Author: Jason Curtis

IMPACT. Operating Department Human Factors Training for the whole team (2020)

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Type of publication:
Conference abstract

Author(s):
Allman T.; Schunke N.; Fenton C.; Branfield L.

Citation:
British Journal of Surgery; 2020; vol. 107 ; p. 14

Abstract:
Aims: We identified a gap in effective staff training and developed a novel truly multidisciplinary training day to capture the whole team and expose them to simulation in their usual environment amongst usual peers. Our aim was to maximise the impact factor of multidisciplinary operating department human factors training and utilise high fidelity simulation to expose unknown unknowns and improve theatre safety.
Method(s): Novel human factors training run onsite. On a rotational basis designated theatre lists are blocked for the mandatory training to ensure all members of the theatre teams can attend ranging from porters to consultants and team leaders. Line managers enforce attendance and feedback is collated. Anaesthesia retained oversight and organisation. 3 main sessions run in parallel by teams of multidisciplinary facilitators.

  1. WHO Steps to Safer Surgery: Trust 'STOP THE LINE' video and discussion.
  2. Raising concerns: discussion lead by consultant surgeon.
  3. Theatre simulation & debrief: High fidelity in the operating theatre.

Result(s): The training received exemplary feedback and review from all staff across specialties.Multiple gaps in knowledge, particularly the location of rarely used emergency equipment and drugs was exposed and this allowed for on the spot, high yield training. Candidate feedback revealed the impact of our training was maximised by the facilitation led by consultant surgeons. Conclusion(s): Human factors training is notoriously variable and limited. We've collaborated surgical, anaesthetic and theatre teams to deliver high impact and resourceful training by addressing the human factors that mould our own learning.

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Laparoscopic ligation of inferior mesenteric artery (IMA) for the management of type II endoleak post endovascular aneurysm repair (EVAR) (2020)

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Type of publication:
Conference abstract

Author(s):
*Mashar R.; *Gangwar A.; *McCloud J.; *Shawish E.

Citation:
British Journal of Surgery; 2020; vol. 107 ; p. 96-97

Abstract:
Aim: Type II endoleaks following EVAR are caused by patent aortic collaterals causing retrograde blood flow, with the IMA being involved in 45-85% of all cases. Transarterial embolization has been described as a management option, but with a high failure rate. We present laparoscopic ligation as an alternative therapeutic strategy, with both technical success and a favourable outcome.
Method(s): An 80-old hypertensive male was diagnosed with a type II endoleak post-EVAR. Shrinkage of the sac was seen initially from 58mm to 52mm on surveillance-computed tomography (CT) of the aorta at 6 months with apersistent type II endoleak involving the IMA and lumbar arteries. Surveillance at 18 months demonstrated a persistent endoleak with enlargement of the sac to 65 mm. After a failed attempt with arterial embolization, he underwent laparoscopic ligation of the IMA Results: The procedure time was 22 minutes and his length of stay was 2 days, with no signs or symptoms of bowel ischaemia. A CT at 2 weeks demonstrated sac shrinkage to 58 mm. Conclusion(s): There have been reports of persistent endoleaks being associated with adverse outcomes, with their primary management remaining controversial. IMA ligation has been associated with sac shrinkage in 65% of patients, an important prognostic factor, and there have been no reported complications thus far. Therefore, it should be strongly considered as an option for management of type II endoleaks in centres with both vascular and general surgical expertise being available

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The annual usage of anaesthetic gases at the Shrewsbury and Telford Hospitals NHS Trust: the environmental impact and potential solutions (2020)

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Type of publication:
Conference abstract

Author(s):
*Thompson T.; *Passey S.; *Mowatt C.

Citation:
British Journal of Surgery; 2020; vol. 107 ; p. 74-75

Abstract:
Aims: The NHS is responsible for 5.5% of the UK's net emissions, with anaesthetic gases comprising of 5% of hospital emissions. Shrewsbury and Telford hospitals (SaTH) are DGH's with 18 combined theatres, 9 at each site. The aim of this study was to evaluate the environmental impact of anaesthetic gases used by the trust and suggest possible improvements.
Method(s): Figures from October 2018-2019 supplied by the hospital pharmacy and compared using the RCoA Anaesthetic Impact Calculator. Costs obtained from pharmacy relating to the available anaesthetic gases and drugs.
Result(s): Over the past year SaTH has emitted the equivalent of 4,819,050kg of CO2 through its anaesthetic gases alone (these gases being sevoflurane, isoflurane, desflurane and nitrous oxide). Of these gases, sevoflurane is the greenest, while nitrous oxide is the worst offender. To give this an idea of scale, to offset, this would require the planting of 10915 trees, which would take up an area of 4-10 hectares of land.
Conclusion(s): We are recommending that SaTH stops using Nitrous oxide and Isoflurane, which is currently under consideration by the consultant body. We would discourage the use of desflurane, and where possible sevoflurane. Encourage the use of total intravenous anaesthetic (TIVA). We postulate this would save the trust aminimum of 5000 per year or 15000 per year with a 10% reduction in sevoflurane use. This would reduce our CO2 equivalent production by over 4.6 million kg.

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The benefits of multidisciplinary human factors training in theatre (2020)

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Type of publication:
Conference abstract

Author(s):
*Jones R.; *Branfield L.

Citation:
British Journal of Surgery; 2020; vol. 107 ; p. 75

Abstract:
Aims: The awareness of Human Factors (HF) and their role in patient safety is vital in the theatre environment.
The aim of this audit was therefore to assess the awareness of human factors within our theatre team during a Human Factors Training Course at a District General Hospital.
Method(s): The Human Factors Training Course started with a questionnaire assessing roles, experience, and awareness of HF. It also looked at staff morale. The course involved a presentation and 2 simulation scenarios in theatre. After completion, there was a post course questionnaire looking at awareness of human factors, effects on staff morale and impact on patient care.
Result(s): Of the respondents, experience varied from 1 to 10+ years. The pre-course awareness of HF averaged 6.1 out of 10. The opinions on morale averaged at 6.7 out of 10, and the effect of HF training on morale averaged 8.4 out of 10. All respondents believed that the course could improve patient care. Post course awareness of HF increased and staff morale also increased as a consequence of the course.
Conclusion(s): From the results we can see that the awareness of human factors within the cohort prior to training was relatively low. Post course, we can see an increase in terms of awareness of human factors. As well as providing a training opportunity, this course had a positive effect on staff morale, and vitally, it was thought that the course would have positive impact on patient care.

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Reflective writing: Training and assessment (2016)

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Type of publication:
Conference abstract

Author(s):
*Sizer, A; Chivers, C; Hayes, K; Khan, R

Citation:
Volume 123, Issue S2. Special Issue: Top Scoring Abstracts of the RCOG World Congress 2016, 20–22 June 2016, ICC Birmingham, United Kingdom

Abstract:
Reflective writing is a mandatory component of the annual review of competence progression (ARCP) for UK trainees in Obstetrics & Gynaecology.

It is often commented at ARCP panels that the quality of reflective writing is poor, but if challenged, consultants often find it difficult to say why.

It has been commented the reflection is not an intuitive process for doctors and is a skill that needs to be learnt. However, there is no clear learning process in the curriculum and an internet search revealed no course or training session that was available in the UK.

A reflective writing workshop was developed in the West Midlands Deanery. This was part of the monthly Symposium teaching for trainees at ST3‐5 level. Prior to the workshop, trainees were asked to submit a representative piece of reflective writing from their ePortfolio that had been submitted in the past 6 months so that the particular case or situation that they had reflected on was still fresh in their memory.

The workshop took the following format:

  • Trainees were split into small groups with a facilitator. They were given three pre-written reflective pieces to discuss, one poor, one average and one good. Following the small group work there was feedback to the entire group.
  • The lead facilitator then gave a presentation on reflective writing and models of reflection, particularly focussing on Gibbs reflective cycle and Rolfe's framework of reflection.
  • Trainees were then asked to work on writing a reflective piece in small groups on a mock scenario using a reflective model. There was further feedback and analysis by the whole group.
  • For the final session each trainee was asked to rewrite the reflection that they had previously submitted.
  • In order to assess the reflections pre- and post- workshop we devised a simple scoring system to take into account the key points of the reflective process, namely structure (ie was any particular model followed), length of the descriptive component, and then a subjective assessment of the descriptive and analytical components as well as the action plan. This gave a score of 10 for each reflective piece.
  • The workshop was very well received by the trainees. Interestingly, feedback from the trainees suggested that consultants needed to develop skills in the assessment of reflection.
    Data will be presented on the workshop and scoring system, including qualitative feedback data.

Triple Negative Male Breast Cancer (2021)

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Type of publication:
Conference abstract

Author(s):
Qavi Q.; Alkistawi F.; Lesi O.; Asaad A.; Abdalla Al-Zawi A.S.; Abraham B.; Kumar S.; Ahmed R.; Barron M.; Arooj *Khan K.; Syed A.; Deniz E.; Abduljawad N.H.; Idaewor P.; Aladili Z.; Rasheed N.; Eldruki S.; Uddin A.

Citation:
European Journal of Surgical Oncology; Feb 2021; vol. 47 (no. 2)

Abstract:
Background: Male breast cancer (MBC) is a rare malignancy, may present at advanced disease stage. Triple negative breast cancer (TNBC) known to have the poorest prognosis of all other histological types of breast cancer. This paper presents a case of 71 years old gentleman diagnosed with TNBC. Material(s) and Method(s): A 71 years old male patient, presented with a right breast lump of a recent history also has chronic kidney disease, gastroesophageal reflux,, and excision of basal cell carcinoma of abdominal wall. Clinically he had a skin dent and apalpable 3cm lump underneath in the right breast axillary tail. Mammogramand breast US showed suspicious lesion in right breast axillary tail in additionto a suspicious lymph node in right axilla. Imaging guided core biopsies weretaken from the breast and axillary abnormalities. The histology revealed grade1 invasive ductal carcinoma NST, ER 0 and PR 0 and HER 2 negative. The Breast Multidisciplinary Team meeting advised for mastectomy and axillary clearance, this has been performed. The postoperative Pathomorphology report revealed 23 mm triple negative invasive ductal carcinoma NST, grade 1with Ki67 10%, T2N1M0. The postoperative MDT recommended annual surveillance with mammogram for 5 years. Result(s): MBC is very rare, it is the cause of 1% of all malignant diseases in men, andcauses < 1% of all breast cancers in both males and females.MBC is diagnosed at an average of 10 years later than the age at which breast cancer is diagnosed in females at 65 years of age.There are some reported risk factors associated with MBC as, cryptorchidism, family history, Klinefelter's syndrome, infertility and smoking. Also it has been reported that Only 1/3 of male patients who have BRCA1/2 mutation maydevelop malignancy of breast, pancreas and prostate. Similar to female breast cancer, the most histological type of male breast cancer is invasive ductalcarcinoma NST, and the oestrogen hormone receptors expression is greaterthan in females (up to 95%).Male triple negative breast cancer (MTNBC) is associated with aggressivedisease course, late stage of diagnosis, large size of the tumour size, hightumor histological grade, and high rate nodal disease, also is reported more in a younger patients.Mastectomy is the mainstay of surgical treatment and the triple-negative breast cancer generally has a better to chemotherapy than tumours with oestrogen hormone-receptor positive expression. Adjuvant radiotherapy is recommended, however it doesn't effect the cause-specific survival rate. Conclusion(s): MBC is uncommon entity, accounting for < 1% of all breast cancer diagnosed in both genders and the MTNBC still is rarer, and mastectomy is the mainstay of surgical treatment. in addition to chemotherapy and radiotherapy, however the later doesn't effect the cause-specific survival rate.

Epidemiology, Incidence and Outcomes from Male breast cancer in Mid and South Essex (2021)

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Type of publication:
Conference abstract

Author(s):
Alkistawi F.E.; Qavi Q.; Omotara L.; Asaad A.; Salih A.; Chicken W.; Elamass M.; Cathcart P.; Venkat S.E.; Syed A.; Barron M.; *Khan K.; Deniz E.; Abduljawad N.; Aladili Z.; Ozua P.; Idaewor P.; Uddin A.; Rasheed N.; Abdalla Al-Zawi A.S.

Citation:
European Journal of Surgical Oncology; Feb 2021; vol. 47 (no. 2)

Abstract:
Background: Breast Cancer is the most common cancer in the United Kingdom and the second most common cancer in the world. Male breast cancer (MBC) is rare, but reported to account for <1 % of all breast cancer cases and 1% of all male malignancies. The management protocols for male breast cancer are largely derived from the evidence in female breast cancer management.In this study we analysed all MBC within our region presenting over a 6 year period. We are reporting the incidence, clinico-pathological features, management and outcomes of MBC patient treated in 3 breast centres serving the Mid and South Essex region of England. Material(s) and Method(s): Retrospective multicentre review of all the male breast cancer patients presented between 2014 and 2019, in Basildon Hospital, Broomfield Hospital & Southend Hospital. We identified 44 patients and collected data from their clinical records. Data related to patients' age, risk factors, histopathology,surgical treatment, adjuvant treatment and survival were analysed. Result(s): Out of 6952 cases of breast cancer diagnosed between 2014 and 2019, 44 cases of male breast cancer were identified which represents 0.63% of all cases. This lies within the international figures of incidence of male breast cancer. The age group ranged between 43 &96 years with higher incidence on the 9th decade of life. Family history was significantly linked to MBC,in our study and it was observed in 31% of cases.Smoking association with male breast cancer needs to be further assessed in a larger study as in our study group only 3 patients were actively smoking, though another 9 were ex-smokers, this gives a total of 25% of cases associated with smoking history.As for female breast cancer, Invasive ductal carcinoma (IDC) is the most common encountered histological subtype (77%), though other histopathologic subtypes were recorded including invasive lobular carcinoma (4.5%), tubular (4.5%), papillary carcinoma (4.5%) Combined IDC & ILC (2.5%) and DCIS (7%).The receptor status is comparable to the reported figures except for the triple negative cancers which showed a higher rate 6.5% compared to less than 1% rate in documented literature. Mastectomy and sentinel node biopsy remains the main line of treatment, though management with hormonal manipulation only was undertaken in 20% of patients due to frailty or metastatic disease. At a median follow-up of 3 years, 11 patients had died, but only 3 deaths were caused by breast cancer, the mortality rate in our cohort was 25%; however the MBC specific mortality in the cohort was only 6.8%. Conclusion(s): Male breast cancer is rare. It maybe associated with late presentation and less favorable outcomes. Public and health professional education is recommended to enable early disease detection. Multi-centre collaboration is suggested to allow access to a larger database for research to determine the risk factors, optimum treatment and outcomes.

Supratentorial vs infratentorial posterior calvarial distraction osteogenesis for the increase of ICV in children with syndromic or multi-suture craniosynostosis: a retrospective cohort study (2021)

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Type of publication:
Journal article

Author(s):
Sharman J.; Rodrigues D.; McGuirk S.; *Panikkar M.; Nishikawa H.; Dover S.; Evans M.; White N.

Citation:
Child's Nervous System; 2021 [epub ahead of print]

Abstract:
Purpose: Craniosynostosis is the premature and pathological fusion of calvarial sutures. One modality of surgical treatment of syndromic craniosynostosis is posterior calvarial distraction (PCD). This can be either supratentorial or infratentorial. Currently, supratentorial PCD may be regarded as safer but produces a smaller increase in calvarial volume compared to infratentorial PCD. This study quantifies and compares the effectiveness of supratentorial and infratentorial PCD to help guide surgical decision-making. Method(s): The CT and/or MRI scans of 47 cases of craniosynostosis who underwent PCD from the Birmingham Children's Hospital (BCH) were converted to sagittal series multi-planar reformatted (MPR) scans for the manual calculation of ICV. The 47 cases were classified as having undergone either supratentorial or infratentorial PCD using lateral plain film radiographs, with 28 and 32 pairs of pre- and post-operative CT/MRI scans reviewed respectively. Result(s): A statistically significant difference between supratentorial and infratentorial PCD was observed for the increase in supratentorial volume (STV) (P = 0.0458) and total intracranial volume (TICV) (P = 0.0437), but not for the increase in infratentorial volume (ITV) (P = 0.0697). The relationship for each volume trended towards convergence but was not achieved before the physical limit of 30 mm distraction had been reached. Intraclass correlation coefficient values for agreement of MRI and CT scans for STV, ITV and total ICV were 0.852, 0.864 and 0.854 respectively. Conclusion(s): Our evidence suggests that supratentorial PCD is more effective for increasing ICV in a clinical setting. CT and MRI imaging modalities are acceptably clinically interchangeable for calculating ICV in craniosynostosis.

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Development and internal validation of clinical prediction models for outcomes of complicated intra-abdominal infection (2021)

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Type of publication:
Journal article

Author(s):
Ahmed, S; Bonnett, L; Melhuish, A; Adil, M T; Aggarwal, I; Ali, W; Bennett, J; Boldock, E; Burns, F A; Czarniak, E; Dennis, R; Flower, B; Fok, R; Goodman, A; Halai, S; Hanna, T; Hashem, M; Hodgson, S H; Hughes, G; Hurndalm, K-H; Hyland, R; Iqbal, M R; Jarchow-MacDonald, A; Kailavasan, M; Klimovskij, M; Laliotis, A; Lambourne, J; Lawday, S; Lee, F; Lindsey, B; Lund, J N; Mabayoje, D A; Malik, K I; Muir, A; Narula, H S; Ofor, U; Parsons, H; *Pavelle, T; Prescott, K; Rajgopal, A; Roy, I; Sagar, J; Scarborough, C; Shaikh, S; Smart, C J; Snape, S; Tabaqchali, M; Tennakoon, A; Tilley, R; Vink, E; White, L; Burke, D; Kirby, A

Citation:
The British Journal of Surgery; Apr 30;108(4):441-447

Abstract:
BACKGROUND Complicated intra-abdominal infections (cIAIs) are associated with significant morbidity and mortality. The aim of this study was to describe the clinical characteristics of patients with cIAI in a multicentre study and to develop clinical prediction models (CPMs) to help identify patients at risk of mortality or relapse.METHODS A multicentre observational study was conducted from August 2016 to February 2017 in the UK. Adult patients diagnosed with cIAI were included. Multivariable logistic regression was performed to develop CPMs for mortality and cIAI relapse. The c-statistic was used to test model discrimination. Model calibration was tested using calibration slopes and calibration in the large (CITL). The CPMs were then presented as point scoring systems and validated further.RESULTS Overall, 417 patients from 31 surgical centres were included in the analysis. At 90 days after diagnosis, 17.3 per cent had a cIAI relapse and the mortality rate was 11.3 per cent. Predictors in the mortality model were age, cIAI aetiology, presence of a perforated viscus and source control procedure. Predictors of cIAI relapse included the presence of collections, outcome of initial management, and duration of antibiotic treatment. The c-statistic adjusted for model optimism was 0.79 (95 per cent c.i. 0.75 to 0.87) and 0.74 (0.73 to 0.85) for mortality and cIAI relapse CPMs. Adjusted calibration slopes were 0.88 (95 per cent c.i. 0.76 to 0.90) for the mortality model and 0.91 (0.88 to 0.94) for the relapse model; CITL was -0.19 (95 per cent c.i. -0.39 to -0.12) and – 0.01 (- 0.17 to -0.03) respectively.CONCLUSION Relapse of infection and death after complicated intra-abdominal infections are common. Clinical prediction models were developed to identify patients at increased risk of relapse or death after treatment, although these require external validation.

Uterotonic agents for first-line treatment of postpartum haemorrhage: a network meta-analysis (2020)

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Type of publication:
Systematic Review

Author(s):
*Parry Smith, William R; Papadopoulou, Argyro; Thomas, Eleanor; Tobias, Aurelio; Price, Malcolm J; Meher, Shireen; Alfirevic, Zarko; Weeks, Andrew D; Hofmeyr, G Justus; Gülmezoglu, Ahmet Metin; Widmer, Mariana; Oladapo, Olufemi T; Vogel, Joshua P; Althabe, Fernando; Coomarasamy, Arri; Gallos, Ioannis D

Citation:
The Cochrane Database of Systematic Reviews; Nov 2020; vol. 11 ; p. CD012754

Abstract:
BACKGROUND Postpartum haemorrhage (PPH), defined as a blood loss of 500 mL or more after birth, is the leading cause of maternal death worldwide. The World Health Organization (WHO) recommends that all women giving birth should receive a prophylactic uterotonic agent. Despite the routine administration of a uterotonic agent for prevention, PPH remains a common complication causing one-quarter of all maternal deaths globally. When prevention fails and PPH occurs, further administration of uterotonic agents as 'first-line' treatment is recommended. However, there is uncertainty about which uterotonic agent is best for the 'first-line' treatment of PPH. OBJECTIVES To identify the most effective uterotonic agent(s) with the least side-effects for PPH treatment, and generate a meaningful ranking among all available agents according to their relative effectiveness and side-effect profile.SEARCH METHODSWe searched the Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (5 May 2020), and the reference lists of all retrieved studies. SELECTION CRITERIA All randomised controlled trials or cluster-randomised trials comparing the effectiveness and safety of uterotonic agents with other uterotonic agents for the treatment of PPH were eligible for inclusion.DATA COLLECTION AND ANALYSIS Two review authors independently assessed all trials for inclusion, extracted data and assessed each trial for risk of bias. Our primary outcomes were additional blood loss of 500 mL or more after recruitment to the trial until cessation of active bleeding and the composite outcome of maternal death or severe morbidity. Secondary outcomes included blood loss-related outcomes, morbidity outcomes, and patient-reported outcomes. We performed pairwise meta-analyses and indirect comparisons, where possible, but due to the limited number of included studies, we were unable to conduct the planned network meta-analysis. We used the GRADE approach to assess the certainty of evidence.MAIN RESULTS Seven trials, involving 3738 women in 10 countries, were included in this review. All trials were conducted in hospital settings. Randomised women gave birth vaginally, except in one small trial, where women gave birth either vaginally or by caesarean section. Across the seven trials (14 trial arms) the following agents were used: six trial arms used oxytocin alone; four trial arms used misoprostol plus oxytocin; three trial arms used misoprostol; one trial arm used Syntometrine® (oxytocin and ergometrine fixed-dose combination) plus oxytocin infusion. Pairwise meta-analysis of two trials (1787 participants), suggests that misoprostol, as first-line treatment uterotonic agent, probably increases the risk of blood transfusion (risk ratio (RR) 1.47, 95% confidence interval (CI) 1.02 to 2.14, moderate-certainty) compared with oxytocin. Low-certainty evidence suggests that misoprostol administration may increase the incidence of additional blood loss of 1000 mL or more (RR 2.57, 95% CI 1.00 to 6.64). The data comparing misoprostol with oxytocin is imprecise, with a wide range of treatment effects for the additional blood loss of 500 mL or more (RR 1.66, 95% CI 0.69 to 4.02, low-certainty), maternal death or severe morbidity (RR 1.98, 95% CI 0.36 to 10.72, low-certainty, based on one study n = 809 participants, as the second study had zero events), and the use of additional uterotonics (RR 1.30, 95% CI 0.57 to 2.94, low-certainty). The risk of side-effects may be increased with the use of misoprostol compared with oxytocin: vomiting (2 trials, 1787 participants, RR 2.47, 95% CI 1.37 to 4.47, high-certainty) and fever (2 trials, 1787 participants, RR 3.43, 95% CI 0.65 to 18.18, low-certainty). According to pairwise meta-analysis of four trials (1881 participants) generating high-certainty evidence, misoprostol plus oxytocin makes little or no difference to the use of additional uterotonics (RR 0.99, 95% CI 0.94 to 1.05) and to blood transfusion (RR 0.95, 95% CI 0.77 to 1.17) compared with oxytocin. We cannot rule out an important benefit of using the misoprostol plus oxytocin combination over oxytocin alone, for additional blood loss of 500 mL or more (RR 0.84, 95% CI 0.66 to 1.06, moderate-certainty). We also cannot rule out important benefits or harms for additional blood loss of 1000 mL or more (RR 0.76, 95% CI 0.43 to 1.34, moderate-certainty, 3 trials, 1814 participants, one study reported zero events), and maternal mortality or severe morbidity (RR 1.09, 95% CI 0.35 to 3.39, moderate-certainty). Misoprostol plus oxytocin increases the incidence of fever (4 trials, 1866 participants, RR 3.07, 95% CI 2.62 to 3.61, high-certainty), and vomiting (2 trials, 1482 participants, RR 1.85, 95% CI 1.16 to 2.95, high-certainty) compared with oxytocin alone. For all outcomes of interest, the available evidence on the misoprostol versus Syntometrine® plus oxytocin combination was of very low-certainty and these effects remain unclear. Although network meta-analysis was not performed, we were able to compare the misoprostol plus oxytocin combination with misoprostol alone through the common comparator of oxytocin. This indirect comparison suggests that the misoprostol plus oxytocin combination probably reduces the risk of blood transfusion (RR 0.65, 95% CI 0.42 to 0.99, moderate-certainty) and may reduce the risk of additional blood loss of 1000 mL or more (RR 0.30, 95% CI 0.10 to 0.89, low-certainty) compared with misoprostol alone. The combination makes little or no difference to vomiting (RR 0.75, 95% CI 0.35 to 1.59, high-certainty) compared with misoprostol alone. Misoprostol plus oxytocin compared to misoprostol alone are compatible with a wide range of treatment effects for additional blood loss of 500 mL or more (RR 0.51, 95% CI 0.20 to 1.26, low-certainty), maternal mortality or severe morbidity (RR 0.55, 95% CI 0.07 to 4.24, low-certainty), use of additional uterotonics (RR 0.76, 95% CI 0.33 to 1.73, low-certainty), and fever (RR 0.90, 95% CI 0.17 to 4.77, low-certainty). AUTHORS' CONCLUSIONS The available evidence suggests that oxytocin used as first-line treatment of PPH probably is more effective than misoprostol with less side-effects. Adding misoprostol to the conventional treatment of oxytocin probably makes little or no difference to effectiveness outcomes, and is also associated with more side-effects. The evidence for most uterotonic agents used as first-line treatment of PPH is limited, with no evidence found for commonly used agents, such as injectable prostaglandins, ergometrine, and Syntometrine®.

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