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Chapter 5: Uterotonics

Dillon Schafer; Yunping Li

INTRODUCTION

Postpartum hemorrhage (PPH) is a leading cause of maternal mortality, accounting for about 35% of all maternal deaths globally.1 Uterine atony remains the single most common cause of PPH, responsible for nearly 80% of total cases.2 Strategy and choice of administrating uterotonic agents are summarized in Table 5-1.

TABLE 5-1Strategies of Administrating Uterotonics
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TABLE 5-1 Strategies of Administrating Uterotonics

WHO recommends use of an effective uterotonic for prevention of PPH for all births

The patients with placenta previa may have PPH despite good uterine tone

If the first-line uterotonics is not efficient, choose the second-line medication immediately

OXYTOCIN (PITOCIN)—FIRST LINE

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Mechanism

Activation of oxytocin receptors in the myometrium. Prolong exposure to oxytocin during labor can lead to receptor desensitization and increase the risk of PPH.3

Side effects

When it is given in large intravenous (IV) doses, oxytocin can cause hypotension, tachycardia, and nausea. Oxytocin is structurally similar to antidiuretic hormone; extended use of oxytocin may cause water retention, hyponatremia, and seizures (Chapter 4, “Oxytocin”).

How to give

Bolus: For PPH high-risk patients, 3 units IV before infusion. Infusion: 20 units in 1 L of Lactated Ringers, infuse at 250 mL/h (5 IU/h) or 375 mL/h (7.5 IU/h) Intramuscular: 10 units intramuscularly (IM) if no IV catheter.

CARBETOCIN (NOT AVAILABLE IN THE UNITED STATES)—FIRST LINE WHERE ITS COST IS COMPARABLE

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Mechanism

Analogue of oxytocin with longer half-life, but more expensive. It is heat stable, suitable for resource-poor countries. Efficacy of carbetocin is noninferior to oxytocin for the prevention of PPH.4

Side effects

Hypotension, nausea and vomiting, headache, abdominal pain.

How to give

100 µg IV or IM.

MISOPROSTOL (CYTOTEC)—FIRST LINE IF OXYTOCIN IS UNAVAILABLE

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Mechanism

Synthetic analogue of PGE1. Stimulates uterine smooth muscle contractions. Less potent than carboprost and methylergonovine.

Side effects

Rigors, transient fever, headache, diarrhea, abdominal pain.

How to give

800-1000 µg per rectum; or 400 or 600 µg by mouth, or 800 µg sublingual. Single dose. Stored at room temperature. World Health Organization recommends the administration PO by community or lay healthcare workers where skilled health personnel are not available.

METHYLERGONOVINE (METHERGINE)—SECOND LINE

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Mechanism

Serotonin receptor agonist in smooth muscle, particularly within the uterus; partial alpha-adrenergic agonist.

Side effects

Avoid in patients with hypertension, preeclampsia, and Raynaud’s syndrome. Other side effects include headache and nausea.

How to give

0.2 mg IM, may repeat in 2-4 hours.

CARBOPROST (HEMABATE)—SECOND LINE

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