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.
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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.
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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
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Pros: readily available, cheaper, must be kept at specific temperatures (not heat stable)
Cons: short half-life, may require continuous infusion
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Duratocin (Carbetocin)
Binds to oxytocin receptors in uterine smooth muscle, increasing both existing contractions and uterine tone. Enhances uterine involution early in postpartum
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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.
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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.
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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
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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)
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Hemabate
Is an analog of the naturally occurring prostaglandin F2α. When used postpartum, hemostasis at the placentation site is achieved via myometrial contractions.
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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
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Contraindication: asthma
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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
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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.
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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
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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.
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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
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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)