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Advances in Social Sciences Research Journal – Vol.7, No.7
Publication Date: July 25, 2020
DOI:10.14738/assrj.77.8666.
Emarah, M. S. A. (2020). Carbetocin Or Oxytocin To Prevent Postpartum Haemorrhage Due To Uterine Aony In Cases Of Elective
Caesarean Section. Advances in Social Sciences Research Journal, 7(7) 739-745.
Carbetocin Or Oxytocin To Prevent Postpartum Haemorrhage Due
To Uterine Aony In Cases Of Elective Caesarean Section
Mohamed S. A. Emarah
Department, Obstetrics and Gynaecology,
Benha Teaching Hospital, Egypt.
ABSTRACT
Background: Despite the technological advancement made in the past
few decades, postpartum haemorrhage (PPH) remains one of the
principal causes of maternal deaths in developing nations. The
administration of uterotonic drugs widely prevents the PPH; therefore,
it is the main point of active management. Among uterotonics, oxytocin
has proven to be very effective in reducing the incidence of PPH. One
prophylactic drug which has been introduced in recent times is
carbetocin, a synthetic long-acting oxytocin analogue. It has a longer half
life of 41 min, allowing it to stimulate a prolonged uterine response of
up to an hour after a single intravenous dose, obviating the need for
infusion. Methods: A total of 120 pregnant women divided into two
groups; Group I (Carbetocin group) included 60 women who received
carbetocin and delivered by caesarean section (CS), Group II (Oxytocin
group) included 60 women who received oxytocin and delivered by
caesarean section (CS). Results: Our result showed that, there was a
statistically significant difference for the prevention of atonic
postpartum hemorrhage between the two groups (p<0.01), for
carbetocin group. There was also a statistically significant difference
between the two groups (p < 0.01), according to need to additional
procedures, such as need to modified B-lynch sutures and need to
bilateral uterine arteries ligation for carbetocin group. Conclusion: We
concluded that carbetocin was a better alternative to traditional
oxytocin in the prevention of PPH after elective caesarean section.
INTRODUCTION
Despite the technological advancement made in the past few decades, postpartum haemorrhage
(PPH) remains one of the principal causes of maternal deaths in developing nations(1).
PPH is responsible for one – fourth of maternal deaths worldwide. PPH is defined as postpartum
blood loss 500ml after vaginal delivery and blood loss > 1000 ml after caesarean delivery. Uterine
atony is the most common cause of PPH. Active management of the third stage of labor (AMTSL) is
recommended for prevention of PPH(2).
Administration of uterotonic agents is an essential component of AMTSL, as this prophylactic
strategy has decreased the incidence of PPH by nearly the half(3).
Page 2 of 7
URL: http://dx.doi.org/10.14738/assrj.77.8666 740
Emarah, M. S. A. (2020). Carbetocin Or Oxytocin To Prevent Postpartum Haemorrhage Due To Uterine Aony In Cases Of Elective Caesarean Section.
Advances in Social Sciences Research Journal, 7(7) 739-745.
The administration of uterotonic drugs widely prevents the PPH; therefore, it is the main point of
active management. Among uterotonics, oxytocin has proven to be very effective in reducing the
incidence of PPH(4).
A single dose of carbetocin has been hypothysed to act as a 16 hours intravenous oxytocin infusion
regarding the increase in uterine tone and the reduction of the risk of PPH in elective caesarean
section(5).
One prophylactic drug which has been introduced in recent times is carbetocin, a synthetic long- acting oxytocin analogue. It has a longer half life of 41 min, allowing it to stimulate a prolonged
uterine response of up to an hour after a single intravenous dose, obviating the need for
infusion(6).
Meta-analysis has shown that when compared to oxytocin, carbetocin reduced the need for
additional uterotonics. This may translate into savings in terms of lower staffing time taken to
monitor and administer the additional medication(7).
Aim of the work
Our study was conducted to compare which is more effective for the prevention of atonic PPH,
during elective caesarean section, oxytocin or carbetocin.
PATIENTS AND METHODS
This prospective randomized clinical trial was conducted at Department Of Obstetrics And
Gynaecology, Benha Teaching Hospital, Egypt. A total of 120 pregnant women attending the delivery
unit in the period from January 2019 to January 2020 were enrolled in the study.
Patients were eligible if they were scheduled for an elective caesarean section through a lower –
segment transverse incision under spinal anaesthesia. Only term pregnancies (after 37 weeks) with
singleton fetuses were included from primgravida (PG) to para 4. Patients were excluded from the
study if they have any known risk factor for PPH (severe anemia, antepartum haemorrhage,
polyhydramnios, multiple gestation or history of PPH). Patients having any medical disorder
contraindicating the use of carbetocin (hepatic disease, renal disease, serious cardiovascular
disorder, preeclampsia, eclampsia or epilepsy) were also excluded from the study. Patients meeting
the above inclusion criteria were counseled about the study, and an oral informed consent was
obtained.
Abdominal ultrasound was performed for all participants for confirmation of the fetal life, maturity
(37), and for exclusion of multiple gestation, polyhydramnios, placenta previa or the presence of
uterine fibroids.
The included subjects were randomly divided into two groups; Group I (Carbetocin group) included
60 women who received carbetocin and delivered by caesarean section, Group II (Oxytocin group)
included 60 women who received oxytocin and delivered by caesarean section.
By the anaesthetists, after cord clamping, cases in the carbetocin group, were given 1 ml of
carbetocin (Pabal, 1 ml ampoule – 100 g/ml, Ferring Pharmaceuticals, Kiel, Germany) containing
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Advances in Social Sciences Research Journal (ASSRJ) Vol.7, Issue 7, July-2020
100 g of carbetocin/ml as a single direct slowly intravenous (IV) injection and cases in the oxytocin
group were given, 10 international units (IU) of oxytocin (Syntocinon, Novartis Pharma AG, Basel,
Switzerland) slowly direct intravenous (IV) injection.
Need to additional procedures such as modified B-lynch sutures or Bilateral Uterine Arteries
Ligation were done, in cases progressed to PPH, due to uterine atony inspite of giving the
uterotonics carbetocin or oxytocin. These additional procedures were recorded in both groups.
Maternal blood pressure was measured before CS and checked immediately after giving the
uterotonic drug, then 30 minutes and 60 minutes later. Pulse was measured before CS and
rechecked 60 minutes after the end of CS. Blood was sampled for haemoglobin and platelet count
before CS and then rechecked 24 hours after CS. For the safety of both drugs used on liver and
kidney functions, blood was withdrawn for AST, ALT and creatinine 24 hours after the end of CS.
Statistical analysis was performed using SPSS version 19.0 (SPSS Inc., Chicago, IL, USA). Descriptive
statistics were used to describe variables; percent, proportion for qualitative variables. Mean, SD,
range for Quantitative variables. Comparison between groups was done using Chi-Square test for
qualitative variables, independent t – test for quantitative variables p values with significance of
less that 0.05% were considered statistically significant.
RESULTS
Table (1): Shows that, there were no statistically significant difference between the two groups for
all demographic variables.
Variable Drug Mean
(SD)
(no) or (%) P value
Age (years)
Carbetocin 30.68
(8.41)
0.965
Oxytocin 30.78
(8.46)
Parity
Carbetocin Nulliparous 29 (48.3 %)
0.714
Mulliparous 31 (51.7 %)
Oxytocin
Nulliparous 27 (45.0 %)
Mulliparous 33 (55.0 %)
BMI
(kg/m2)
Carbetocin 20.997
(4.791)
0.933
Oxytocin 21.280
(4.876)
Gestational age
(weeks)
Carbetocin 38.29
(0.92)
0.877
Oxytocin 38.31
(0.93)
Birth weight
(grams)
Carbetocin 2959.83
(387.71)
0.981
Oxytocin 2963.67
(339.53)
Table (2): Shows that, there was a statistically significant difference between the two groups for the
prevention of postpartum haemorrhage (p < 0.01) for carbetocin group.
Variable Drug (no) or (%) P value
Postpartum
hemorrhage
Carbetocin 3 (5 %) 0.01
Oxytocin 12 (20 %)
Page 4 of 7
URL: http://dx.doi.org/10.14738/assrj.77.8666 742
Emarah, M. S. A. (2020). Carbetocin Or Oxytocin To Prevent Postpartum Haemorrhage Due To Uterine Aony In Cases Of Elective Caesarean Section.
Advances in Social Sciences Research Journal, 7(7) 739-745.
In table (3) there was a statistically significant difference between the two groups according to
success rate, need to modified B – lynch sutures or need to bilateral uterine arteries ligation (p <
0.01) for carbetocin group.
Table (3): Final outcome for the two groups.
Variable Drug (no) or (%) P value
Success rate
Carbetocin 57 (95 %) 0.01
Oxytocin 48 (80 %)
Failure rate
Carbetocin 3 (5 %) 0.01
Oxytocin 12 (20 %)
Need to modified B-lynch
sutures
Carbetocin 2 (3.3 %) 0.01
Oxytocin 8 (13.3 %)
Need to Bilateral Uterine
Arteries ligation
Carbetocin 1 (1.6 %) 0.01
Oxytocin 4 (6.6 %)
Fig. (1) : Final outcome for the two groups
DISCUSSION
The third stage of labor is defined as the time between delivery of the baby and delivery of the
placenta. It is potentially the most dangerous part for the mother. The main risk is the occurrence
of postpartum hemorrhage(8). Around the world, one maternal death every 4 minutes occurs as
result of PPH which considers a potentially life – threatening complication and is one of the major
contributors to maternal mortality and morbidity.
Active management of the third stage of labor has three components; use of an uterotonic agent,
early cord clamping and controlled cord traction. Use of a uterotonic agent is the key for prevention
of PPH(9). Several studies have shown that the use of uterotonic agents can reduce the incidence of
PPH up to 30% - 40% and use of these drugs for PPH prevention is approved by all researchers(10).
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Advances in Social Sciences Research Journal (ASSRJ) Vol.7, Issue 7, July-2020
The study aimed at evaluation of effect of carbetocin in preventing PPH compared with oxytocin in
elective caesarean section.
Our study showed that, there was a statistically significant difference for success rate the in the
prevention of atonic PPH between the two drugs (p < 0.01) for carbetocin group. There was also a
statistically significant difference between the two groups according to need to additional
procedures such as need to modified B-Lynch sutures or need to Bilateral Uterine Arteries Ligation,
for carbetocin group.
Dansereau et al., compared the effectiveness of 100 mcg of IV carbetocin with continuous infusion
of oxytocin for 8 hours (25 IU of oxytocin in 1000 mL of Ringer's lactate, 125 mL per hour) among
women undergoing elective caesarean section. Carbetocin group had benefit of decreased need for
therapeutic oxytocics (4.7% vs. 10.1%; p<0.05)(11).
Boucher et al., compared the effectiveness of 100 mcg of intramuscular carbetocin to 2h of 10 I.U of
intravenous oxytocin infusion administrated immediately after placental delivery among women
with high risk pregnancies after vaginal delivery. The authors reported that the carbetocin need
significantly less uterine massage than oxytocin (43.4% versus 62.3%; P = 0.02), with no significant
difference between the agents regarding the need for additional uterotonic drugs, the amount of
bleeding, the prevention of PPH and the haemoglobin difference before and after delivery(12).
Attilakos et al., compared carbetocin 100 mcg or oxytocin 5 IU administrated intravenously after
the delivery of the baby in women undergoing caesarean sections. The carbetocin group needed
significantly less additional uterotonics (33.5% versus 45.5%). On the other hand, they found no
significant difference in the blood loss, PPH and fall in haemoglobin(13).
Larciprete et al., compared the effectiveness of 100 mcg IV carbetocin to 20 IU of oxytocin in 1000ml
of 0.9% NaCL solution IV (150 mL/hour) administrated to women with high risk pregnancies
undergoing caesarean sections. More women needed additional uterotonic agents in the oxytocin
group (23.5% versus 0%, P <0.01), though there was no significant difference in estimated blood
loss and in the drop of haemoglobin level(14).
Maged et al., compared carbetocin 100mcg or oxytocin 5 IU administrated intramuscularly after the
delivery of the baby in women with at least 2 risk factors for PPH undergoing vaginal delivery. The
authors found that the carbetocin was superior to oxytocin regarding postpartum blood loss
(337.73 + 118.77 versus 378 + 143.2), occurrence of PPH (4% versus 16%), need for additional
uterotonics (23% versus 37%) and the change in haemoglobin level (0.55 + 0.35 versus 0.96 + 0.62).
There was no significant difference between the two groups regarding occurrence of major PPH.
Regarding drugs side effects, the incidence of tachycardia was significantly higher in the carbetocin
group(15).
Amornpetchakul et al., compared carbetocin 100 mcg to oxytocin 5 IU administrated intravenously
after the placental delivery in women with high risk pregnancies undergoing vaginal delivery. The
carbetocin group had less postpartum blood loss (146.7 + 90.4 vs. 195.1 + 146.2 mL; P < 0.01), a
lower incidence of atonic PPH (0 % vs. 6.3%; P < 0.01), less usage of additional uterotonic drugs