Postpartum hemorrhage is the most common cause of maternal mortality in Indonesia, prevention of postpartum hemorrhage is the key in reducing maternal mortality in the world, the method of presenting uterotonics is one of the many methods, and this slide will discuss the difference between carbetocin and some existing uterotonics.

1. CURRENT UPDATE IN POST PARTUM
HEMORRHAGE
Ryan Saktika Mulyana

2. Angka kematian Ibu (AKI) di Indonesia termasuk salah satu
yang tertinggi di ASEAN 1
AKI di beberapa negara ASEAN, 2015 2
35
7
22
1 18
0
17
0
6
9
6
0 2
5
2
4
7
30
5
0
50
100
150
200
250
300
350
400
AKI di Indonesia,
Hasil SUPAS thn 2015
: 305/ 100.000
kelahiran hidup 3
12 x Malaysia
4 x Vietnam
Hampir 2 x Kamboja
References :
1.Achadi EL. Kematian Maternal dan Neonatal di Indonesia pada Rakerkesnas 2019. Fakultas Kesehatan Masyarakat Universitas Indonesia. 2019; Available at: https://www.kemkes.go.id/resources/download/info- terkini/rakerkesnas-
2019/SESI%20I/Kelompok%201/1-Kematian-Maternal-dan-Neonatal-di-Indonesia.pdf (Last accessed 3 August 2020)
2. ASEAN. ASEAN Statistical Report on Millennium Development Goals 2017. 2017; Available at : https://asean.org/storage/2012/05/ASEAN_MDG_2017.pdf (Last Accessed 3 August 2020)
3. Badan Pusat Statistik. Angka Kematian Ibu Menurut Pulau. Angka Indonesia dari Profil Penduduk Indonesia Hasil SUPAS 2015. Available at : https://www.bps.go.id/dynamictable/2018/06/05/1439/angka- kematian-ibu-menurut-pulau-per-
100-000-kelahiran-hidup-2015.html (Last accessed 3 August 2020)
Sumber : Asean Secretariat, 2017

3. Perdarahan Obstetri menjadi penyebab tertinggi kasus kematian Ibu1
References :
1.Achadi EL. Kematian Maternal dan Neonatal di Indonesia pada Rakerkesnas 2019. Fakultas Kesehatan Masyarakat Universitas Indonesia. 2019; Available at: https://www.kemkes.go.id/resources/download/info- terkini/rakerkesnas-
2019/SESI%20I/Kelompok%201/1-Kematian-Maternal-dan-Neonatal-di-Indonesia.pdf (Last accessed 3 August 2020)
2. Mavrides E, et al on behalf of the Royal College of Physicians. Prevention and management of Postpartum haemorrhage. BJOG 2016; DOI: .10.1111/1471-0528.14178.
3. Lalonde A. Prevention and treatment of postpartum hemorrhage in low-resource settings. International Journal of Gynecology & Obstetrics. 2012;117(2): 108–118. doi:10.1016/j.ijgo.2012.03.001
4.Anderson JM, Etches D. Prevention and Management of Postpartum Hemorrhage. American Academy of Family Physicians. 2007;75:875–882. Available at: https://www.aafp.org/afp/2007/0315/p875.html (Last accessed 3 August 2020)
Penyebab kematian maternal di Indonesia
( Studi Banten II, 2015-2017 ).1
Penyebab PPH yang paling umum adalah Atonia Uteri 3,4
“4 T ” penyebab PPH ( Post Partum
Haemorrhage ) 2
Tone (Tonus) : Kelainan pada kontraksi uterus, atonia uteri
Trauma : Cedera rahim, serviks, atau vagina
Tissue (Jaringan): Sisa plasenta atau gumpalan darah
Thrombin : Koagulasi yang abnormal
38.3%
19.1%
13.6%
29%
PerdarahanObstetri
Pre-Eklampsia/Eklampsia
Anemiapadakehamilan
Lain-lain
AtoniaUteri
Trauma
Tissue
Thrombin
70%
20%
9%
1%

4. ➡ AKI sebesar 69,04 per 100.000 kelahiran hidup.
Tren Angka Kematian Ibu (AKI) per 100.000 kelahiran hidup di Provinsi Bali tahun 2008-2019
80.4
73.4
57.5
84.2
89.6
72.1 70.5
83.4
78.7
68.63
53.02
69.04
0
10
20
30
40
50
60
70
80
90
100
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Dalam waktu satu tahun (Januari–Desember 2019) ➡ 46 kasus
kematian ibu di Provinsi Bali dengan 66.625 KH

5. Distribusi kematian ibu pre-hospital dan in-hospital per kelahiran
hidup menurut Kabupaten/Kota di Provinsi Bali
Kabupaten / Kota
Jumlah kematian ibu AKI
(%)Pre-hospital (n) In-hospital (n) Jumlah (n) Kelahiran hidup
Jembrana - 5 5 4323 115,66
Tabanan - 5 5 5214 95,90
Badung - 3 3 10653 77,41
Gianyar 1 7 8 6568 28,16
Klungkung - 5 5 2663 187,76
Bangli 1 5 6 3259 184,10
Karangasem - 3 3 6878 43,62
Buleleng 1 8 9 10477 85,90
Denpasar - 2 2 16590 12,05
Jumlah 3 43 46 66625 69,04

6. Tempat kematian Frekuensi
Jumlah kasus (n) Persen (%)
Non Fasilitas kesehatan - -
Dead on arrival 3 6,52
Fasilitas kesehatan
 PPK 1
 PPK 2
 RSUP
1
31
11
2,17
67,40
23,91
Jumlah 46 100,00
Distribusi kematian ibu menurut tempat kematian

7. Penyebab kematian
Frekuensi
Jumlah kasus (n) Persen (%)
Obstetrik
 Perdarahan
 Pre-eklampsia
 Infeksi
12
8
-
26,09
17,39
-
Non Obstetrik
 MOF
 Gagal napas
 Ensefalopati
 Keganasan
 Gagal jantung
 Peritonitis
 RTA
 DHF
 SOL
 Pneumonia
3
1
2
3
11
1
1
1
1
2
6,52
2,17
4,35
6,52
23,91
2,17
2,17
2,17
2,17
4,35
Jumlah 46 100,00
Distribusi kematian ibu berdasakan penyebab obstetri
dan non obstetri

8. Cara persalinan
Frekuensi
Jumlah kasus (n) Persen (%)
Normal 11 23,91
SC 18 39,13
Belum lahir 17 36,96
Jumlah 46 100,00
Distribusi Kematian Ibu Menurut Cara Persalinan

9. Manajemen
Atonia Uteri
Pervaginam

12. Manajemen
PPH Profilaksis SC ?

19. Dibandingkan Oksitosin, Pabal®
(Carbetocin) terbukti mengurangi kebutuhan
uterotonik tambahan / pijat rahim untuk pencegahan perdarahan pasca
persalinan sesar 1,2
Double-blind Randomised Trials (n=377)1
Proporsipasienyang
membutuhkanterapi
uterotoniktambahan(%)
50
4
5
4
0
3
5
3
0
25
20
15
10
5
0
RR = 0.74 (95% CI: 0.57-0.95)
P= 0.023
CI: Confidence Interval; RR: Relative Risk
Pasien yang
membutuhkan terapi
uterotonik tambahan
berkurang 26% dengan
Pabal®
(Carbetocin)1
Pasien diberikan 100
mcg Carbetocin atau 5
IU Oksitosin lewat IV
setelah kelahiran bayi.
45.
5
33.
5
Proporsipasien
denganmembutuhkan
pijatrahim(%)
Analisis Cochrane (n=739)2
RR=0.54 (95% CI: 0.31-0.96)
P= 0.035
References :
1.Attilakos G et al. Carbetocin versus oxytocin for the prevention of postpartum haemorrhage following caesarean section: the results of a double-blind randomised trial. BJOG. 2010;117:929-936. DOI: 10.1111/j.1471-0528.2010.02585.x
2. Su LL, Chong YS, Samuel M. Carbetocin for preventing postpartum haemorrhage. Cochrane Database of Systematic Reviews 2012, Issue 4. Art. No. CD005457. DOI: 10.1002/14651858.CD005457.pub4.
3. Borruto F, Treisser A, Comparetto C. Utilization of carbetocin for prevention of postpartum hemorrhage after cesarean section: a randomized clinical trial. Arch Gynecol Obstet. 2009;280(5):707-12. DOI:10.1007/s00404-009-0973-8
4. Dansereau J, Joshi AK, Helewa ME, et al. Double-blind comparison of carbetocin versus oxytocin in prevention of uterine atony after cesarean section. Am J Obstet Gynecol. 1999;180(3):670-676.
DOI: 10.1016/s0002-9378(99)70271-1
0
5
1
0
1
5
2
0
Pasien yang membutuhkan pijat
rahim setelah persalinan
sesar berkurang 46%
dengan Pabal®
(Carbetocin)2
Dosis Carbetocin yang digunakan 100 mcg pada
kedua studi.
Dosis Oksitosin bervariasi pada kedua studi :
1)10 IU infus IV selama 2 jam 3
,
2)5 IU Injeksi IV dan dilanjutkan dengan 20 IU
infus IV
selama 8 jam 4
14.
6
7.
9
Carbetoc
in
( n= 188 )
Oksitos
in
( n= 189 )
Carbetoc
in
( n= 369 )
Oksitos
in
( n= 370 )
RR: Relative RiskCI: Confidence Interval;

20. Jangan Lupa drip 2 ampul
sampai 6 jam post SC yaKan sudah Pakai
Carbetocin mbok!
Atahhh….

22. 135,559
pregnant
women
196
Trial
seven uterotonic agents
and placebo
53 countries (including high-,
middle- and low-income countries)

23. Agents for prevention of PPH ≥ 500 mL
Ergometrine plus
oxytocin
(RR 0.70, 95% CI
0.59 to 0.84, moderate
certainty)
Carbetocin
(RR 0.72, 95% CI 0.56 to
0.93, moderate certainty)
Misoprostol plus
oxytocin
(RR 0.70,
95% CI 0.58 to 0.86, low
certainty)

24. Agents for prevention of PPH ≥ 1000 mL
Ergometrine plus
oxytocin
Carbetocin
Misoprostol plus
oxytocin

25. Misoprostol plus
oxytocin
Vomiting (RR 2.11, 95% CI 1.39 to 3.18, high
certainty) and fever (RR 3.14, 95% CI 2.20 to 4.49,
moderate certainty).
Ergometrine plus
oxytocin
Vomiting (RR 2.93, 95% CI 2.08 to 4.13,
moderate certainty) and
may make little or no difference to the
risk of hypertension.

28. Efek mual lebih ringan tapi tidak berbeda signifikan
dengan oxitocyn
Tidak ada perbedaan signifikan terhadap
Tekanan darah, Nadi dan kebutuhan Vassopresor
Dan kehilangan darah

29. Pabal®
(Carbetocin) dapat menjadi pilihan untuk pencegahan perdarahan
pasca persalinan sesar dengan profil keamanan yang baik.1
Carbetocin (Pabal®
) memiliki efek samping yang hampir sama dengan
Oksitosin pada pasien sesar.2
Meta-analisis hasil penelitian perbandingan Oksitosin dengan Carbetocin pada wanita yang menjalani operasi sesar
NE, not estimable.
References :
1.Su LL, Chong YS, Samuel M. Carbetocin for preventing postpartum haemorrhage. Cochrane Database of Systematic Reviews 2012, Issue 4. Art. No. CD005457. DOI: 10.1002/14651858.CD005457.pub4.
2. Jin B et al. Carbetocin for the prevention of postpartum hemorrhage: a systematic review and meta-analysis of randomized controlled trials. J Matern Fetal Neonatal Med 2015;29(3):400-407.
DOI: 10.3109/14767058.2014.1002394

30. Carbetosin yang stabil terhadap panas tidak kalah dengan
oksitosin untuk pencegahan kehilangan darah setidaknya 500 ml
atau penggunaan agen uterotonik tambahan

31. Oxitocyn Inside
Sing perlu repot luh, ne anggo,
Carbetocin….

32. Penggunaan Oxitocyn dan Carbetocin sama sama dapat
direkomendasikan pada operasi SC sebagai agen uterotonika

33. Oxitocin Masuk!
OK, Masuk!
Metergin Masuk!
Ok!
Pasien PEB dok!
Atahhh….oopp
Tensi 180/120 dok

36. The need for additional
uterotonic agents
was reduced when
carbetocin 100 mg was
used compared to
oxytocin (RR 0.57; 95% CI
0.49 to 0.65; p < 0.001).
The need for blood transfusionwas also found to
be significantly reduced when carbetocin was
used as the prophylactic uterotonic
in cesarean sections. Pooled analysis from four
studies involving 1207 women showed a risk
reduction of 0.31 (95% CI 0.15 to 0.64;
p = 0.002). Heterogeneity I2 was 37.0, reflecting
moderate heterogeneity across studies
The risk ratio (RR) of PPH with carbetocin
was 0.79 (95% CI 0.66 to 0.94; p = 0.009).
Variation in RR attributable to
heterogeneity I2 was 25.8%.

37. A previous meta-analysis had also demonstrated a trend towards lower risk of PPH (RR 0.66;
95% CI 0.42 to 1.06), although it was not statistically significant.
(Su LL, Chong YS, Samuel M. Carbetocin for preventing postpartum haemorrhage. Cochrane Database Syst Rev 2012 Feb 15;2:CD005457)
In a recent large retrospective study involving more than 1000 patients, findings
of the investigators also showed a significant reduction in PPH in women undergoing cesarean section
when carbetocin was used rather than oxytocin (16.36% vs 30.45%)
Razali N, Md Latar IL, Chan YK, Omar SZ, Tan PC. Carbetocin compared to oxytocin in emergency cesarean section: a randomized trial. Eur J Obstet Gynecol Reprod Biol 2016 Mar;198:35e9.)

40. Carbetocin masuk!
Pasiennya BPJS dok!
Ga ditanggung dok..
Atahhh…

43. THANK YOU