How is uterine atony-related postpartum hemorrhage (PPH) treated?

Updated: Jun 27, 2018
  • Author: John R Smith, MD, FACOG, FRCSC; Chief Editor: Ronald M Ramus, MD  more...
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Two well-designed trials indicate that oxytocin should be the drug of choice for both prophylaxis and treatment of post partum hemorrhage caused by uterine atony. [42]

Assess uterine size and tone by placing a hand on the uterine fundus and massaging the uterus, which serves to express any clots that have accumulated in the uterus or vagina. If the uterus is found to be boggy and not well contracted, commence vigorous massage and therapeutic oxytocin. Oxytocin can be administered as a 5-U intravenous bolus, as 20 U in 1 L of NS intravenously run as fast as possible, or as 10 U intramyometrially with a spinal needle if no immediate intravenous access is available. [6]

Emptying the bladder may aid in ongoing assessment and facilitate uterine contraction and subsequent therapeutic maneuvers. Wearing a waterproof gown, elbow-length gloves, and eye protection is prudent during the management of PPH. Sterile technique is used.

If the uterus remains atonic, commence bimanual massage. A hand is placed on the fundus, and the second hand is placed anterior to the cervix in the vagina. Prepare the perineum and vagina. The vaginal hand may be covered in povidone-iodine solution (Proviodine) or a lubricant to allow it to enter the vagina with less difficulty. Take care to minimize the chance of causing or worsening trauma in the lower genital tract. Trauma to the vaginal sidewalls and cervix may be palpated as the hand is gently introduced into the vagina, and blood clots may be evacuated from the vagina, cervix, and lower uterine segment.

The vaginal hand is placed in the anterior fornix, and the abdominal hand is placed on the posterior aspect of the fundus. The uterus is raised from the pelvis, pivoted anteriorly, and compressed between the two hands. The compression expels clots and decreases bleeding. Massaging the uterus between the hands aids in promoting and sustaining contraction. Bimanual massage results in a decrease in bleeding, even if the uterus remains relatively atonic, thus allowing resuscitation a chance to begin to catch up with blood loss.

Use other uterotonic agents if the uterus remains atonic despite oxytocin administration and bimanual massage. The traditional second-line agent for uterine atony has been ergonovine (or ergotrate) given as an initial dose of 100 or 125 mcg intravenously or intramyometrially or 200 or 250 mcg intramuscularly. The maximum total dose is 1.25 mg. Hypertension is a relative contraindication. In some regions, the availability of ergot preparations has become problematic. Every effort should be made to secure supplies of this inexpensive and useful agent.

Many authorities now recommend the use of intramuscular carboprost as the second-line agent when it is available. The recommended dose is 250 mcg intramuscularly or intramyometrially, not to exceed 2 mg (8 doses). Asthma is a relative contraindication. Carboprost has been shown to be 80-90% effective in stopping PPH in cases refractory to oxytocin and ergonovine. Intramuscular administration of these agents is not recommended if the patient demonstrates evidence of shock because absorption would be compromised.

Misoprostol may also become a valuable agent in the treatment of PPH. One small case series reported that a dose of 1000 mcg given rectally was effective in causing sustained uterine contraction in 14 cases refractory to oxytocin, ergonovine, or both. [43, 44] Recent trials are examining whether the more rapid onset of sublingual/buccal misoprostol will improve its efficacy in the setting of acute PPH. [45] At this time, however, misoprostol remains a third-line agent in the management of PPH. [46] The low cost of the drug and its heat stability (does not require refrigeration) makes it especially appealing for use in the developing world. More trials are pending.

A meta-analysis that included data from 88,947 women reported that compared to oxytocin alone; ergometrine plus oxytocin, carbetocin monotherapy, or misoprostol plus oxytocin were all associated with a reduced risk for postpartum hemorrhage. In the oxytocin group, 10.5% had a postpartum hemorrhage of ≥ 500 mL compared with 7.2% in the ergometrine plus oxytocin group, 7.6% in the carbetocin group, and 7.7% in the misoprostol plus oxytocin group. [83]

Winikoff et al examined sublingual (SL) misoprostol for PPH when oxytocin is not feasible to administer. Oxytocin is considered the standard of care for treating postpartum hemorrhage, but because of refrigeration requirements and the need for intravenous administration, it is not always clinically viable, particularly in primitive clinical settings. Active bleeding was controlled within 20 min for 440 (90%) women administered misoprostol 800 mcg SL (n=488) and 468 (96%) administered oxytocin 40 units IV (n=490) (relative risk [RR], 0.94; 95% confidence interval [CI], 0.91-0.98). Additional blood loss of 300 mL or greater after treatment occurred for 147 (30%) of women receiving misoprostol and 83 (17%) receiving oxytocin (RR, 1.78; 95% CI, 1.40-2.26). The authors concluded that in circumstances where it is not feasible to use oxytocin for postpartum hemorrhage, misoprostol is a suitable alternative. [47]

A study by Quibel et al found that adding misoprostol with prophylactic routine oxytocin did not have an effect on the rate of postpartum hemorrhage risk and increased the rate of adverse events. The study reported that the rate of postpartum hemorrhage was 8.4% (68/806) in the misoprostol and 8.3% (66/797) in the placebo group (P=.98). In the misoprostol group there was a significant increase in adverse events with fever being the highest occurrence (30.4% in the misoprostol group vs 6.3% in the placebo group). The study was stopped after early results showed that misoprostol was associated with adverse events. [48]

A study by Diop et al that compared the efficacy of misoprostol and oxytocin when delivered by auxiliary midwives at maternity huts in Senegal via Uniject concluded that misoprostol could be more appropriate for community-level prophylaxis of postpartum hemorrhage. [49]

The investigational agent carbetocin has been compared with oxytocin for prevention of postpartum hemorrhage. Attilakos et al compared the effectiveness of carbetocin and oxytocin when given for postpartum hemorrhage after cesarean delivery in a double-blind, randomized trial. The primary outcome measure was women who required additional pharmacologic oxytocic interventions. Results showed that significantly more women required additional oxytocics in the oxytocin group compared with the carbetocin group. [50]

A double-blind study that compared heat-stable carbetocin with oxytocin after vaginal birth for postpartum hemorrhage prevention in 29,645 women reported that the frequency of blood loss of at least 500 ml or the use of additional uterotonic agents was 14.5% in the carbetocin group and 14.4% in the oxytocin group (consistent with noninferiority) and that the frequency of blood loss of at least 1000 ml was 1.51% in the carbetocin group and 1.45% in the oxytocin group (crossing the margin of noninferiority). [84]

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