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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 3rd 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