Medical Management of Atonic PPH
Pharmacologic management of atonic PPH includes the use of oxytocin, ergometrine and prostaglandins. Intravenous oxytocin is the preferred initial agent in PPH treatment, regardless of whether a prophylactic dose was administered. If bleeding continues after oxytocin administration or if oxytocin is unavailable, IV ergometrine, ergometrine-oxytocin fixed dose (Syntometrine) or a prostaglandin such as misoprostol 800 μg sublingual can be administered. Simultaneous administration of misoprostol with treatment doses of oxytocin is not recommended. Carboprost is may be useful when bleeding is resistant to other agents.
If bleeding proves unresponsive to uterotonics, consideration may be given to tranexamic acid (TXA), a synthetic derivative of lysine with antifibrinolytic properties, or recombinant activated factor VII (rvFIIa), the latter of which is discussed later. A 2010 Cochrane Review of TXA reported decreased blood loss after vaginal and cesarean birth but called for further investigation around efficacy and safety. Two more recent randomized controlled trials (RCT) concurred, yet were underpowered to evaluate safety concerns such as thrombolytic events.[32,33] The WOMAN Trial is currently evaluating TXA for PPH treatment. WHO provides a weak recommendation for TXA where oxytocin and prostaglandins fail to control atonic PPH; however, RCOG reports that fibrinolytic inhibitors seldom have a place in PPH management.
Expert Rev of Obstet Gynecol. 2013;8(6):525-537. © 2013 Expert Reviews Ltd.