EDC - "Every Drop Counts"
DRUGS
Oxytocin
Used for both prevention and treatment of postpartum hemorrhage. Oxytocin increases uterine tone by activating G-protein coupled receptors triggering increases in intracellular calcium levels in uterine myofibrils. Oxytocin also increases local prostaglandin production leading to further uterine contraction.
Delivery: intramuscular injection (IM), intravenous injection (IV)
Dosing:
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IM 10 units after delivery of the placenta
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IV: 5 or 10 units given initially followed by a maintenance infusion of up to 10 units/hour. Maximum cumulative dose of 40 units.
Onset of action: 3 - 5 min (IM), 1 min (IV)
Duration: 2 - 3 hours (IM), 1 hour (IV)
Half-life: 3 minutes
Storage Temperature: store at 20°C to 25°C (68°F to 77°F).
Cost: 2$/shot
Contraindications: severe toxemia
Pros: readily available, cheaper, must be kept at specific temperatures (not heat stable)
Cons: short half-life, may require continuous infusion
Duratocin (Carbetocin)
Binds to oxytocin receptors in uterine smooth muscle, increasing both existing contractions and uterine tone. Enhances uterine involution early in postpartum
Delivery: intramuscular injection (IM), intravenous injection (IV)
Dosing:
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Following vaginal delivery: IV, IM- 100 mcg (single dose only)
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Following caesarean section: IV- 100 mcg (single dose only)
Onset of action: 1 minute (IV)
Duration: 120 minutes (IM), 60 minutes (IV)
Half-life: 85 - 100 minutes
Storage Temperature:
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Ampoule: Store at 2°C to 8°C (36°F to 46°F)
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Vial: Store at 15°C to 30°C (59°F to 86°F)
Cost: $18/shot
Contraindications: serious cardiovascular disorders.
Pros: longer half-life, stable at room temperature
Cons: more expensive
Ergometrine
Primarily affects uterine smooth muscles to produce sustained contractions. Has slight alpha-adrenergic blocking activity.
Delivery: intramuscular (IM), intravenous (IV), intracoronary (off-label route)
Onset of action: 2-5 minutes (IM), immediate (IV)
Duration: > 3 hours (IM), ~45 minutes (IV)
Storage Temperature:
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Store ampules at 2°C to 8°C (36°F to 46°F). Protect from light.
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Following dilution in normal saline, solution can be stored up to 4 hours at room temperature
Cost: $2 per 500ug
Pros:
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effective in causing uterine contractions
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quick acting
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can be given IV, IM, or orally
Cons:
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contraindicated in hypertension, peripheral vascular disease, impaired hepatic or renal disease
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may not work for those with calcium deficiency
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can cause nausea/vomiting, and seizures with high blood pressure
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Overdose ergotism
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Most often given with Oxytocin in the UK and the British Commonwealth (for historical reasons)
Hemabate
Is an analog of the naturally occurring prostaglandin F2α. When used postpartum, hemostasis at the placentation site is achieved via myometrial contractions.
Delivery: intramuscular (IM) - administer deep IM. Rotate site if repeat injections are required.
Dosing: Initial: 250 mcg; if needed, may repeat at 15- to 90-minute intervals; maximum total dose: 2 mg (8 doses)
Duration: 15 - 90 min
Onset of action: 45 minutes
Half-life: 35 - 40 minutes
Excretion: Urine
Storage Temperature: store under refrigeration at 2°C to 8°C (36°F to 46°F)
Cost: $400 - $500 / injection
Contraindication: asthma
Pros:
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can work well on an atonic uterus
Cons:
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Needs to be given IM or IV
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Expensive
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Side effects: nausea, abdominal pain, diarrhea
Misoprostol
Misoprostol is a synthetic analog of prostaglandin E1 (alprostadil). It is rapidly and almost completely absorbed from the GI tract. The drug undergoes first pass metabolism (de-esterification) to form misoprostol acid, the principal and active metabolite.
Delivery: Oral
Dosing:
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Prevention: 600 mcg as a single dose administered immediately after delivery
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Treatment: 600 to 1,000 mcg as a single dose
Duration: 1 - 4 hours
Half-life: 20 - 40 minutes
Storage Temperature: Store at or below 25°C (77°F)
Cost: $6 / tablet
Contraindication: Asthma
Pros:
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Easy to use
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Inexpensive
Cons:
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Can give abdominal pain, nausea, diarrhea
Tranexamic Acid
Tranexamic acid (TXA) is an antifibrinolytic agent used to prevent PPH during vaginal and caesarean delivery. TXA forms a reversible complex that displaces plasminogen from fibrin resulting in inhibition of fibrinolysis; it also inhibits the proteolytic activity of plasmin.
Delivery: Oral, IV
Dosing: 1 gm IV can be repeated in 30 minutes if no improvement.
Duration: 3 hours
Half-life: 2 hours (IV), 11 hours (Oral)
Storage Temperature:
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Ampules/vials: Store at 20°C to 25°C (68°F to 77°F)
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Tablets: Store at 25°C (77°F)
Cost: $4/mL, $6.50/tablet
Pros:
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seems to work well if given early (not so after 3 hours)
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Inexpensive
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Easy use (either IV or orally)
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IV for very heavy bleeding
Cons:
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Disagreement on claimed effectiveness (WOMAN Trial)