JURNAL
-
Upload
pusat-grosir-baju-beesweet -
Category
Documents
-
view
184 -
download
0
description
Transcript of JURNAL
LEMBAR PENGESAHAN
Nama : Eva Apiani
Fakultas : Kedokteran Umum
Tingkat : Universitas Trisakti Jakarta
Bidang Pendidikan : Ilmu Kandungan dan Kebidanan
Periode Kepaniteraan Klinik : 3 September 2012 – 9 November 2012
Judul : Sebuah Penelitian untuk Bandingkan Efektivitas Misoprostol, Oksitosin,
Methyl-ergometrine dan Ergometrin-Oksitosin dalam Mengurangi
kehilangan Darah di dalam Manajemen persalinan kala 3
Diajukan : 24 Oktober 2012
Pembimbing : Letkol Kes dr. Zakaria, Sp. OG
Telah Diperiksa dan Disahkan Tanggal Mengetahui :
Ketua SMF Ilmu Kandungan dan Kebidanan Pembimbing
RSPAU dr. Esnawan Antariksa Jakarta
Letkol Kes dr. Zakaria, Sp. OG Letkol Kes dr. Zakaria, Sp. OG
1
DAFTAR ISI
Lembar pengesahan …………………………………………………………………………….1
Daftar isi ………………………………………………………………………...……………….2
Journal : A Study to Compare the Efficacy of Misoprostol, Oxytocin, Methyl-ergometrine
and Ergometrine–Oxytocin in Reducing Blood Loss in Active Management of 3rd Stage of
Labor
Abstract
Objective ……………………………………………………………………….….….….4
Study Design…………………………………………………………………………..….4
Results…………………………………………………………………………….............4
Conclusion…………………………………………………………………………….….5
Introduction………………………………………………………………………………………
Aims and Objectives………………………………………………………..……………………6
Material and Method………………………………………………………..…………..………6
Results……………………………………..……………………………………………………...7
Conclusion……………………………………..………………………………………………..12
References……………………………………..…………………………………………….…..13
JURNAL : Sebuah Penelitian untuk Bandingkan Efektivitas Misoprostol,
Oksitosin, Methyl-ergometrine dan Ergometrin-Oksitosin dalam Mengurangi
kehilangan Darah di dalam Manajemen persalinan kala 3
Abstrak
Objektif ……………………………………………………………………….….….….15
2
Design penelitian…………………………………………………………………....….15
Hasil ……………………………………………………………………………........….15
Kesimpulan ………………………………………………………………………….….16
Pengantar ………………………………………………………………………………………16
Maksud dan Tujuan ………………………………………………………..………………….16
Bahan dan Metode………………………………………………………..…………..……..…17
Hasil ……………………………………..……………………………………………………...18
Kesimpulan ……………………………………..…………………………………………..…..22
Daftar pustaka……………………………..……………………………….……………….…..24
J Obstet Gynaecol India. 2011 August; 61(4): 408–412.
3
Published online 2011 September 23. doi: 10.1007/s13224-011-0060-5
PMCID: PMC3295875
A Study to Compare the Efficacy of Misoprostol, Oxytocin, Methyl-
ergometrine and Ergometrine–Oxytocin in Reducing Blood Loss in Active
Management of 3rd Stage of Labor
J. T. Gohil 1,2 and Beenu Tripathi1
Author information ► Article notes ► Copyright and License information ►
Go to:
Abstract
Objectives
The purpose of the study was to compare the efficacy of misoprostol 400 μg per rectally,
injection oxytocin 10 IU intramuscular, injection methylergometrine 0.2 mg intravenously and
injection (0.5 mg ergometrine + 5 IU oxytocin) intramuscular on reducing blood loss in third
stage of labor, duration of third stage of labor, effect on haemoglobin of the patient, need of
additional oxytocics or blood transfusion and associated side effects and complications.
Study Design
A prospective non-randomized uncontrolled study was carried out in the Department of
Obstetrics and Gynecology, SSG Hospital and Medical College, Baroda enrolling 200 women
and dividing them into four groups. Active management of 3rd stage of labor was done using one
of the 4 uterotonics as per the group of the patient. The main outcome measures were the amount
of blood loss, the incidence of postpartum hemorrhage and a drop in hemoglobin concentration
from before delivery to 24 h after delivery.
Results
Methylergometrine was found to be superior to rest of the drugs in the study with lowest duration
of third stage of labor (P = 0.000096), lowest amount of blood loss (P = 0.000017) and lowest
4
incidence of PPH (P = 0.03). There was no significant difference in the pre-delivery and the
post-delivery hemoglobin concentration amongst the four groups with P = 0.061. The need of
additional oxytocics and blood transfusion was highest with misoprostol as compared to all other
drugs used in the study with P = 0.037 and 0.009, respectively. As regards side effects,
misoprostol was associated with shivering and pyrexia in significantly high number of patients as
compared to the other drugs used in the study while nausea, vomiting and headache were more
associated with methylergometrine and ergometrine–oxytocin. However all the side effects were
acceptable and preferable to the excessive blood loss.
Conclusion
Methylergometrine has the best uterotonic drug profile amongst the drugs used, strongly
favouring its routine use as oxytocic for active management of third stage of labor. Misoprostol
was found to cause a higher blood loss compared to other drugs and hence should be used only in
low resource setting where other drugs are not available. The role of misoprostol in third stage of
labor needs larger studies to be proved.
Keywords: Uterotonics, 3rd stage of labor, Post-partum hemorrhage, Brass-V drapes
Introduction
PPH is the most serious complication in obstetric practice. The greatest number of maternal
deaths from hemorrhage is due to PPH, which is almost entirely a preventable condition. PPH
occurs in approximately 4% of vaginal deliveries, and estimates are that it causes significant
morbidity and 25% of all the maternal child birth related deaths [1]. The WHO defines PPH as
blood loss of 500 ml or more in first 24 h post partum [2]. Postpartum blood loss is difficult to
evaluate especially in developing country like India where most of the women are anaemic with
poor reserve and this conditions are further aggravated by increased demand during pregnancy
and blood loss during 3rd stage of labor [3]. The days of expectant management, the so called
“hands off” [4] approach seems to be over, in view of serious consequences of PPH. An attempt
was hence made to study the efficacy of various oxytocics i.e. oxytocin, methylergometrine,
syntometrine and misoprostol in reducing blood loss in active management of third stage labor,
at the Department of Obstetrics and Gynecology, SSG hospital and Medical College, Baroda.
5
Aims and Objectives
To study the effect of injection oxytocin 10 IU intramuscular, tablet misoprostol 400 μgms per
rectally, injection Syntometrine (0.5 mg methylergometrine + 5 IU oxytocin) intramuscular,
injection methylergometrine 0.2 mg intravenously on reducing blood loss in third stage of labor,
duration of third stage of labor, effect on hemoglobin of the woman, need of additional oxytocics
or blood transfusion and associated side effects and complications.
Material and Method
A prospective non-randomized uncontrolled clinical trial was carried out in the Department of
Obstetrics and Gynecology, SSG Hospital and Medical College, Baroda from June 2007 to June
2008. Total 200 women were enrolled in the study. Women were allotted to one of the 4 groups
once they fulfilled all the selection and exclusion criteria such that every 5th woman was in the
same group. Active management of 3rd stage of labor was done in Group A with tablet
misoprostol 400 μg per rectal, Group B with injection oxytocin 10 IU intramuscular, Group C
with injection methyl ergometrine 0.2 mg intravenously and Group D with injection
syntometrine (methyl ergometrine 0.5 mg + oxytocin 5 IU).
Women with singleton pregnancy, between 37 and 42 week of gestation, anticipated vaginal
delivery, vertical lie, no high risk factors and ready to give written and informed consent were
enrolled in the study. While women with hemoglobin <8 gm%, pregnancy induced hypertension,
abruptioplacentae/Marginal placenta previa/lowlying, placenta, multiplepregnancy,
grandmultipara, malpresentation, polyhydramnios, previous uterine scar, chorioamnionitis,
prolonged labor, intra uterine fetal death, coagulation abnormalities. History of medical disorder
—Asthma/epilepsy/heart or renal disease were excluded from the study. On admission to labor
room, hemoglobin and blood grouping was done. All the women were followed through the 1st
and 2nd stage of labor. After this calibrated BRASS V(R) DRAPE [5] was kept under the buttocks
6
of the patient in such a way that whatever blood used to come out was collected in the receptacle.
Cord was clamped and cut immediately, and baby handed over to pediatrician.
The residents avoided traction on the umbilical cord, until there was evidence of placental
separation. As soon as signs of placental separation appeared the placenta was delivered by
controlled cord traction. Time interval between the delivery of the baby and the placenta was
noted. Duration of the 3rd stage was thus calculated. Pulse rate, temperature and blood pressure
were recorded 1 h after delivery. Patient was kept in labor room under observation for a period of
2 h any complaint such as nausea, vomiting, fever, headache, chills, diarrhoea and shivering was
noted. In case of marked bleeding and uterus remaining flabby, uterus was massaged and inj.
PGF2α 250 mg intramuscular was given. Blood transfusion given if required. Inspection of vulva
for perineal tears and per-speculum examination for cervical tear was carried out and if present
patients were not taken into series. A repeat hemoglobin estimation was done and 2nd post-
partum day after 24 h. The statistical analysis was performed using student’s t test for continuous
variables and the χ2 and fisher’s exact test for categorical data. P value of <0.05 was considered
statistically significant. Data were calculated as means, standard deviations (SD), numbers and
frequency (%).
Results
The women in all the four groups were comparable as regards their age, weeks of gestation and
mode of onset of labor. (Table 1).
7
Demographic variables of the women
There was no statistically significant difference amongst the groups as regards the duration of
first and second stage of labor with P value of 0.11 and 0.43, respectively for stage one and stage
two of the labor, showing that the groups were comparable as regards the 1st and 2nd stage of
labor. The duration of third stage of labor was significantly reduced with methylergometrine with
P = 0.000096 and lowest amongst the drugs used in the study. Methylergometrine given
intravenously has immediate action and hence maximum reduction in duration of 3rd stage of
labor. Misoprostol given per rectally has delayed onset of action and hence longer duration of
3rd stage of labor compared to methylergometrine. A study by Bamigboye et al. [6] compared
rectal misoprostol with synometrine for the management of third stage of labor and found the
same results. Ng et al. [7] carried out a multicentre randomized control trial of oral misoprostol
and intramuscular Syntometrine in the management of third stage of labor. There was no
significant difference between the two groups in the mean blood loss, incidence of PPH and fall
in hemoglobin concentration. Need of additional oxytocic was higher in misoprostol (RR = 1.62)
group but manual removal of placenta was reduced (RR = 0.29). Shivering and pyrexia was more
common in the misoprostol group. Sanjay rao et al. [8] compared effectiveness of tablet
misoprostol 400 μg orally to that of intramuscular oxytocin, 0.5 mg IV methylergometrine and
125 μg of intramuscular PGF2α after the delivery of the baby. The results were compared in
terms of fall in haemoglobin levels, mean duration of third stage of labor, amount of post partum
8
hemorrhage and the need of additional oxytocics. The results were comparable in all the four
groups.
The average amount of the blood loss with the four drugs in the present study was 355, 281, 243
and 260 ml, respectively with misoprostol, oxytocin, methylergometrine and ergometrine–
oxytocin combination with P = 0.000017, showing that of the drugs used methylergometrine is
the most effective drug in reducing the blood loss in third stage of labor. Of the drug used
intravenous methylergometrine is the most effective drug in reducing the 3rd stage blood loss.
The reduction in blood loss is particularly important in our country where most of child bearing
population is anaemic. This reduction in blood loss reduce the incidence of post partum anaemia,
infection and hence morbidity.
Considering PPH as a blood loss of ≥500 ml, 20% patients given misoprostol developed PPH as
compared with 10, 4, 6%, respectively with group B, C and D with P = 0.03 (<0.05), which is
statistically significant. Thus among the four methylergometrine was found to have the lowest
blood loss, strongly favouring its routine use as oxytocic for active management of third stage of
labor. There was no significant difference in the pre-delivery and the post-delivery hemoglobin
concentration amongst the four groups with P = 0.061. E1Rafaey et al. [9] also reported no
significant differences between misoprostol and oxytocin when comparing the drop in
haemoglobin concentration. This can be explained by hemodilution that occurs during pregnancy
so as to compensate for the loss during pregnancy. The post partum values of haemoglobin
shows variable difference in different mothers hence we calculated the percentage difference,
which was also not significant. The results of our study were comparable with that of the other
studies. Mcdonald and Abbott (2007-cochrane review) [10] compared effects of oxytocin with
ergometrine–oxytocin in reducing risk of PPH (i.e. blood loss of 500 ml) and found that
ergometrine–oxytocin was associated with small reduction in the risk of PPH (odds ratio = 0.82)
but more of nausea, vomiting and hypertension. Parson et al. [11] compared rectal misoprostol
800 μg versus oxytocin 10 IU intramuscular with delivery of anterior shoulder. The results were
compared in terms of change in haemoglobin concentration before and after delivery, need of
additional oxytocics, estimated blood loss, transfusion and medication side-effects. The results
were comparable in both the groups.
9
Assessment of blood loss by visual estimation has shown to underestimate the true blood loss. A
more objective method would be an assessment of the hematocrit concentration as suggested by
ACOG. This is however not adopted in our study due to lack of resources. The need of additional
oxytocics and blood transfusion was highest with misoprostol as compared to all other drugs
used in the study with P = 0.037 and 0.009, respectively. The late absorption of rectal
Misoprostol delays its effect in controlling hemorrhage during 1st hour of delivery leading to
more need of oxytocic as compared to intravenous methylergometrine, which has immediate
onset of action requiring rarely any additional oxytocic. Methylergometrine is associated with
equal or lower blood loss as compared to oxytocin and ergometrine–oxytocin in most of the
studies and hence should be a preferred drug for prevention of PPH if not contraindicated.
(Table 2). Hence role of misoprostol in third stage of labor needs larger studies to be proved.
There was increased frequency of headache in patients given methylergometrine and
ergometrine–oxytocin. Ergotamine is the most potent vasoconstrictor. The dehydrogenated
amino acid alkaloids are powerful alpha-adrenergic blocking agents, hence causing headache.
Methylergometrine and ergometrine–oxytocin were associated with rise in blood pressure though
the incidence is low and not statistically significant with P = 0.12. However, since hypertensive
10
patients were not included in series, no untoward effect was seen due to this rise in blood
pressure. There was higher incidence of nausea and vomiting in patients given ergometrine–
oxytocin and methylergometrine as compared to other drugs. Ergotamine increases peristaltic
activity and can potentate the action of neostigmine on the gut and hence causing nausea and
vomiting. Misoprostol caused significantly higher rate of pyrexia and shivering (P = 0.01 and
0.003) as compared to other drugs used in the study. Shivering after misoprostol is due to
centrally mediated PGE1 effect associated with thermoregulatory physiology. Also the staffs
were aware of the side effects leading to assessment bias. Diarrhoea was also caused more
frequently with misoprostol. However the difference was not statistically significant.
Lumbiganon et al. [12] report that though this may be of limited clinical concern, it can make the
obstetrician suspicious of infection and cause unnecessary tests or initiation of antibiotic therapy.
They also report a dose-related modest difference of 15% reduction in shivering when 400 mg is
used instead of 600 mg. The advantages of the rectal route of misoprostol are less gastrointestinal
side effects and advantageous especially in patients under anaesthesia and not able to tolerate
orally. However, none of the side effects were life threatening or serious rather most of them
subsided with 6–8 h post partum and very few patients actually required some treatment to
alleviate them. These side effects are acceptable and preferable to excessive bleeding.
Administration of the drug post-delivery should be done after proper counselling to mother
regarding its side effects and their benign course (Table 3).
11
Conclusion
The main interest of the study was in trying to substitute intravenous methylergometrine and
intramuscular oxytocin and ergometrine–oxytocin with per rectal misoprostol was to avoid use of
intravenous canulas and needles which is most relevant in country like ours with a high
incidence of HIV infection and where use of disposable needles and IV canulas are currently
unattainable. Vaginal route of misoprostol has been used for termination of pregnancy but as this
route is not feasible after delivery rectal route was chosen which also has practical advantage of
ease of administration in the patients who are vomiting or unable to take orally or are under
anaesthesia. Amongst the four drugs oxytocin had the least side effects and maximum benefits.
Rectal misoprostol is superior to oral route for limiting the side effects while maintaining the
uterotonic effects and can be considered as a uterotonic for third stage of labor only if
methylergometrine or oxytocin cannot be used consistently and appropriately for various reasons
like drug shortage, staff not knowing intravenous/intramuscular administration, storage and
refrigeration problem etc.
The two major limitations of the study were, first the trial was not double blinded leading to
biased results and secondly inability to eliminate the use of additional oxytocics and blood
transfusion that results in a probability of masking the drop in hemoglobin concentration.
Methylergometrine has the best uterotonic drug profile amongst the drugs used, strongly
favouring its routine use as oxytocic for active management of third stage of labor. Misoprostol
was found to cause a higher blood loss compared to other drugs and hence should be used only in
low resource setting where other drugs are not available. The role of misoprostol in third stage of
labor needs larger studies to be proved.
12
References
1. Maughan KL, Heim SW, Galazka SS. Preventing post-partum hemorrhage: managing the
third stage of labour. AAFP. 2006;73(6):1025–1028.
2. Fenton JJ, Baumeister LM, Fogarty J. Active management of third stage of labour among
American Indian women. Fam Med. 2005;37(6):410–414. [PubMed]
3. Justus Hofmeyr G, Sandra Ferreira V, Nikodem C, et al. Misoprostol for treating post
partum hemorrhage: a randomized controlled trial [ISRCTN72263357] BMC Pregnancy
childbirth. 2004;4:16. doi: 10.1186/1471-2393-4-16. [PMC free article] [PubMed] [Cross
Ref]
4. Prendiville WJ, Elbourne D, Mc Donald S. Active versus expectant management in third
stage of labour. Cochrane Database system Rev. 2000;(3):CD000007.
5. Patel A, Goudar SS, Geller SE, et al. Drape estimation vs. visual assessment for
estimating postpartum hemorrhage. Int J Gynecol Obstet. 2006;95(3):312. doi:
10.1016/j.ijgo.2006.08.003. [Cross Ref]
6. Bamigboyee AA, Merell DA, Hofmeyr GI, et al. Rectal misoprostol in the prevention of
postpartum hemorrhage: a placebo-controlled trial. Acta Obstet Gynecol Scand.
1998;77:178. doi: 10.1080/j.1600-0412.1998.770209.x. [PubMed] [Cross Ref]
7. Ng PS, Chan AS, Sin WK, et al. A multicentre randomized controlled trial of oral
misoprostol and intramuscular syntometrine in the management of third stage of labour.
Human Reprod. 2001;16(1):31–35. doi: 10.1093/humrep/16.1.31. [Cross Ref]
8. Rao SB, Fonseca M, Ajmera S, et al. Is oral misoprostol a promising alternative to
standard oxytocics in third stage of labour? Bombay Hosp J. 2002;44(1):30–35.
9. El-Refacy H, O’Brein P, Wale M, et al. Misoprostol in third stage of labour. Br J Obstet
Gynecol. 1997;104:336–339. doi: 10.1111/j.1471-0528.1997.tb11464.x. [Cross Ref]
10. Mac Donald SJ, Abbott JM, Higgins SP. Prophylactic ergometrine-oxytocin versus
oxytocin for third stage of labour. Cochrane database of systematic reviews 2007.
11. Parsons SM, Walley RL, Crane JM, et al. Rectal misoprostol versus oxytocin in the
management of third stage of labour. J Obstet Gynecol. 2007;29(9):711–718.
13
JURNAL
Sebuah Penelitian untuk Bandingkan Efektivitas Misoprostol, Oksitosin,
Methyl-ergometrine dan Ergometrin-Oksitosin dalam Mengurangi
kehilangan Darah di dalam Manajemen persalinan kala 3
Disusun Guna Memenuhi Tugas dan Melengkapi Syarat Dalam Menempuh ProgramStudi
Profesi Dokte
Di susun oleh :
Eva apiani 030.07.086
Pembimbing :
Letkol Kes dr. Zakaria, Sp. OG
RUMAH SAKIT PUSAT ANGKATAN UDARA
DOKTER ESNAWAN ANTARIKSA
FAKULTAS KEDOKTERAN UNIVERSITAS TRISAKTI
PERIODE 3 SEPTEMBER 2012 – 9 NOVEMBER 2012
14
Sebuah Penelitian untuk Bandingkan Efektivitas Misoprostol, Oksitosin, Methyl-
ergometrine dan Ergometrin-Oksitosin dalam Mengurangi kehilangan Darah di dalam
Manajemen persalinan kala 3
Abstrak
Objektif : Tujuan dari penelitian ini adalah untuk membandingkan khasiat dari misoprostol 400
lg pre rektal, injeksi oksitosin 10 IU intramuskular, injeksi methylergometrine 0,2 mg intravena
dan injeksi (0,5 mg ergometrine? 5 IU oksitosin) intramuskular dalam mengurangi hilangan
darah pada kala III, durasi dari persalinan kala III, efek pada hemoglobin pasien, kebutuhan
oxytocics tambahan atau transfusi darah dan hubungan dengan efek samping dan komplikasi .
Desain penelitian :non-randomized uncontrolled. Penelitian dilakukan di Departemen Obstetri
dan Ginekologi, SSG Hospital dan Medical College, Baroda. Terdaftar 200 wanita dan membagi
mereka menjadi empat kelompok. Manajemen aktif persalinan kala 3 dilakukan dengan
menggunakan salah satu dari 4 uterotonics sesuai kelompok pasien. ukuran hasil adalah jumlah
kehilangan darah, kejadian perdarahan postpartum dan penurunan kadar hemoglobin dari
sebelum melahirkan sampai 24 jam setelah melahirkan.
Hasil: Methylergometrine terbukti lebih unggul dalam penelitian dengan durasi terendah dari
persalinan kala 3 (P = 0,000096), jumlah terendah dari kehilangan darah (P = 0,000017) dan
insiden terendah PPP (P = 0,03). Tidak ada perbedaan kadar hemoglobin yang signifikan
sebelum persalinan dan sesudah persalinan diantara empat kelompok dengan P = 0,061.
Kebutuhan oxytocics tambahan dan transfusi darah adalah tertinggi dengan misoprostol
dibandingkan dengan semua obat lain yang digunakan dalam penelitian dengan P = 0,037 dan
0,009 masing-masing. Mengenai efek samping misoprostol berkaitan dengan cukup tingginya
jumlah pasien yang menggigil dan demam dibandingkan dengan obat lain yang digunakan
dalam penelitian. sementara mual, muntah dan sakit kepala yang lebih terkait dengan
methylergometrine dan ergometrine-oksitosin. Namun semua efek samping masih dapat diterima
dan lebih baik daripada kehilangan darah yang berlebihan.
15
Kesimpulan : Methylergometrine merupakan obat uterotonika terbaik di antara obat-obatan
lain yang digunakan, sangat mendukung untuk digunakan rutin sebagai oksitosik untuk
manajemen aktif persalinan kala 3. Misoprostol terbukti menyebabkan kehilangan darah lebih
tinggi dibandingkan dengan obat lain dan karenanya harus hanya digunakan dalam sumber daya
yang rendah di mana obat lain tidak tersedia. Peran misoprostol di persalinan kala 3
membutuhkan penelitian yang lebih besar harus dibuktikan.
Pengantar
PPP merupakan komplikasi yang paling serius dalam praktek kebidanan. Sebagian besar
kematian ibu akibat perdarahan yang disebabkan PPP, yang hampir seluruhnya merupakan
kondisi yang dapat dicegah. PPP terjadi pada sekitar 4% dari persalinan vagina, dan di perkiraan
bahwa hal itu menyebabkan morbiditas yang signifikan dan 25% dari semua kelahiran anak ibu
terkait kematian [1]. WHO mendefinisikan PPP sebagai kehilangan darah 500 ml atau lebih dalam
24 jam pertama post partum [2].kehilangan darah Postpartum sulit untuk di evaluasi terutama di
negara berkembang seperti India di mana sebagian besar wanita mengalami anemia dengan
miskin cadangan dan kondisi ini semakin diperparah oleh peningkatan kebutuhan selama
kehamilan dan kehilangan darah selama persalinan kala 3 [3]. Hari-hari manajemen hamil,yang
disebut'' hands off'' [4] Pendekatan ini tampaknya lebih, melihat konsekuensi serius dari
PPP.Maka suatu usaha dibuat untuk mempelajari efektifitas dari berbagai oxytocics misalnya
oksitosin, methylergometrine, syntometrine dan misoprostoldalam mengurangi hilangannya
darah dalam pengelolaan aktif persalinan kala 3 , di Departemen Obstetri dan Ginekologi,SSG
rumah sakit dan Medical College, Baroda.
Maksud dan Tujuan
Untuk mempelajari pengaruh injeksi oksitosin 10 IU intramuskular, tablet misoprostol 400 lgms
per rektal, injeksi Syntometrine (0,5 mg methylergometrine 5 IU? Oksitosin) intramuskular,
injeksi methylergometrine 0,2 mg intravena dalam mengurangi kehilangan darah dalam
persalinan kala 3, lama durasi dari kala 3, efek pada hemoglobin wanita, kebutuhan oxytocics
tambahan atau transfusi darah dan hubungan efek samping dan komplikasi.
16
Bahan dan Metode
Sebuah uji klinis prospektif terkontrol non-acak dilakukan di Departemen Obstetri dan
Ginekologi, SSG Hospital dan Medical College, Baroda dari Juni 2007 sampai Juni 2008. Total
200 perempuan yang di ikutsertakan dalam penelitian. Perempuan yang dialokasikan untuk
salah satu dari 4 kelompok setelah mereka memenuhi semua seleksi dan eksklusi. Kriteria
sehingga setiap wanita 5th berada di kelompok yang sama. Manajemen aktif persalinan kala 3
dilakukan di Grup A dengan tablet misoprostol 400 lg per rektal, Grup B dengan injeksi
oksitosin 10 IU intramuskular, Grup C dengan injeksi mg ergometrine metil 0,2 intravena dan
Grup D dengan injeksi syntometrine (metil ergometrine 0,5 mg? oksitosin 5 IU).
Wanita dengan kehamilan tunggal, usia kehamilan antara 37 dan 42 minggu , diantisipasi
persalinan pervagina , tidak ada faktor risiko tinggi dan siap untuk memberikan keterangan dan
informed consent sudah terdaftar dalam penelitian ini. sementara wanita dengan hemoglobin 8
gm%, hipertensi kehamilan diinduksi, solusio placentae / Marginal plasenta previa , lowlying
plasenta, kehamilan ganda, grand multipara, malpresentation,polihidramnion, bekas luka di
rahim sebelumnya, korioamnionitis, kematian janin intra uterin, kelainan koagulasi. Riwayat
gangguan-medis Asma / epilepsi / penyakit jantung atau ginjal dikecualikan dari penelitian.
Masuk ke ruang bersalin, pengelompokan hemoglobin dan darah dilakukan. Semua perempuan
Diikuti dari persalinan kala 1 dan kala 2 . Setelah ini dikalibrasiBRASS V(R) DRAPE [5]
disimpan di bawah pantat pasien, sedemikian rupa sehingga apapun darah yang digunakan
dikumpulkan dalam wadah tersebut. plasenta segera dijepit dan dipotong, bayi diserahkan
kepada dokter anak.
Warga menghindari tarikan pada tali pusat, Sampai Ada bukti pemisahan plasenta.
Segera setelah tanda-tanda pemisahan plasenta Muncul, plasenta dilahirkan dengan tarikan tali
pusat terkendali. interval waktu Antara lahir bayi dan plasenta telah di catat. Durasi dari kala 3
telah hitung. tingkat, nadi , suhu dan tekanan darah telah tercatat 1 jam setelah melahirkan.
Pasien tetap berada di ruang bersalin dan di observasi selama 2 jam. Keluhan Seperti mual,
muntah, demam, sakit kepala, menggigil, Diare dan menggigil diperhatikan. Dalam kasus yang
di tandai dengan perdarahan dan rahimtersisa lembek, uterus dipijat dan di berikan inj.
PGF2a250 mg intramuskular. Transfusi darah diberikan bila diperlukan. Pemeriksaan vulva
untuk robekan perineum dan pemeriksaan perspeculum
17
untuk robekan serviks dilakukan jika ada di pasein maka tidak dimasukan ke dalam seri.
Estimasi ulangi hemoglobin ke 2 post partum setelah 24 jam. Statistik analisis ini dilakukan
menggunakan test siswa untuk terus-menerus variabel dan v2 dan fisher tepat tes untuk data
kategoris. Nilai P \0.05 dianggap signifikan secara statistik. Data dihitung sebagai berarti, deviasi
standar (SD), nomor, dan frekuensi (%).
Hasil
Semua Perempuan dalam empat kelompok adalah sebanding dalam hal usia mereka,
usia kehamilan dan mode onset persalinan. (Tabel 1). Tidak ada perbedaan yang signifikan
secara statistik antara grup mengenai durasi persalinan kala 1 dan kala 2 dengan nilai P 0,11 dan
0,43, masing-masing untuk persalinan kala 1 dan kala 2 , menunjukkan bahwa semua kelompok
sebanding dalam hal persalinan kala 1 dan kala 2 . Durasi persalinan ala 3 secara signifikan
berkurang dengan methylergometrine P = 0.000096 dan merupakan yang terendah di antara obat-
obatan lain yang digunakan dalam penelitian. Methylergometrineyang diberikan intravena
memiliki efek segera oleh karna itu terdapat penurunan maksimum dalam durasi kala 3
persalinan.
Misoprostol yang diberikan prerectal memiliki onset tindakan yang lama dan karenanya
durasi yang lebih lama dari persalinan kala 3 dibandingkan untuk methylergometrine. Sebuah
studi oleh Bamigboye et al. [6] membandingkan misoprostol per rectal dengan synometrine
dalam manajemen kala 3 persalinan dan menemukan hasil yang sama. Ng et al. [7] Melakukan
18
uji coba acak multisenter secara terkontrol mengenai misoprostol oral dan Syntometrine
intramuskular dalam pengelolaan kala 3 persalinan . Tidak ada perbedaan yang signifikan antara
kedua kelompok dalam rata-rata kehilangan darah, kejadian PPP dan konsentrasi hemoglobin.
Kebutuhan tambahan oxytocic lebih tinggi pada kelompok misoprostol (RR = 1,62) tapi
pengangkatan plasenta secara manual berkurang (RR = 0,29). Menggigil dan pireksia adalah
lebih umum pada kelompok misoprostol. Sanjay Rao et al. [8] membandingkan efektivitas
misoprostol 400 oral dengan oksitosin intramuskular , 0,5 mg IV Methylergometrine dan 125 lg
intramuskular PGF2a setelah melahirkan bayi. Hasil Dibandingkan dalam penurunan kadar
hemoglobin, durasi persalinan kala 3, jumlah perdarahan postpartum dan kebutuhan oxytocics
tambahan. Hasil sebanding di semua empat kelompok.
Jumlah rata-rata kehilangan darah dengan ke empat obat-obatan dalam studi adalah 355,
281, 243 dan 260 ml, berturut-turut mulai dari misoprostol, oxytosin, methylergometrine dan
kombinasi ergometrine–oxytocin dengan P = 0.000017, menunjukkan bahwa methylergometrine
adalah obat yang paling efektif dalam mengurangi kehilangan darah dalam kala 3 persalinan.
methylergometrine intravena merupakan obat yang paling efektif dalam mengurangi kehilangan
darah di kala 3 persalinan. Pengurangan kehilangan darah sangat penting di negara kita yang
mana sebagian besar penduduk anemia. Pengurangan kehilangan darah mengurangi timbulnya
post partum anemia, infeksi dan morbiditas.
Mengingat PPP sebagai kehilangan darah C500 ml, 20% pasien yang diberikan
misoprostol berkembang menjadi PPP dibandingkan dengan 10, 4, 6%, masing-masing dengan
Grup B, C dan D dengan P = 0,03 (\0.05), yang merupakan signifikan secara statistik. Dengan
demikian antara empat methylergometrine ditemukan memiliki kehilangan darah yang
terendah, sangat menguntungkan penggunaannya sebagai oxytocic rutin untuk manajemen aktif
kala 3 persalinan . Ada tidak ada perbedaan yang signifikan dalam konsentrasi hemoglobi pre-
delivery dan post-delivery di antara empat kelompok dengan P = 0.061. E1Rafaey et al. [9] juga
melaporkan tidak ada perbedaan yang signifikan antara misoprostol dan oxytosin ketika
membandingkan penurunan konsentrasi hemoglobin . Hal ini dapat dijelaskan oleh hemodilution
yang terjadi selama kehamilan untuk mengkompensasi kerugian selama kehamilan. nilai
hemoglobin post partum menunjukkan perbedaan variabel pada ibu yang berbeda karna itu kita
menghitung perbedaan persentase, yang juga tidak signifikan. Hasil studi kami yang sebanding
dengan studi yang lain. McDonald dan Abbott (2007-cochrane review) [10] membandingkan
19
efek oxytosin dengan ergometrine–oxytocin dalam mengurangi risiko PPP (yaitu kehilangan 500
ml darah) dan menemukan bahwa ergometrine–oxytocin berkaitan dengan penurunan risiko PPH
(rasio peluang = 0.82) tetapi lebih mual, muntah, dan hipertensi. Parson et al. [11] dibandingkan
misoprostol 800 lg pre rectal dengan oxytosin 10 IU intramuskular dalam persalinan bahu
anterior . Hasil yang dibandingkan dalam hal perubahan dalam konsentrasi hemoglobin sebelum
dan sesudah persalinan, membutuhkan tambahan oxytocics, diperkirakan kehilangan darah ,
transfusi dan efek samping obat . Hasil yang sebanding dalam kedua group.
Penilaian kehilangan darah dengan estimasi visual telah ditunjukan untuk meremehkan
kehilangan darah yang benarnya. Sebuah metode yang lebih obyektif akan menilai konsentrasi
hematokrit sebagaimana disarankan oleh ACOG. Namun hal ini tidak dilakukan dalam penelitian
kami karena Kurangnya sumber daya. Kebutuhan oxytocics tambahan dan transfusi darah yang
tertinggi adalah dengan Misoprostol seperti Dibandingkan dengan semua obat lain yang
digunakan dalam penelitian dengan P = 0,037 dan 0,009 masing-masing. Penyerapan yang
lambat dari Misoprostol prerectal berefek dalam pegendalian perdarahan Selama 1 jam
persalinan mengarah ke kebutuhan lebih oxytocic sebagai Dibandingkan dengan
Methylergometrine intravena, Yang memiliki onset langsung dan jarang membutuhkan oxytocic
tambahan . Methylergometrine terkait kehilangan Darah adalah sama atau lebih rendah
Dibandingkan dengan oksitosin dan Ergometrin-oksitosin dikebanyakan penelitian dan
karenanya harus menjadi obat pilihan untuk pencegahan PPP jika tidak kontraindikasi. (Tabel 2).
Oleh karena itu peran misoprostol dalam kala 3 persalinan memburtuhkan penelitian yang lebih
besar.
20
Ada Peningkatan frekuensi sakit kepala pada pasien yang diberikan Methylergometrine
dan Ergometrin-oksitosin. Ergotamine adalah vasokonstriktor kuat. The dehydrogenated amino
acid alkaloids adalah agen bloking alpha adrenergic yang kuat oleh karena itu menyebabkan
sakit kepala. Methylergometrine dan Ergometrin-oksitosin terkait dengan peningkatan tekanan
darah meskipun Insidennya rendah dan tidak signifikan secara statistik dengan p = 0,12. Namun,
karena pasien hipertensi tidak dimasuk ke dalam seri, tidak ada efek yang tak diinginkan terlihat
karena hal ini menyebabkan kenaikan tekanan darah. Insiden mual dan muntah pada pasien yang
di berikan Ergometrin-oksitosin dan Methylergometrine lebih tinggi bila dibandingkan dengan
obat lain. Ergotamine meningkatkan aktivitas peristaltik dan potensial aksi dari neostigmine pada
usus dan karenanya menyebabkan mual muntah. Misoprostol Secara signifikan menyebabkan
pireksia dan menggigil lebih tinggi tingkat (P = 0,01 dan 0,003) bila dibandingkan dengan obat
lain yang digunakan dalam penelitian ini. Menggigil setelah misoprostol adalah karena pusat
PGE1 dimediasi efeknya terkait dengan fisiologi thermoregulatory. Para staf juga menyadari
efek samping yang mengarah bias penilaian. Diare juga lebih sering pada pemberian
Misoprostol. Namun Perbedaan itu tidak signifikan secara statistik. Lumbiganon et al. [12]
melaporkan hal tersebut meskipun klinis ini Mungkin terbatas pada kekhawatiran, hal itu dapat
membuat dokter kandungan mencurigai adanya infeksi dan menyebabkan tes yang tidak perlu
atau inisiasi terapi antibiotik Mereka Juga elaporkan perbedaan yang berhubungan dengan
dosis, pengurangan menggigil sebnyak 15% Ketika 400 mg digunakan sebagai pengganti dari
600 mg. Keuntungan dari rute rektal misoprostol adalah sedikit efek samping pada
21
gastrointestinal,terutama pada pasien di bawah anestesi dan tidak Mampu melakukan secara oral.
Namun, tidak ada efek samping yang serius atau mengancam kehidupan. kebanyakan mereka
mereda setelah 6-8 jam post partum dan sangat sedikit pasien yang memerlukan beberapa
perawatan untuk meringankan keluhan tersebut. Efek ini dapat diterima dan lebih disukai
daripada perdarahan yang berlebihan. Administrasi pemeberian obat pasca-persalinan harus
dilakukan untuk ibu setelah konseling yang tepat Mengenai efek sampingnya dan mereka jinak
saja (Tabel 3).
Kesimpulan
Kepentingan utama dalam studi ini adalah mencoba untuk menggantikan
methylergometrine intravena dan oxytosin intramuskular dan ergometrine–oxytocin dengan
misoprostol pre rectal untuk menghindari penggunaan canulas intravena dan jarum yang mana
paling relevan di negara seperti kita dengan tingginya insiden infeksi HIV dan di mana
menggunakan jarum sekali pakai dan IV canulas saat ini tak terjangkau. Vagina rute misoprostol
telah digunakan untuk penghentian kehamilan tetapi rute ini tidak layak setelah persalinan, pre
rectal dipilih yang juga karena praktis, memiliki keuntungan dan kemudahan administrasi pada
pasien yang muntah atau tidak dapat di minum peroral atau di bawah anestesi.Di antara empat
obat, oksitosin memiliki efek samping yang sedikit dan manfaat yang maksimal. Misoprostol
prerektal lebih unggul rute oral untuk Membatasi efek samping sementara Mempertahankan efek
uterotonika dan dapat dianggap sebagai uterotonika untuk kala 3 persalinan hanya jika
22
Methylergometrine atau oxytocin tidak dapat digunakan secara konsisten dan untuk berbagai
alasan yang tepat seperti kekurangan obat, staf tidak tahu pengunaan intravena / intramuskular,
masalah penyimpanan dan pendingin, dll.
Dua Keterbatasan utama dalam penelitian adalah, pertama percobaan tidak double
blinded sehingga mengarah ke hasil yang bias dan kedua ketidakmampuan untuk menghilangkan
penggunaan oxytocics tambahan dan transfusi darah yang menghasilkan kemungkinan
tertutupnya penurunan kadar hemoglobin. Methylergometrine memiliki profil obat uterotonic
terbaik antara obat-obatan yang digunakan, yang sangat menguntungkan penggunaannya rutin
sebagai oxytocic untuk aktif manajemen kala 3 persalinan Misoprostol telah dibuktikan
menyebabkan kehilangan darah lebih tinggi dibandingkan dengan obat lain dan karenanya harus
digunakan jika dalam sumberdaya yang kurang dimana obat lain tidak tersedia. Peran
misoprostol dalam kala 3 persalinan membutuhkan penelitian yang lebih besar untuk dibuktikan.
23
Daftar pustaka
1. Maughan KL, Heim SW, Galazka SS. Preventing post-partum hemorrhage: managing the
third stage of labour. AAFP. 2006;73(6):1025–8.
2. Fenton JJ, Baumeister LM, Fogarty J. Active management of third stage of labour among
American Indian women. Fam Med. 2005;37(6):410–4.
3. Justus Hofmeyr G, Sandra Ferreira V, Nikodem C, et al. Misoprostol for treating post
partum hemorrhage: a randomized controlled trial [ISRCTN72263357]. BMC Pregnancy
childbirth. 2004;4:16.
4. Prendiville WJ, Elbourne D, Mc Donald S. Active versus expectant management in third
stage of labour. Cochrane Database system Rev. 2000;(3):CD000007.
5. Patel A, Goudar SS, Geller SE, et al. Drape estimation vs. visual assessment for
estimating postpartum hemorrhage. Int J Gynecol Obstet. 2006;95(3):312.
6. Bamigboyee AA, Merell DA, Hofmeyr GI, et al. Rectal misoprostol in the prevention of
postpartum hemorrhage: a placebocontrolled trial. Acta Obstet Gynecol Scand.
1998;77:178.
7. Ng PS, Chan AS, Sin WK, et al. A multicentre randomized controlled trial of oral
misoprostol and intramuscular syntometrine in the management of third stage of labour.
Human Reprod.
1. 2001;16(1):31–5.
8. Rao SB, Fonseca M, Ajmera S, et al. Is oral misoprostol a promising alternative to
standard oxytocics in third stage of labour? Bombay Hosp J. 2002;44(1):30–5.
24
9. El-Refacy H, O’Brein P, Wale M, et al. Misoprostol in third stage of labour. Br J Obstet
Gynecol. 1997;104:336–9.
10. Mac Donald SJ, Abbott JM, Higgins SP. Prophylactic ergometrine- oxytocin versus
oxytocin for third stage of labour. Cochrane database of systematic reviews 2007.
11. Parsons SM, Walley RL, Crane JM, et al. Rectal misoprostol versus oxytocin in the
management of third stage of labour. J Obstet Gynecol. 2007;29(9):711–8.
25