1 |1 | 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

2 |2 | 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 Africa WHO analysis of causes of maternal death: a systematic review Lancet 367: , 2006

3 |3 | Africa Regional Meeting on Interventions for Impact in Essential Maternal and Newborn Care, Addis Ababa, Feb 21, 2011 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 |4 | Africa Regional Meeting on Interventions for Impact in Essential Maternal and Newborn Care, Addis Ababa, Feb 21, 2011 PPH prevention (2007) 9 questions related to management of the 3 rd 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 |5 | Africa Regional Meeting on Interventions for Impact in Essential Maternal and Newborn Care, Addis Ababa, Feb 21, 2011 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 |6 | Africa Regional Meeting on Interventions for Impact in Essential Maternal and Newborn Care, Addis Ababa, Feb 21, 2011 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 |7 | Africa Regional Meeting on Interventions for Impact in Essential Maternal and Newborn Care, Addis Ababa, Feb 21, 2011 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 > 40 o C

8 |8 | Africa Regional Meeting on Interventions for Impact in Essential Maternal and Newborn Care, Addis Ababa, Feb 21, 2011 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 2 nd line treatment not available or if bleeding continues –Offer a prostaglandin as third line treatment

9 |9 | Africa Regional Meeting on Interventions for Impact in Essential Maternal and Newborn Care, Addis Ababa, Feb 21, 2011 Misoprostol as an adjunct Four trials – over 1800 women who had AMTSL with oxytocin – 1000 mcg Outcomes –Addl blood loss > 500 ml (RR 0.83; 95% CI ) –Addl blood loss > 1 L (RR 0.76; 95% CI ) –Blood transfusion (RR 0.96; 95% CI ) 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 | Africa Regional Meeting on Interventions for Impact in Essential Maternal and Newborn Care, Addis Ababa, Feb 21, 2011 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 ) –Receiving addl uterotonics (RR 1.79; 95% CI ) –Temp > 40 o 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 | Africa Regional Meeting on Interventions for Impact in Essential Maternal and Newborn Care, Addis Ababa, Feb 21, 2011 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 | Africa Regional Meeting on Interventions for Impact in Essential Maternal and Newborn Care, Addis Ababa, Feb 21, 2011 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 | Africa Regional Meeting on Interventions for Impact in Essential Maternal and Newborn Care, Addis Ababa, Feb 21, 2011 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 | 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 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 | Africa Regional Meeting on Interventions for Impact in Essential Maternal and Newborn Care, Addis Ababa, Feb 21, 2011 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