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Carbetocin at Cesarean delivery for Labor Arrest: A Randomised Controlled Trial to determine ED90.
Abstract Number: BP 5
Abstract Type: Original Research
In 2009, the Society of Obstetricians and Gynecologists of Canada recommended a bolus dose of carbetocin 100mcg IV at elective cesarean delivery (CD) to be used instead of oxytocin infusion for prevention of PPH (1). A recent dose-finding study has determined the ED90 of carbetocin at elective CD to be only 14.8mcg (95%CI 13.7-15.8) (personal communication). Similar to what has been observed with oxytocin (2), it is expected that the ED90 of carbetocin in women who have undergone labor will be higher, secondary to oxytocin receptor desensitization, but this has yet to be studied. The purpose of this study was to establish the ED90 of carbetocin at CD for labor arrest.
We conducted a prospective, double-blind, randomized dose-finding study of carbetocin using a biased coin up-and-down sequential allocation designed to cluster doses near ED90. Inclusion criteria were women with no other risk factors for PPH undergoing CD for labor arrest under epidural anesthesia, having received at least 4h of oxytocin infusion. The first patient received 20mcg IV Carbetocin, and the subsequent doses were determined by randomization with increments or decrements of 20mcg, up to a maximum of 140mcg. Uterine tone was assessed by the obstetrician, and rated as satisfactory, unsatisfactory or indeterminate. The primary outcome was the need for additional uterotonics during CD. Secondary outcomes included estimated blood loss and adverse effects.
23 patients out of the proposed 40 have been recruited. Patient demographics, obstetric and intraoperative data as well as adverse effects are shown in Table 1. 70% of patients responded successfully to the blinded carbetocin dose within the range of 20–140mcg. 30% patients required the use of additional uterotonics during the CD. The average estimated blood loss was 1043 (494) mL. Hypotension was seen in 39% of patients.
Only 70% patients had adequate uterine tone in response to carbetocin, suggesting that the ED90 of carbetocin at CD for labor arrest may be higher than that at elective CD. This implies that the oxytocin-induced desensitization phenomenon may also affect the response to carbetocin. The incidence of hypotension is similar to that seen in previous studies using lower doses of Carbetocin given as a bolus, suggesting that possibly the speed of administration may affect the incidence of hypotension.
2)Obstet Gynecol 2006;107:45-5