The three most effective drugs for prevention of PPH ≥ 500 mL compared to oxytocin alone were
Ergometrine plus oxytocin: RR 0.69 (95% CI, 0.57 to 0.83; moderate-quality evidence)
Carbetocin: RR 0.72 (95% CI, 0.52 to 1.00; very low-quality evidence)
Misoprostol plus oxytocin: RR 0.73 (95% CI, 0.60 to 0.90; moderate-quality evidence)
The authors calculate that while 10.5% of women receiving oxytocin would experience PPH ≥ 500mL, the following would occur using these 3 regimens
Ergometrine plus oxytocin: 7.2%
Misoprostol plus oxytocin: 7.7%
The results for PPH ≥1000mL were similar to PPH ≥ 500mL results when compared to oxytocin alone, with ergometrine plus oxytocin being consistently significant (carbetocin and misoprostol plus oxytocin trending)
Ergometrine plus oxytocin combination: RR 0.77 (95% CI, 0.61 to 0.95; high-quality evidence)
Carbetocin: RR 0.70 (95% CI, 0.38 to 1.28; low-quality evidence)
Misoprostol plus oxytocin combination: RR 0.90 (95% CI 0.72 to 1.14; moderate-quality evidence)
There were no significant differences between all drugs for maternal deaths or severe morbidity
Poorest side-effect rankings when compared to oxytocin alone
Ergometrine plus oxytocin combination
Vomiting: 1.9% versus 0.6%
Hypertension: 1.2% versus 0.7%
Misoprostol plus oxytocin combination
Fever: 11.4% versus 3.6%
The authors looked at additional outcomes and found that all agents except ergometrine were effective for preventing blood transfusion when compared with placebo or no treatment
Misoprostol plus oxytocin was the only intervention more effective when compared with oxytocin alone
The misoprostol plus oxytocin combination likewise was the only intervention that was more effective compared to oxytocin when assessing change in hemoglobin
Two combination treatments (oxytocin with either ergometrine or misoprostol) had greater efficacy than oxytocin alone, but introduced more side effects
Carbetocin was also more efficient than oxytocin alone and did not lead to more side effects; however, the evidence is poor for many studies including carbetocin and conclusions need to be verified
Oxytocin, the WHO recommended treatment, while associated with decreased risk of PPH, may not be the most efficient treatment
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