How is uterine atony treated in postpartum hemorrhage (PPH)?

Updated: Jan 02, 2018
  • Author: Maame Yaa A B Yiadom, MD, MPH; Chief Editor: Bruce M Lo, MD, MBA, CPE, RDMS, FACEP, FAAEM, FACHE  more...
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Uterine atony should always be treated empirically in the early postpartum period. Uterine massage will stimulate uterine contractions and frequently stops uterine hemorrhage. The examiner's gloved hand can be placed into the lower uterus, extracting any large clots or tissue that prevent adequate contractions.

Do not apply excessive pressure on the fundus of the uterus as this may increase the risk of inversion. Note that massaging a hard, contracted uterus can actually impede detachment of the placenta and increase bleeding.

With a boggy uterus, continue to massage and administer uterotonics to increase uterine contraction. Give oxytocin, an analogue of the identically named endogenous hormone, 20-40 units in 1 L lactated Ringer (LR) at 600 mL/h to maintain uterine contraction and to control hemorrhage. Ergotamines (eg, ergonovine, methylergonovine [Methergine]) can be used instead of, or with the failure of oxytocin, to facilitate uterine contraction. [20] Other alternatives include 15-methyl-prostaglandin, also known as carboprost (Hemabate) (0.25 mg IM), and misoprostol (1 mg PR), which is an inexpensive prostaglandin E1 analogue that has been used in several trials with good success in controlling postpartum hemorrhage in cases refractory to oxytocin. In settings in which oxytocin use is not feasible, misoprostol might be a suitable treatment alternative for postpartum hemorrhage. [21] See the Medication section for more details.


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