JOURNAL READING

Arlina Miftahurrohmah
 Risk Factors for Uterine Atony / Postpartum
Hemorrhage Requiring Treatment after Vaginal Delivery

Penulis : Luisa A Wetta, MD1, Jeff M Szychowski,

PhD2, Ms. Samantha Seals, MS2, Melissa S
Mancuso, MD1, Joseph R Biggio, MD1, and
Alan TN Tita, MD, PhD1

Publikasi : Center for Womens Reproductive Health

and Division of Maternal-Fetal Medicine,
Department of Obstetrics and Gynecology,
University of Alabama at Birmingham

Penelaah : Arlina M

Tanggal Telaah : 9 April 2015

 INTRODUCTION
Insiden perdarahan postpartum :
Amerika Serikat -> perdarahan postpartum
meningkat sekitar 26% dari 2,3% pada tahun 1994
menjadi 2,9% pada 2006

Atonia uteri dilaporkan dapat khusus meningkat

hingga 80% dari kasus postpartum hemorrhage.
 TUJUAN

melakukan analisis
multivariabel yang lebih
komprehensif untuk
mengidentifikasi faktor-faktor
risiko independen atonia uteri
atau perdarahan postpartum
 BAHAN DAN METODE

Analisis
Uji acak statistik Software SAS
(Randomized Percobaan versi 9.2 ; SAS
Trial) klinis 3-arm Institute Inc,
double blind Cary, NC

Signifikansi p
0,05
 SUBYEK PENELITIAN

Oksitosin 10 Unit Oksitosin 80 Unit

n 659 n 481 n 658 n 1.798

Oksitosin 40 Unit
Ekslusi

Kehamilan < 24
minggu

Menjalani
persalinan sesar
Inklusi
Memiliki kematian
janin Tidak dicantumkan

Memiliki edema
paru

Koagulopati atau
kardiomiopati
 Etnisitas dilaporkan
Kegemukan jika BMI 25- obesitas jika BMI 30 sendiri sebagai
29,9 kg dari/m2 kg/m2 Hispanik, Hitam, Putih,
atau Lainnya

Korioamnionitis yakni adanya

Hidramnion yakni tanda-tanda klinis (terutama
volume cairan ketuban demam intrapartum) yang
Anemia jika Hb <9
>25cm atau kantong mengarah ke diagnosis klinis
vertikal terbesar >8cm dan pengobatan antibiotic
untuk korioamnionitis.

Persalinan kala 2 panjang

Tahap ketiga yang
>1 jam sejak dilatasi serviks
lengkap untuk persalinan
berkepanjangan jika
multipara dan >2 jam antara
>30 menit dari waktu
dilatasi serviks lengkap dan
persalinan bayi ke
persalinan jika nulipara
persalinan plasenta.
Setiap rejimen terdiri dari dosis yang
ditentukan dalam 500ml larutan kristaloid
diberikan selama 1 jam setelah melahirkan
plasenta (yaitu pada kadar 500cc per jam)

Protokol ini disetujui oleh Institutional

Review Board di University of Alabama di
Birmingham (UAB).
 HASIL

Non hispanik (OR

Hispanik (OR 2,1;
1,6; 95% CI 1,0-
95% CI 1,3-3,4) Merupakan faktor risiko
2,5)
independen yang konsisten

Preeklamsia (OR Korioamnionitis

3,2; 95% CI 2,0- (OR 2,8; 95% CI
4,9) 1,6-5,0)
Patient/Problem Mengevaluasi oksitosin dosis tinggi
dibandingkan oksitosin dosis
rendah sebagai profilaksis atonia
uteri pada wanita yang menjalani
persalinan pervaginam bersamaan
21 faktor risiko potensial yang
dievaluasi

Intervention Oksitosin 10 unit pada persalinan

pervaginam

Comparison Oksitosin 40 unit dan 80 unit pada

persalinan pervaginam

Outcome Fx. risiko independen yakni etnis

kulit putih hispanik dan non-
hispanik, preeklamsia dan
korioamnionitis.
1. Did the trial address a clearly focused
issue?

Population 1.798 wanita yang secara acak dibuat menjadi 3

kelompok

Intervention Diberikan oksitosin dosis 10U pada persalinan

pervaginam

Diberikan oksitosin dosis 40U dan 80U pada

Comparison persalinan pervaginam

Fx. Risiko independen untuk atonia uteri yakni

Outcomes etnis kulit putih hispanik dan non-hispanik,
preeklampsia dan korioamnionitis
2. Was the assignment of patients to
treatments randomized?

YES, On page 2

We conducted a secondary
analysis of a three-arm double
blind randomized clinical trial of
different doses of oxytocin at
University Hospital, Birmingham,
AL
3. Were all of the patients who entered the
trial properly accounted for at its
conclusion

YES, On page Our study sample included all 1798 women

2-3 randomized and analyzed in the primary
trial. Six hundred fifty-eight women were
randomized to 80 units of oxytocin, 481
women to 40 units (this arm was terminated
at interim review), and 659 to 10 units of
oxytocin. The distribution of the population
according to characteristics under study is
presented in Table 1.
4. Were patients, health workers and study
personnel blind to treatment?

All participating women

granted informed
consent. Information
concerning patient
demographic and clinical
YES, on page characteristics as well as
2 outcomes of interest,
including postpartum
hemorrhage or atony
requiring therapy, were
abstracted by trained
research nurses.
5. Were the groups similar at the start of
the trial?

YES, on page
3

The study population

consisted of women who
were predominantly obese,
African American,
underwent labor induction
and received an epidural.
6. Aside from the experimental intervention,
were the groups treated equally?

Our study sample

included all 1798 658 wanita diacak
women randomized untuk oksitosin
and analyzed in the dosis 80 unit
primary trial

659 wanita diacak 481 wanita diacak

untuk oksitosin untuk oksitosin
dosis 10 unit dosis 40 unit
7. How large was the treatment effect?

The frequency of the primary outcome,

treated uterine atony or hemorrhage, was YES,
7% overall (118 women) and did not differ
by study group.20 The prevalence of this
on
outcome by categories of each of the 21 page
potential risk factors for uterine atony or
hemorrhage and the corresponding
3
unadjusted OR (95% CI) are presented in
Table 2.
8. How precise was the estimate of
the treatment effect?

OR <1,5 P value
CI 95%
and >0,67 0,05
9. Can the results be applied to the local
population?
10. Were all clinically important outcomes
considered?
11. Are the benefits worth the harms and
costs?

Harms Costs

This medicine its

There is no harm not difficult to find
and reachable