Treatment of postpartum haemorrhage

The full guidance on the treatment of postpartum haemorrhage has been published in the International Journal of Gynecology and Obstetrics 2007;99(supp 2):S202-5, and is available as a read-only pfd file here.

Recommended Dosage: 600mcg orally stat

Regimen

There is currently insufficient evidence available to recommend any specific misoprostol dose for treatment of postpartum hemorrhage.

In the absence of reliable evidence on misoprostol use for PPH treatment, we recommend using the prophylactic dose of 600 mg orally or sublingually. This dose was selected after careful review of the sparse data from PPH treatment and the large body of data on 600 mg oral misoprostol for postpartum hemorrhage prevention.

Misoprostol should be used only after the provider has exhausted all standard PPH treatments (oxytocin drip, uterine massage, and/or compression). All potential causes for PPH should be explored to assure that the PPH is not due to another factor besides uterine atony.

If misoprostol has been given as prophylaxis for PPH, misoprostol should not be used for treatment within the time frames given below. Dosages above 600 mg orally or sublingually are not recommended at this time.

A repeat dose of misoprostol should not be given unless at least two hours have elapsed since the first dose. If the initial dose was associated with pyrexia or marked shivering, then at least six hours should lapse before the second dose is given.

Several large multi-centre randomized controlled trials are currently underway to assess the efficacy of misoprostol at several doses for PPH treatment, and their results will be available in 2008.

Course of Treatment

After delivery, if PPH is diagnosed, treatment should be immediate. Where available, first line treatments include administration of uterotonics, including oxytocin and ergometrine along with continued uterine massage. If these methods do not stop the bleeding, misoprostol can also be given to the woman. In settings where no other uterotonic agents are available, misoprostol 600 mg can be used for the primary treatment of PPH. The misoprostol can be given either orally or sublingually. Sublingual use might be helpful when women are unconscious or under anesthetic.

These recommendations are produced by an expert group on misoprostol brought together by WHO in Bellagio, Italy in Feb 2007. These recommendations do not reflect official WHO guidelines, but have been released early so as to provide guidance to clinicians worldwide. The excerpt above is taken from:

J Blum, Z Alfirevic, G Walraven, A Weeks, B Winikoff. Treatment of Postpartum Hemorrhage with Misoprostol.
International Journal of Gynecology and Obstetrics 2007;99(supp 2):S202-5.

Alternative Guidelines

Additional guidelines on the treatment of postpartum haemorrhage are available here.

Postpartum Haemorrhage Treatment *STAT = single dose taken immediately
	Route	Dose	Time period	Max. Dose	Level of evidence	Notes
Bellagio/ FIGO	Orally Sublingual	600µg 600µg	- STAT	1	IB	Limited evidence for benefit – use conventional oxytocics first.
WHO	Sublingual	800µg	STAT	1	IA	Only use if there is no oxytocic treatment available As LAST RESORT
NICE	Guidelines state should not be used alone	-	-	-	-	Treatment combinations of ergometrine /oxytocin/ misoprostol. No doses given.
RCOG	Oral Rectal	600 µg 1000µg	STAT STAT	1 1	II II	If Contraindicated ONLY if PPH due to Uterine Atony
SOGC	Oral or Sublingual Rectal	400 -800 µg 800-1000µ	STAT STAT	1 1	-	OFF LABEL – not approved in Canada – risk of higher pyrexia. OFF LABEL
ACOG	-	-	-	-	-	No guidelines
Gynuity	Oral	600 µg	STAT	1	IB	Administer in 3^rd stage of labour – part of AMTSL Additional Misoprostol should NOT be given after initial 6 hours of this dose
POPPHI	Oral Sublingual Rectal	600µg 800 µg 1000 µg	STAT STAT STAT	1 1 1	IB	Only use if there is no oxytocic treatment available
FLASOG	Oral Rectal	600µg 600µg	STAT STAT	1 1	IB	Use of Misoprostol ONLY if there is no alternative treatment OFFLABLE – insufficient evidence