Postpartum Hemorrhage – Medications to Treat Uterine Atony

Unfortunately, postpartum hemorrhage (PPH) is still a leading cause of maternal mortality worldwide. Under the auspices of ACOG District II, multiple providers and hospitals came together as part of the Safe Motherhood Initiative, developing protocols and checklists for professional use.

CLINICAL ACTIONS:

In the setting of PPH, consider the 4 ‘T’s

Tone (atony)
Trauma (laceration)
Tissue (retained products)
Thrombin (coagulopathy)

If uterine atony is identified the following drugs have been shown to be effective:

DRUG	DOSE	CONTRA INDICATIONS
Oxytocin (Pitocin)	10-40 units per 500-1000ml solution
Methyl-ergonovine (Methergine)	0.2 mg IM	Avoid: Hypertension
Prostaglandin F2 Alpha (Hemabate)	250 micrograms IM (may repeat in q15 minutes, maximum 8 doses)	Avoid: Asthma Caution: Hypertension
Misoprostol (Cytotec)	800 – 1000 micrograms PR 600 micrograms PO 800 micrograms SL

SYNOPSIS:

The key to managing PPH is identifying the severity of the situation early and quantifying estimated blood loss (EBL). A 2nd large bore (16 gauge or larger) should be placed and Ringers Lactate used to replace blood loss at 2:1 while, at the same time that the team is notified, medications are brought to the patient and massive transfusion protocol is initiated. Initiate fundal massage and place a Foley catheter.

KEY POINTS:

ABCs
- Airway: Assess and stabilize
- Breathing: Supplemental oxygen, 5-7 L/min by tight face mask
- Circulation: do NOT wait for change in vitals
  - Compromised blood volume: pallor, delayed capillary refill and decreased urinary output
  - Late signs: decreased BP and tachycardia
Consider intrauterine balloon tamponade
Tranexamic acid, administered within 3 hours of birth, has been shown to significantly reduce maternal death due to PPH
Surgical Interventions may be a life-saving measure and should not be delayed while waiting to correct coagulopathy