WHO recommendations on the use of uterotonics for the treatment of postpartum haemorrhage (PPH)

WHO recommendations on the use of uterotonics for the treatment of postpartum haemorrhage (PPH)

Recommendations

 

  • Intravenous oxytocin alone is the recommended uterotonic drug for the treatment of PPH. (Strong recommendations, low-quality evidence)
  • If intravenous oxytocin is unavailable, or if the bleeding does not respond to oxytocin, the use of intravenous ergometrine, oxytocin-ergometrine fixed dose, or a prostaglandin drug (including sublingual misoprostol, 800 µg) is recommended. (Strong recommendations, low-quality evidence

 

Date these recommendations were published: September 2012

 

Remarks

The GDG recommended IV oxytocin as the first line uterotonic drug for the treatment of PPH, including when women have already received this drug for the prophylaxis of PPH.

The GDG recognized that IV oxytocin may not be available in all settings. It encourages health care decision-makers in these settings to strive to make oxytocin available.

In settings where IV oxytocin is unavailable to women who have received prophylactic IM oxytocin during the third stage of labour, the GDG considered misoprostol to be a valid alternative.

If PPH prophylaxis with misoprostol has been administered and if injectable uterotonics are unavailable, there is insufficient evidence to guide further misoprostol dosing and consideration must be given to the risk of potential toxicity.

There is no added benefit to offering misoprostol simultaneously to women receiving oxytocin for the treatment of PPH (i.e. adjunct misoprostol).

The GDG noted that the two largest trials of misoprostol for the treatment of PPH (Winikoff 2010, Blum 2010) reported the use of a 800 μg dose administered sublingually. The majority of the GDG members agreed that 800 μg is an acceptable sublingual misoprostol dose for the treatment of PPH, though some members of the GDG expressed concern related to the risk of hyperpyrexia associated with this dosage.

If IV oxytocin has been used for the treatment of PPH and the bleeding does not stop, there is a paucity of data to recommend preferences for second line uterotonic drug treatment. Decisions in such situations must be guided by the experience of the provider, the availability of the drugs, and by known contraindications.

In situations in which IM oxytocin can be administered and there is no possibility of IV treatment with ergot alkaloids/injectable prostaglandins, there is a paucity of data to recommend a preference of IM oxytocin over misoprostol or other uterotonics. Decisions in such situations must be guided by the experience of the provider, the availability of the drugs, and by known contraindications.

 

Related links

WHO recommendations for the prevention and treatment of postpartum haemorrhage

Evidence Base and GRADE tables for these recommendations

 

Links to the supporting systematic reviews

Begley CM, Gyte GM, Murphy DJ, Devane D, McDonald SJ, McGuire W. Active versus expectant management for women in the third stage of labour. Cochrane Database Syst Rev. 2011(7):CD007412. In editorial process.

Westhoff G, Cotter AM, Tolosa JE. Prophylactic oxytocin for the third stage of labour to prevent postpartum haemorrhage. Cochrane Database of Systematic Reviews 2013, Issue 10. Art. No.: CD001808. DOI: 10.1002/14651858.CD001808.pub2.

McDonald S, Murphy D, Sheehan S. Prophylactic ergometrine-oxytocin versus other uterotonics for active management of the third stage of labour. Cochrane Database Of Systematic Reviews.

Su LL, Chong YS, Samuel M. Oxytocin agonists for preventing postpartum haemorrhage. Cochrane Database Syst Rev. 2012

Tunçalp Ö, Hofmeyr GJ, Gülmezoglu AM. Prostaglandins for preventing postpartum haemorrhage. Cochrane Database of Systematic Reviews. 2011(Issue 3. Art.No.: CD000494.)

Mousa HA, Alfirevic Z. Treatment for primary postpartum haemorrhage. Cochrane Database Syst Rev. 2012; In editorial process.

 

Resources

VIDEO: Active management of the third stage of labour
VIDEO: Caesarean section evidence-based surgical technique

Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice

 

These recommendations should be cited as: WHO Reproductive Health Library. WHO recommendations on the use of uterotonics for the treatment of postpartum haemorrhage (last revised 2012). The WHO Reproductive Health Library; Geneva: World Health Organization.