A comparison between Oxytocin alone versus combined therapy in postpartum females with uterine atony: a cross-sectional study in Damascus, Syria

A comparison between Oxytocin alone versus combined therapy in postpartum females with uterine atony: a cross-sectional study in Damascus, Syria | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A comparison between Oxytocin alone versus combined therapy in postpartum females with uterine atony: a cross-sectional study in Damascus, Syria Ghena mhd bashir nashawy, Shrook muaz alderi, Raed Kaser Abdullah, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7914859/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Uterine atony, defined as the failure of the uterus to contract adequately following delivery, is the leading cause of postpartum hemorrhage (PPH), accounting for over half of all cases. Despite oxytocin being the first-line uterotonic agent, many cases require escalation to second-line therapies such as misoprostol, methylergonovine, or mechanical interventions. Identifying the most effective management strategy is critical to reducing maternal morbidity and improving recovery outcomes. Objective aims to collect the data surrounding this area, assess the incidence of complications due to uterine atony, and compare the efficacy of oxytocin monotherapy, versus with methylergonovine, or misoprostol, or the combination of prostaglandin and uterine tamponade. Methods This retrospective cross-sectional study included 402 women diagnosed with uterine atony at Al Zahrawi Hospital for Obstetrics and Gynecology in Damascus, Syria, between January 2022 and June 2025. Patients were grouped based on treatment received: oxytocin alone (n = 169) or combination therapy (n = 231), which included misoprostol, methylergonovine, uterine tamponade, or multiple interventions. Primary outcomes were hysterectomy and bleeding severity. Secondary outcomes included transfusion need, hospital stay duration, and associations with clinical variables. Data were analyzed using Chi-square tests and descriptive statistics. Results Hysterectomy was required in 35 cases (8.7%), and transfusion in 35 cases (8.7%), with no statistically significant difference between treatment groups. Significant associations were found between treatment type and age, gestational age, parity, anemia status, bleeding amount, and hospital stay duration ( p < 0.05). Combination therapy was associated with reduced postpartum complications and shorter hospital stays. Conclusion While hysterectomy and transfusion rates did not differ significantly between groups, combination therapy showed potential benefits in reducing postpartum complications and hospital stay duration. Further prospective studies are warranted to confirm these findings and guide clinical practice. Epidemiology Obstetrics & Gynecology uterine atony postpartum hemorrhage cross-sectional damascus syria Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Intro Uterine atony is the leading factor for post-partum hemorrhage for women around the globe, causing about 70% of postpartum hemorrhage cases (Mitta et al., 2023 ), it causes complications in a wide scale and could lead to death, with up to a fourth of females die due to postpartum hemorrhage caused by uterine atony (Evensen et al., 2017 ). Uterine atony could be correlated and caused by multiple factors such as, multiparity, multiple gestations, polyhydramnios (Almutairi, 2020 ). Currently, uterine atony is managed with uterotonics (e.g., oxytocin) and uterine massage to reduce the amount of blood loss from females (Lisonkova et al., 2016 ). There is a lack of unity on the best possible management for atonic postpartum hemorrhage (Van Netten et al., 2025 ). Recent research has investigated the use of secondary uterotonics and medications such as prostaglandins to reduce the overuse of oxytocin and saturation of its receptors (Van Netten et al., 2025 ). Although there is some research on this field in multiple countries, Syria doesn’t have any research surrounding this serious topic, in spite the lack of resources to fully manage the cases during the war, and no epidemiological data is given on this matter .Our study aims to collect the data surrounding this area, assess the incidence of complications due to uterine atony, and compare the efficacy of oxytocin monotherapy, versus with methylergonovine, or misoprostol, or the combination of prostaglandin and uterine tamponade. Methods Study Design and Setting: This retrospective cross-sectional study was conducted at Al-Zahrawi Hospital for Obstetrics and Gynecology, a tertiary care center in Damascus, Syria. Data were collected from previous patient records spanning between January 2022 to June 2025. The study was a single center and based on manual chart reviews of inpatient admissions and emergency records. Participants We included women of all ages who were diagnosed with uterine atony following delivery. Exclusion criteria were: absence of uterine atony in the medical record and missing data in key outcome variables. A total of 402 patients met the inclusion criteria and were analyzed. Exposure and Group Classification: Patients were categorized into two groups according to the treatment regimen applied: -Group 1: Oxytocin Only - Group 2: Oxytocin combined with other medical interventions, including prostaglandin, methylergometrine, both agents, or additional measures such as uterine tamponade using gauze rolls. Treatment decisions were made at the discretion of the attending clinician Outcomes The primary outcomes were the need for blood transfusion and hysterectomy. Secondary outcomes included: - Length of hospital stay (> 24 hours) - Estimated bleeding amount - Parity - Duration of labor - Presence of anemia - Maternal age and gestational age - Pre-existing chronic conditions (hypertension, type 2 diabetes mellitus, or other) - Mode of delivery (vaginal or cesarean) - Amniotic fluid status - Use of magnesium sulfate - Presence of preeclampsia - Need for intensive care unit (ICU) admission All outcomes were extracted from clinical notes and discharge summaries. The length of Labor was categorized according to American College of Obstetricians and Gynecology (ACOG) guidelines. Data Management and Missing Data Three cases had missing data: one in mode of delivery and two in transfusion status. These were excluded from the relevant analyses but retained for other comparisons where data were complete. Statistical Analysis Data were analyzed using SPSS version 29. Descriptive statistics were used to summarize baseline characteristics and outcomes. All variables were categorical (ordinal and nominal), all variables were compared using chi square or fisher’s exact tests, as appropriate. Only p-values were reported, as the data did not meet the assumptions for parametric testing or regression modeling. A significance threshold of p < 0.05 was applied. Sensitivity and Subgroup Analyses Due to the limited number of events in some outcomes (e.g., hysterectomy), no formal sensitivity or subgroup analyses were performed. However, exploratory comparisons were made across key clinical variables to assess consistency of trends. Ethical Considerations The study was approved by the Ethical Review Board of Damascus University and conducted in accordance with the principles of the Declaration of Helsinki. Informed consent was waived due to the retrospective nature of the study and anonymized data handling. Results Table 1 characteristics of the sample Table 1 shows the characteristics of the sample of women As observed, the majority of the women were within the 20–35 age range (76.3 and a higher percentage of pregnancies were in the normal range of 37–42 weeks (96.8%). Over half the women had 3 or more previous pregnancies. Additionally, 63.2% of labors had a normal duration, while others experienced prolonged labor Almost a third of the women had a natural birth rather than a cesarean delivery. Twins were rare, as only 1.5% of births were twins. The majority of the newborns (84.5%) were within the normal weight range (2500–3999 g). The presence of anemia had a semi-equal distribution, with a slight advantage towards its absence; 58.8% of women were not anemic. Most women had minimal blood loss, with 76.5% of the women losing only 500–999 ml Most women did not experience preeclampsia and did not need magnesium sulfate during birth (97.8%). All women in the sample had no fibromas (100 No pregnancy had polyhydramnios; rather, the majority (98.2%) had norm-hydramnios. The management during birth was more skewed towards multi-intervention management, with 57.8% of births having oxytocin with other interventions. Most women did not need a hysterectomy (91.2%), and the exact same percentage did not require blood transfusion. Only 10.5% of women had a previous history of hypertension, and 4% had “other” chronic diseases (asthma, hypothyroidism, IBD, etc.). Almost all women didn’t require ICU admission, with only 8 cases required ICU admission. Additionally, 14.5% of women had more than 24 hours stay in the hospital. A correlation between hysterectomy, blood transfusion and type of management provided no statistical significance (p-value < 0.05). On the other hand, age, gestational age, parity, amount of bleeding, anemia, and length of hospital stay had highly significant results (p-value < 0.001), as shown from the figures (1–5) and Table 2. Type of delivery, amniotic fluid levels, magnesium sulfate usage, preeclampsia, ICU admission, and chronic illnesses had no statistical significance (p > 0.05). Discussion Uterine atony has a significant role in postpartum hemorrhage and could lead to death. There are also discrepancies in the optimum management of postpartum hemorrhage and a lack of consensus regarding optimal dosages and the selection of uterotonic agents. This highlights the need to improve the management of uterine atony to prevent complications and reduce postpartum bleeding to the best of our ability to mitigate complications and mortality. Our sample shows a normal age group, with 76.8% of the women being between the ages of 20–35. The gestational age of the pregnancies was normal, as 96.8% were between 37–42 weeks, which is a healthy range. Higher parity was observed compared to Western countries, as over half the sample had more than 3 previous pregnancies, which could be attributed to the common and well-known customs and traditions related to having many children (Taha et al., 2022 ). Almost two-thirds of the pregnancies had a normal duration and 25% had prolonged labor duration. Additionally, 64.7% had a natural birth as this is the preferred method of delivery; this could be attributed to personal preferences, the high cost of cesarean delivery and its complications, or the requirement of overnight stay in hospitals (Serçekuş et al., 2015 ). Twins were a rare occurrence, with only 1.5% of births being twins, which is lower than in Eastern Africa according to Getachew T. et al. ( 2024 ) (Getachew et al., 2024 ). Most newborns were within the normal weight range between 2500–3999 g. Most women were non-anemic, but nonetheless a high percentage were anemic (41.3%). None of the females in the sample had fibromas, which is inconsistent with previous literature that indicates that almost 30% of women have fibromas; this could be attributed to the lack of reporting of fibromas by the patients during history taking or to detection bias. However, detection bias usually overestimates the percentage of fibroid prevalence according to Mousa et al. (Mousa et al., 2021 ). Blood loss was minimal in the majority, with 76.5% having blood loss less than 1000 ml. Only 2.3% of patients had preeclampsia; the prevalence in previous studies in the Middle East varied in percentages according to Hegazy et al. (Hegazy et al., 2024 ) The usage of magnesium sulfate had the same percentage, which could be explained by the indications of magnesium sulfate that clarify its correlation with preeclampsia. Most pregnancies had normo-hydramnios (98.2%); none experienced polyhydramnios, which is unexpected. According to Dashe and the prevalence of polyhydramnios is 1–2% of all pregnancies; this is likely due to detection bias (Pagan et al., 2023 ). The management of uterine atony was balanced but leaned slightly toward combined therapy of oxytocin and other interventions, as 42.3% had oxytocin only. The interventions could be oxytocin with prostaglandin, methylergonovine, or using gauze for uterine tamponade, or the three combined. Although the usage of gauze is a nontraditional intervention compared to the intrauterine balloon tamponade, it could be justified due to the lack of suitable equipment (Abul et al., 2023 ). Most women required neither a hysterectomy nor a blood transfusion, with 91.2% not requiring each. This could be because blood transfusion is reserved for only high-risk patients such as those with copious blood loss or major surgical intervention, and as previously stated, the majority of patients did not experience high blood loss during birth. Additionally, 2% of patients needed an ICU admission, while 14.5% required a more than 24-hour stay. This could be due to the lack of beds in the ICU department in Al-Zahrawi Hospital. After statistical analysis, hysterectomy and blood transfusion had no statistically significant correlation with type of management (p-value = 0.427 and 0.186, respectively). On the other hand, type of management had a significant correlation with amount of blood loss, parity, age, gestational age, length of stay, and anemia with p-value 0.05). References Abul A, Al-Naseem A, Althuwaini A, Al-Muhanna A, Clement NS (2023) Safety and efficacy of intrauterine balloon tamponade vs uterine gauze packing in managing postpartum hemorrhage: A systematic review and meta-analysis. AJOG Global Rep 3(1):100135. https://doi.org/10.1016/j.xagr.2022.100135 Almutairi WM (2020) Incidences of Atonic Postpartum Hemorrhage and Related Risk Factors at a Tertiary Hospital in Saudi Arabia. Nurs Rep 10(2):164–171. https://doi.org/10.3390/nursrep10020020 Evensen A, Anderson JM, Fontaine P (2017) Postpartum Hemorrhage: Prevention and Treatment. Am Family Phys 95(7):442–449 Getachew T, Negash A, Debella A, Yadeta E, Lemi M, Balis B, Balcha T, Bekele H, Abdurke M, Alemu A, Shiferaw K, Eyeberu A (2024) Prevalence and adverse outcomes of twin pregnancy in Eastern Africa: A systematic review and meta-analysis. BMC Pregnancy Childbirth 24(1):169. https://doi.org/10.1186/s12884-024-06326-0 Hegazy A, Eid FA, Ennab F, Sverrisdóttir YB, Atiomo W, Azar AJ (2024) Prevalence of pre-eclampsia in women in the Middle East: A scoping review. Front Public Health 12:1384964. https://doi.org/10.3389/fpubh.2024.1384964 Lisonkova S, Haslam MD, Dahlgren L, Chen I, Synnes AR, Lim KI (2016) Maternal morbidity and perinatal outcomes among women in rural versus urban areas. CMAJ: Can Med Association J 188(17–18):E456. https://doi.org/10.1503/cmaj.151382 Mitta K, Tsakiridis I, Dagklis T, Grigoriadou R, Mamopoulos A, Athanasiadis A, Kalogiannidis I (2023) Incidence and Risk Factors for Postpartum Hemorrhage: A Case-Control Study in a Tertiary Hospital in Greece. Medicina 59(6):1151. https://doi.org/10.3390/medicina59061151 Mousa M, Al-Jefout M, Alsafar H, Kirtley S, Lindgren CM, Missmer SA, Becker CM, Zondervan KT, Rahmioglu N (2021) Prevalence of Common Gynecological Conditions in the Middle East: Systematic Review and Meta-Analysis. Front Reproductive Health 3:661360. https://doi.org/10.3389/frph.2021.661360 Pagan M, Magann EF, Rabie N, Steelman SC, Hu Z, Ounpraseuth S (2023) Idiopathic polyhydramnios and pregnancy outcome: Systematic review and meta-analysis. Ultrasound Obstet Gynecol 61(3):302–309. https://doi.org/10.1002/uog.24973 Serçekuş P, Egelioglu Cetisli N, İnci FH (2015) Birth preferences by nulliparous women and their partners in Turkey. Sex Reproductive Healthc 6(3):182–185. https://doi.org/10.1016/j.srhc.2015.03.002 Taha Z, El Ktaibi F, Dhaheri A, Papandreou AI, D., Hassan A, A (2022) Prevalence and Sociodemographic Profiles of Grand Multipara in Abu Dhabi, United Arab Emirates. Nutrients 14(21):4686. https://doi.org/10.3390/nu14214686 Van Netten C, Vallabhaneni K, Hardwick B, Anumba D, Briley AL, Collins P, Collis RE, Deja E, Gkioni E, Gyte G, Hickey H, Hinshaw K, Hughes DA, Kenyon S, Lavender T, Meher S, Plumpton C, Robson S, Rosala-Hallas A, Weeks A (2025) Carboprost versus Oxytocin as the first-line treatment of primary postpartum haemorrhage (COPE): Protocol for a phase IV, double-blind, double-dummy, randomised controlled trial and economic analysis. BMJ Open 15(5):e101255. https://doi.org/10.1136/bmjopen-2025-101255 Tables Tables 1 to 6 are available in the Supplementary Files section. Additional Declarations The authors declare no competing interests. Supplementary Files table1.png Characteristics of the sample table2.png Correlation between Hysterectomy and blood transfusion with group of management table3.png correlation between age, and gestational age with group of treatment table4.png A comparison between delivery type, amniotic fluid amount, magnesium sulfate usage, and group of management table6.png correlation between history of chronic disease and its subtypes, with group of management table67.png correlation between hysterectomy, delivery, amniotic fluid level, Mgso4 usage and group of management Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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19:10:20","extension":"png","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":24196,"visible":true,"origin":"","legend":"\u003cp\u003eCorrelation between Hysterectomy and blood transfusion with group of management\u003c/p\u003e","description":"","filename":"table2.png","url":"https://assets-eu.researchsquare.com/files/rs-7914859/v1/85b11ef798ee85a0910effdb.png"},{"id":94136096,"identity":"a2f45b26-4b3c-4096-9097-8a97f1a47909","added_by":"auto","created_at":"2025-10-22 19:02:20","extension":"png","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":29130,"visible":true,"origin":"","legend":"\u003cp\u003ecorrelation between age, and gestational age with group of treatment\u003c/p\u003e","description":"","filename":"table3.png","url":"https://assets-eu.researchsquare.com/files/rs-7914859/v1/d028c1e0d3797fa58545eee0.png"},{"id":94136106,"identity":"f22465ec-d7d2-43fc-a03d-85e9a85c96fd","added_by":"auto","created_at":"2025-10-22 19:02:20","extension":"png","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":142042,"visible":true,"origin":"","legend":"\u003cp\u003eA comparison between delivery type, amniotic fluid amount, magnesium sulfate usage, and group of management\u003c/p\u003e","description":"","filename":"table4.png","url":"https://assets-eu.researchsquare.com/files/rs-7914859/v1/29680fa7950166cf37e4e8e0.png"},{"id":94136108,"identity":"c9130804-d384-4bb5-a06e-5035474e7156","added_by":"auto","created_at":"2025-10-22 19:02:20","extension":"png","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":182496,"visible":true,"origin":"","legend":"\u003cp\u003ecorrelation between history of chronic disease and its subtypes, with group of management\u003c/p\u003e","description":"","filename":"table6.png","url":"https://assets-eu.researchsquare.com/files/rs-7914859/v1/a3db5b4a49ef259606efb822.png"},{"id":94136104,"identity":"9c1c5f5b-0aa0-478d-8a08-efc2c59f3179","added_by":"auto","created_at":"2025-10-22 19:02:20","extension":"png","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":106054,"visible":true,"origin":"","legend":"\u003cp\u003ecorrelation between hysterectomy, delivery, amniotic fluid level, Mgso4 usage and group of management\u003c/p\u003e","description":"","filename":"table67.png","url":"https://assets-eu.researchsquare.com/files/rs-7914859/v1/373faf7b8be028c8abf822bc.png"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eA comparison between Oxytocin alone versus combined therapy in postpartum females with uterine atony: a cross-sectional study in Damascus, Syria\u003c/p\u003e","fulltext":[{"header":"Intro","content":"\u003cp\u003eUterine atony is the leading factor for post-partum hemorrhage for women around the globe, causing about 70% of postpartum hemorrhage cases (Mitta et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), it causes complications in a wide scale and could lead to death, with up to a fourth of females die due to postpartum hemorrhage caused by uterine atony (Evensen et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Uterine atony could be correlated and caused by multiple factors such as, multiparity, multiple gestations, polyhydramnios (Almutairi, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Currently, uterine atony is managed with uterotonics (e.g., oxytocin) and uterine massage to reduce the amount of blood loss from females (Lisonkova et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). There is a lack of unity on the best possible management for atonic postpartum hemorrhage (Van Netten et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Recent research has investigated the use of secondary uterotonics and medications such as prostaglandins to reduce the overuse of oxytocin and saturation of its receptors (Van Netten et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Although there is some research on this field in multiple countries, Syria doesn\u0026rsquo;t have any research surrounding this serious topic, in spite the lack of resources to fully manage the cases during the war, and no epidemiological data is given on this matter .Our study aims to collect the data surrounding this area, assess the incidence of complications due to uterine atony, and compare the efficacy of oxytocin monotherapy, versus with methylergonovine, or misoprostol, or the combination of prostaglandin and uterine tamponade.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design and Setting:\u003c/h2\u003e\u003cp\u003e This retrospective cross-sectional study was conducted at Al-Zahrawi Hospital for Obstetrics and Gynecology, a tertiary care center in Damascus, Syria. Data were collected from previous patient records spanning between January 2022 to June 2025. The study was a single center and based on manual chart reviews of inpatient admissions and emergency records.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eWe included women of all ages who were diagnosed with uterine atony following delivery. Exclusion criteria were: absence of uterine atony in the medical record and missing data in key outcome variables. A total of 402 patients met the inclusion criteria and were analyzed.\u003c/p\u003e\n\u003ch3\u003eExposure and Group Classification:\u003c/h3\u003e\n\u003cp\u003ePatients were categorized into two groups according to the treatment regimen applied:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e-Group 1: Oxytocin Only\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e- Group 2: Oxytocin combined with other medical interventions, including prostaglandin, methylergometrine, both agents, or additional measures such as uterine tamponade using gauze rolls. Treatment decisions were made at the discretion of the attending clinician\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\n\u003ch3\u003eOutcomes\u003c/h3\u003e\n\u003cp\u003eThe primary outcomes were the need for blood transfusion and hysterectomy.\u003c/p\u003e\u003cp\u003eSecondary outcomes included:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e- Length of hospital stay (\u0026gt;\u0026thinsp;24 hours)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e- Estimated bleeding amount\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e- Parity\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e- Duration of labor\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e- Presence of anemia\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e- Maternal age and gestational age\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e- Pre-existing chronic conditions (hypertension, type 2 diabetes mellitus, or other)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e- Mode of delivery (vaginal or cesarean)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e- Amniotic fluid status\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e- Use of magnesium sulfate\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e- Presence of preeclampsia\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e- Need for intensive care unit (ICU) admission\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eAll outcomes were extracted from clinical notes and discharge summaries. The length of Labor was categorized according to American College of Obstetricians and Gynecology (ACOG) guidelines.\u003c/p\u003e\n\u003ch3\u003eData Management and Missing Data\u003c/h3\u003e\n\u003cp\u003eThree cases had missing data: one in mode of delivery and two in transfusion status. These were excluded from the relevant analyses but retained for other comparisons where data were complete.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eData were analyzed using SPSS version 29. Descriptive statistics were used to summarize baseline characteristics and outcomes. All variables were categorical (ordinal and nominal), all variables were compared using chi square or fisher\u0026rsquo;s exact tests, as appropriate. Only p-values were reported, as the data did not meet the assumptions for parametric testing or regression modeling. A significance threshold of p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was applied.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSensitivity and Subgroup Analyses\u003c/h3\u003e\n\u003cp\u003eDue to the limited number of events in some outcomes (e.g., hysterectomy), no formal sensitivity or subgroup analyses were performed. However, exploratory comparisons were made across key clinical variables to assess consistency of trends.\u003c/p\u003e\n\u003ch3\u003eEthical Considerations\u003c/h3\u003e\n\u003cp\u003e The study was approved by the Ethical Review Board of Damascus University and conducted in accordance with the principles of the Declaration of Helsinki. Informed consent was waived due to the retrospective nature of the study and anonymized data handling.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cem\u003eTable\u0026nbsp;1 characteristics of the sample\u003c/em\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;1 shows the characteristics of the sample of women As observed, the majority of the women were within the 20\u0026ndash;35 age range (76.3 and a higher percentage of pregnancies were in the normal range of 37\u0026ndash;42 weeks (96.8%). Over half the women had 3 or more previous pregnancies. Additionally, 63.2% of labors had a normal duration, while others experienced prolonged labor Almost a third of the women had a natural birth rather than a cesarean delivery. Twins were rare, as only 1.5% of births were twins. The majority of the newborns (84.5%) were within the normal weight range (2500\u0026ndash;3999 g). The presence of anemia had a semi-equal distribution, with a slight advantage towards its absence; 58.8% of women were not anemic. Most women had minimal blood loss, with 76.5% of the women losing only 500\u0026ndash;999 ml Most women did not experience preeclampsia and did not need magnesium sulfate during birth (97.8%). All women in the sample had no fibromas (100 No pregnancy had polyhydramnios; rather, the majority (98.2%) had norm-hydramnios. The management during birth was more skewed towards multi-intervention management, with 57.8% of births having oxytocin with other interventions. Most women did not need a hysterectomy (91.2%), and the exact same percentage did not require blood transfusion. Only 10.5% of women had a previous history of hypertension, and 4% had \u0026ldquo;other\u0026rdquo; chronic diseases (asthma, hypothyroidism, IBD, etc.). Almost all women didn\u0026rsquo;t require ICU admission, with only 8 cases required ICU admission. Additionally, 14.5% of women had more than 24 hours stay in the hospital. A correlation between hysterectomy, blood transfusion and type of management provided no statistical significance (p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05). On the other hand, age, gestational age, parity, amount of bleeding, anemia, and length of hospital stay had highly significant results (p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.001), as shown from the figures (1\u0026ndash;5) and Table\u0026nbsp;2. Type of delivery, amniotic fluid levels, magnesium sulfate usage, preeclampsia, ICU admission, and chronic illnesses had no statistical significance (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eUterine atony has a significant role in postpartum hemorrhage and could lead to death. There are also discrepancies in the optimum management of postpartum hemorrhage and a lack of consensus regarding optimal dosages and the selection of uterotonic agents. This highlights the need to improve the management of uterine atony to prevent complications and reduce postpartum bleeding to the best of our ability to mitigate complications and mortality. Our sample shows a normal age group, with 76.8% of the women being between the ages of 20\u0026ndash;35. The gestational age of the pregnancies was normal, as 96.8% were between 37\u0026ndash;42 weeks, which is a healthy range. Higher parity was observed compared to Western countries, as over half the sample had more than 3 previous pregnancies, which could be attributed to the common and well-known customs and traditions related to having many children (Taha et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Almost two-thirds of the pregnancies had a normal duration and 25% had prolonged labor duration. Additionally, 64.7% had a natural birth as this is the preferred method of delivery; this could be attributed to personal preferences, the high cost of cesarean delivery and its complications, or the requirement of overnight stay in hospitals (Ser\u0026ccedil;ekuş et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Twins were a rare occurrence, with only 1.5% of births being twins, which is lower than in Eastern Africa according to Getachew T. et al. (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) (Getachew et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Most newborns were within the normal weight range between 2500\u0026ndash;3999 g. Most women were non-anemic, but nonetheless a high percentage were anemic (41.3%). None of the females in the sample had fibromas, which is inconsistent with previous literature that indicates that almost 30% of women have fibromas; this could be attributed to the lack of reporting of fibromas by the patients during history taking or to detection bias. However, detection bias usually overestimates the percentage of fibroid prevalence according to Mousa et al. (Mousa et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Blood loss was minimal in the majority, with 76.5% having blood loss less than 1000 ml. Only 2.3% of patients had preeclampsia; the prevalence in previous studies in the Middle East varied in percentages according to Hegazy et al. (Hegazy et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) The usage of magnesium sulfate had the same percentage, which could be explained by the indications of magnesium sulfate that clarify its correlation with preeclampsia. Most pregnancies had normo-hydramnios (98.2%); none experienced polyhydramnios, which is unexpected. According to Dashe and the prevalence of polyhydramnios is 1\u0026ndash;2% of all pregnancies; this is likely due to detection bias (Pagan et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). The management of uterine atony was balanced but leaned slightly toward combined therapy of oxytocin and other interventions, as 42.3% had oxytocin only. The interventions could be oxytocin with prostaglandin, methylergonovine, or using gauze for uterine tamponade, or the three combined. Although the usage of gauze is a nontraditional intervention compared to the intrauterine balloon tamponade, it could be justified due to the lack of suitable equipment (Abul et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Most women required neither a hysterectomy nor a blood transfusion, with 91.2% not requiring each. This could be because blood transfusion is reserved for only high-risk patients such as those with copious blood loss or major surgical intervention, and as previously stated, the majority of patients did not experience high blood loss during birth. Additionally, 2% of patients needed an ICU admission, while 14.5% required a more than 24-hour stay. This could be due to the lack of beds in the ICU department in Al-Zahrawi Hospital. After statistical analysis, hysterectomy and blood transfusion had no statistically significant correlation with type of management (p-value\u0026thinsp;=\u0026thinsp;0.427 and 0.186, respectively). On the other hand, type of management had a significant correlation with amount of blood loss, parity, age, gestational age, length of stay, and anemia with p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.001. On the contrary, preeclampsia, chronic illnesses, type of delivery, magnesium sulfate usage, amniotic fluid levels, and ICU admission were not statistically significant (p-value\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAbul A, Al-Naseem A, Althuwaini A, Al-Muhanna A, Clement NS (2023) Safety and efficacy of intrauterine balloon tamponade vs uterine gauze packing in managing postpartum hemorrhage: A systematic review and meta-analysis. 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Sex Reproductive Healthc 6(3):182\u0026ndash;185. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.srhc.2015.03.002\u003c/span\u003e\u003cspan address=\"10.1016/j.srhc.2015.03.002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTaha Z, El Ktaibi F, Dhaheri A, Papandreou AI, D., Hassan A, A (2022) Prevalence and Sociodemographic Profiles of Grand Multipara in Abu Dhabi, United Arab Emirates. Nutrients 14(21):4686. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/nu14214686\u003c/span\u003e\u003cspan address=\"10.3390/nu14214686\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVan Netten C, Vallabhaneni K, Hardwick B, Anumba D, Briley AL, Collins P, Collis RE, Deja E, Gkioni E, Gyte G, Hickey H, Hinshaw K, Hughes DA, Kenyon S, Lavender T, Meher S, Plumpton C, Robson S, Rosala-Hallas A, Weeks A (2025) Carboprost versus Oxytocin as the first-line treatment of primary postpartum haemorrhage (COPE): Protocol for a phase IV, double-blind, double-dummy, randomised controlled trial and economic analysis. BMJ Open 15(5):e101255. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1136/bmjopen-2025-101255\u003c/span\u003e\u003cspan address=\"10.1136/bmjopen-2025-101255\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 6 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Syrian Private University","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"uterine atony, postpartum hemorrhage, cross-sectional, damascus, syria","lastPublishedDoi":"10.21203/rs.3.rs-7914859/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7914859/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUterine atony, defined as the failure of the uterus to contract adequately following delivery, is the leading cause of postpartum hemorrhage (PPH), accounting for over half of all cases. Despite oxytocin being the first-line uterotonic agent, many cases require escalation to second-line therapies such as misoprostol, methylergonovine, or mechanical interventions. Identifying the most effective management strategy is critical to reducing maternal morbidity and improving recovery outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eaims to collect the data surrounding this area, assess the incidence of complications due to uterine atony, and compare the efficacy of oxytocin monotherapy, versus with methylergonovine, or misoprostol, or the combination of prostaglandin and uterine tamponade.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective cross-sectional study included 402 women diagnosed with uterine atony at Al Zahrawi Hospital for Obstetrics and Gynecology in Damascus, Syria, between January 2022 and June 2025. Patients were grouped based on treatment received: oxytocin alone (n = 169) or combination therapy (n = 231), which included misoprostol, methylergonovine, uterine tamponade, or multiple interventions. Primary outcomes were hysterectomy and bleeding severity. Secondary outcomes included transfusion need, hospital stay duration, and associations with clinical variables. Data were analyzed using Chi-square tests and descriptive statistics.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHysterectomy was required in 35 cases (8.7%), and transfusion in 35 cases (8.7%), with no statistically significant difference between treatment groups. Significant associations were found between treatment type and age, gestational age, parity, anemia status, bleeding amount, and hospital stay duration (\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05). Combination therapy was associated with reduced postpartum complications and shorter hospital stays.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhile hysterectomy and transfusion rates did not differ significantly between groups, combination therapy showed potential benefits in reducing postpartum complications and hospital stay duration. Further prospective studies are warranted to confirm these findings and guide clinical practice.\u003c/p\u003e","manuscriptTitle":"A comparison between Oxytocin alone versus combined therapy in postpartum females with uterine atony: a cross-sectional study in Damascus, Syria","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-22 19:02:15","doi":"10.21203/rs.3.rs-7914859/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4cbfc069-16a0-4204-9d22-e85cfe490d43","owner":[],"postedDate":"October 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":56651633,"name":"Epidemiology"},{"id":56651634,"name":"Obstetrics \u0026 Gynecology"}],"tags":[],"updatedAt":"2025-10-22T19:02:15+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-22 19:02:15","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7914859","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7914859","identity":"rs-7914859","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}