As I have written many times before postpartum hemorrhage (PPH) or excessive uterine bleeding after childbirth is the leading cause of maternal mortality in low-and-middle income countries. The recommended drug to prevent PPH according to the World Health Organization (WHO) is oxytocin. When administered in its recommended dose it causes little to no side effects. Oxytocin, the WHO’s current gold standard therapy, however, must be refrigerated and administered by skilled health workers posing two obstacles to its wider use in low resource, tropical settings.

Some countries have approved misoprostol, an oral drug, to prevent PPH, but there are several concerns that its use can be misappropriated for abortions instead of used solely for PPH. The World Health Organization has listed misoprostol as an alternative to oxytocin if it is not available.

Now, another PPH preventative drug, carbetocin, has been added to the latest updated 2019 WHO Essential Medicines List. The announcement was made last week. Unlike oxytocin, even at high temperatures carbetocin remains effective. The recommendation is that carbetocin can be used when oxytocin is not available or if its quality is uncertain. Additionally, the cost must be comparable to oxytocin.

Ferring, the manufacturer of carbetocin, has already registered the drug for use after Cesearean sections in more than 80 countries and is now registering it to also be used after all births.

A recent double-blind, randomized, non-inferiority clinical trial in ten countries with 30,000 women and 23 hospitals was funded by MSD for Mothers and conducted by the World Health Organization to determine the efficacy of carbetocin when compared to oxytocin. (I wrote about the start of this clinical trial in 2015). Depending on the amount of blood loss carbetocin was either non-inferior to oxytocin or not non-inferior. The less the blood loss the more equal both drugs performed. The more blood loss carbetocin was less effective. The researchers did say that the latter trial was underpowered for the outcome.

It should be noted that there are global concerted efforts to make oxytocin usable as an inhaled dry powder which would wipe out its cold storage requirement. Leading the research is Professor Michelle McIntosh and her team at Monash Institute of Pharmaceutical Sciences in Australia. They have many key partners such as Glaxo Smith Kline and Grand Challenges Canada and now recently Johnson and Johnson.

Photo: UN Photo/Eskinder Debebe