Evaluation of Carbetocin and oxytocin for prevention of post Partum hemorrhage in women undergoing cesarean delivery at a regional hospital in western Kenya

Abstract

The burden of maternal morbidity and mortality is highest in Sub Saharan Africa and Southern Asia. Moreover, postpartum hemorrhage (PPH) is the largest contributor of maternal deaths in these regions. In Kisumu County, most of these deaths occur at the regional referral hospital Jaramogi Oginga Odinga Teaching and Referral Hospital (JOOTRH). The use of uterotonics for the prevention of postpartum hemorrhage has resulted in a significant reduction in maternal morbidity and mortality, and thus remains an integral part of active management of third stage of labor. WHO recommends use of oxytocin for prevention of PPH in all births. Oxytocin is widely and readily available in most health facilities, including JOOTRH, and continues to be the preferred first-line uterotonic drug for PPH prophylaxis. Carbetocin is a heat-stable, longer-acting synthetic analog of oxytocin that is administered as a single dose within 1minute of delivery. Proper management of PPH cannot be overemphasized because of its undisputed impact on maternal morbidity and mortality. Although oxytocin is readily and widely available at JOOTRH and is currently the preferred uterotonic agent for all births, there is paucity of data on the effectiveness of this locally available drug. It is important to address the question of effectiveness of locally available oxytocin to ensure PPH is effectively prevented. This was done in the form of a comparative study between the standard first-line uterotonic, oxytocin and its analog carbetocin. This study aimed to evaluate the effectiveness of carbetocin and oxytocin in preventing postpartum hemorrhage in women undergoing cesarean delivery at JOOTRH. The specific objectives were to compare the incidences of use of additional uterotonics between oxytocin and carbetocin, to compare blood pressure levels following administration of oxytocin and carbetocin, to compare blood loss in the oxytocin and carbetocin groups, and to compare the incidence of need for blood transfusion. This study was a quasi-experimental trial. Pregnant women who underwent elective and emergency cesarean delivery at JOOTRH who met the eligibility criteria were allocated to receive oxytocin until the desired sample size (77) was achieved, and subsequently allocated to receive carbetocin until the desire sample of 77 was reached. A total of 154 women (77 for each study arm) were recruited in the study. The intervention arm received 100mcg carbetocin IV, whereas the control arm received 10IU oxytocin (the current standard of care). The sample size was calculated using a formula by Charan & Biswas. OpenEpi, version 3, an open-source calculator, was used to confirm the power which was 84.94%. Variables of interest were use of additional uterotonics, blood pressure readings, estimated blood loss and need for transfusion. Blood pressure readings were summarized as means and standard deviations while use of additional uterotonics, blood loss and need for transfusion were summarized as frequency counts and percentages. Inferential analysis was used to analyze the collected data. Pearson's Chi-square test of independence was used to assess the association between the study arm and the sociodemographic and obstetric characteristics of the participants. Propensity score matching was used to minimize selection bias. Binary logistic regression was employed to compare the use of additional uterotonics, need for transfusion, and blood loss between the control and intervention groups, while blood pressure changes were analyzed using linear regression analysis. In this study, we observed that participants in the oxytocin arm were eight times more likely to receive additional uterotonics (OR=8.00, 95% CI 3.77,18.20, P-value <0.001). There were no statistically significant differences in systolic blood pressure (P value 0.11), diastolic blood pressure (P value 0.30) and pulse rate (P value 0.20) measurements. There was no statistically significant difference in blood loss (P-value 0.39) and need for transfusion (P-value 0.30) across the two groups. In conclusion, carbetocin was more effective in preventing PPH, as its use was associated with a reduced need for additional uterotonics. There were no significant differences in blood pressure changes, rates of blood loss, or need for transfusion. This study recommends that carbetocin be included as a first-line agent in PPH prophylaxis in women undergoing cesarean delivery.