Significance of uterotonics for the prevention and treatment of postpartum hemorrhage

Abstract

The incidence of postpartum hemorrhage (PPH) has increased in recent years, with uterine atony as the most frequent reason. In up to 60% of cases there are no identifiable risk factors for PPH. Therefore, prevention and early treatment of PPH must focus on all pregnant women. Available uterotonic agents are oxytocin, the oxytocin agonist carbetocin, prostaglandins E1 and E2, such as sulprostone and misoprostol, and methyl ergometrine. To minimize blood loss, 3–5 IU of oxytocin are given intravenously in a short infusion after delivery. After cesarean section carbetocin with a longer half-life is an alternative to oxytocin. This management can prevent up to 79% of PPH in a high-risk population and significantly reduces the use of additional uteronics. Preventive application of uterotonics is one of the three pillars of the patient blood management as it reduces the rate of anemia and the need for blood transfusion. Uterotonics have cardiovascular side effects like hypotension, reflex tachycardia and increase of cardiac output per minute, which are especially important in patients with unstable conditions like hemorrhagic shock. The treatment of PPH includes stepwise management according to the D‑A-CH algorithm, where oxytocin or carbetocin are the first-line medications alone or in combination with prostaglandins. Uterotonics are also used in combination with mechanical or surgical measures to treat other causes of PPH.