical trials assessing misoprostol effectiveness in preventing primary postpartum haemorrhage (PPH) in home and community settings in low- and middle-income countries. Of 172 identified studies of misoprostol use in labour only six fulfilled the inclusion criteria. All trials used 600 μg misoprostol in the intervention arm; three assessed misoprostol alongside components of active management of the third-stage labour (AMTSL), two used expectant management of labour and one allowed birth attendants to choose management practice. The three AMTSL studies showed no significant differences in PPH incidence or referral to higher centres and only one study showed significant decrease in severe PPH using misoprostol. One expectant management study and the choice of management by birth attendants study found significant decreases in PPH incidence with misoprostol. All studies showed significantly increased risk of shivering with misoprostol. Studies were biased by use of alternative uterotonics in the control arm, confounding management practices, and subjective assessment and, with one exception, exclusion of high-risk women. PPH incidence fell in both the control and intervention groups in both the landmark papers that informed the World Health Organization (WHO) decision to admit misoprostol to the Essential Medicines List. This suggests factors other than misoprostol use are crucial. Current evidence does not support misoprostol use in home and community settings in low- and middle-income countries for PPH prevention. WHO should rethink its recent decision to include misoprostol on the Essential Medicines List.
Topics: Evidence-Based Medicine; Female; Humans; Labor Stage, Third; Misoprostol; Oxytocics; Patient Safety; Postpartum Hemorrhage; Practice Guidelines as Topic; Pregnancy; Pregnancy Outcome; Randomized Controlled Trials as Topic; Treatment Outcome; United Kingdom; World Health Organization
PubMed: 22907551
DOI: 10.1258/jrsm.2012.120044 -
Pregnancy Hypertension Mar 2022Eclampsia is a pregnancy complicationcharacterized bygeneralized tonic-clonicconvulsions.Not all seizures in pregnancy are eclamptic, and othercauses include epilepsy,...
BACKGROUND
Eclampsia is a pregnancy complicationcharacterized bygeneralized tonic-clonicconvulsions.Not all seizures in pregnancy are eclamptic, and othercauses include epilepsy, infection,stroke,tumor, and ruptured aneurysm.
CASE
A 19-year-old G1P0 presentedinlabor at term. She had a generalized tonic-clonicseizure one hour aftervaginaldelivery for which she received methergine for uterine atony. Seizure activity resolved with lorazepam and magnesium sulfate for presumed eclampsia.Brain imaging revealedvasoconstriction of theleftposterior cerebral artery and blood in the subarachnoid space,andshewas diagnosed with eclampsia with reversible cerebral vasoconstrictive syndrome (RCVS).
CONCLUSION
RCVS isapregnancy-related cause of seizure that should remain on the differential for any patient presenting with a seizure in the peripartum period, especially with use of vasoconstrictive agents. Management is controversial but involves calcium channel blockers and magnesium sulfate, as well as avoidance of vasoconstrictive agents.
Topics: Eclampsia; Female; Humans; Methylergonovine; Oxytocics; Posterior Leukoencephalopathy Syndrome; Postpartum Hemorrhage; Pregnancy; Seizures; Young Adult
PubMed: 35063759
DOI: 10.1016/j.preghy.2022.01.002 -
Global Health, Science and Practice Aug 2014Although maternal mortality has declined substantially in recent years, efforts to address postpartum hemorrhage (PPH) and preeclampsia/eclampsia (PE/E) must be...
INTRODUCTION
Although maternal mortality has declined substantially in recent years, efforts to address postpartum hemorrhage (PPH) and preeclampsia/eclampsia (PE/E) must be systematically scaled up in order for further reduction to take place. In 2012, a key informant survey was conducted to identify both national and global gaps in PPH and PE/E program priorities and to highlight focus areas for future national and global programming.
METHODS
Between January and March 2012, national program teams in 37 countries completed a 44-item survey, consisting mostly of dichotomous yes/no responses and addressing 6 core programmatic areas: policy, training, medication distribution and logistics, national reporting of key indicators, programming, and challenges to and opportunities for scale up. An in-country focal person led the process to gather the necessary information from key local stakeholders. Some countries also provided national essential medicines lists and service delivery guidelines for comparison and further analysis.
RESULTS
Most surveyed countries have many elements in place to address PPH and PE/E, but notable gaps remain in both policy and practice. Oxytocin and magnesium sulfate were reported to be regularly available in facilities in 89% and 76% of countries, respectively. Only 27% of countries, however, noted regular availability of misoprostol in health facilities. Midwife scope of practice regarding PPH and PE/E is inconsistent with global norms in a number of countries: 22% of countries do not allow midwives to administer magnesium sulfate and 30% do not allow them to perform manual removal of the placenta.
CONCLUSIONS
Most countries surveyed have many of the essential policies and program elements to prevent/manage PPH and PE/E, but absence of commodities (especially misoprostol), limitations in scope of practice for midwives, and gaps in inclusion of maternal health indicators in the national data systems have impeded efforts to scale up programs nationally.
Topics: Disease Management; Female; Global Health; Health Policy; Health Services Accessibility; Humans; Midwifery; National Health Programs; Oxytocics; Postpartum Hemorrhage; Pre-Eclampsia; Pregnancy
PubMed: 25276587
DOI: 10.9745/GHSP-D-14-00034