Table 1.
Medical Therapy for Postpartum Hemorrhage.*
| Medication | Mechanism of Action | Route of Administration and Dose | Concerns and Contraindications | Adverse Effects |
|---|---|---|---|---|
| First-line therapy: oxytocin | Stimulates oxytocin receptors in the uterus | IV route, 10–40 IU/500–1000 ml of lactated Ringer’s solution; IM or IMM route, 5–10 IU for up to 4 doses | SIADH, hypotension | Rapid bolus administration may cause hyponatremia, hypotension, tachycardia, and arrhythmia |
| Second-line therapy | ||||
| Methylergonovine maleate (ergot alkaloid) | Partial agonist or antagonist at serotoninergic, dopaminergic, α1-adrenergic receptors in the uterus | IM or IMM route, 0.2 mg every 2–4 hr, for a maximum of 5 doses; oral route, 0.2 mg every 6–8 hr for 2–7 days | Hypertension, cardiovascular disease (stroke, Renaud’s disease) | Elevated blood pressure, nausea, vomiting, myocardial infarction |
| Carboprost tromethamine (PGF2α) | PGF2α agonist in uterine myometrium | IM or IMM route, 250 μg every 15–90 min for a maximum of 8 doses | Asthma, cardiovascular disease, hepatic disease, renal disease | Nausea, vomiting, and diarrhea |
| Adjunctive agents | ||||
| Tranexamic acid | Diminishes the dissolution of hemostatic fibrin by plasmin, stabilizing clot in uterine vessels | IV route, 1 g (100 mg/ml) over a 10-min period; if bleeding persists after 30 min or stops and restarts within 24 hr after the first dose, a second dose may be administered | Contraindicated if known hypersensitivity to tranexamic acid, thromboembolic event during pregnancy, history of hypercoagulopathy | Headache, musculoskeletal pain, nausea, diarrhea |
| Recombinant factor VIIa | Activates clotting cascade by cleaving factor IX and factor X, which activates these factors and leads to activation of thrombin and fibrin | IV route, 50–100 μg/kg (single dose) | Severe anemia, severe thrombocytopenia, hyperfibrinogenemia, allergy to mouse, hamster, or bovine proteins | Thromboembolic events, cerebrovascular infarcts, myocardial infarction |
| Treatment of uncertain usefulness: misoprostol | PGE1 agonist in the uterine myometrium | Sublingual, oral, or rectal route (sublingual route preferred), 600–1000 μg in single dose; repeat doses not recommended | Sepsis, allergy to misoprostol, concurrent anticoagulant therapy, cardiovascular disease; efficacy is disputed | Nausea, vomiting, fever, diarrhea |
*
IM denotes intramuscular, IMM intramyometrial, IV intravascular, PGE1 prostaglandin E1, PGF2α 15-methyl prostaglandin F2α, and SIADH syndrome of inappropriate antidiuretic hormone secretion.