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Postpartum haemorrhage: ergometrine (query bank)

Published: 05/08/2013

Question

In our protocol for postpartum haemorrhage (PPH) we give syntometrine (ergometrine 500mcg and syntocinon 5 units) and repeat ergometrine IV (500mcg) if there is ongoing bleeding. Please can you advise on the correct dose, interval of administration of ergometrine, route and the total dose allowed for ergometrine?

Answer

The following guidelines provide information on ergometrine for PPH.

World Health Organization recommendations for the prevention and treatment of postpartum haemorrhage. 2012.

Box 4: Recommendations for the treatment of PPH – uterotonics

“13. Intravenous oxytocin is the recommended uterotonic drug for the treatment of PPH. (Strong recommendation, moderate quality evidence)

14. If intravenous oxytocin is unavailable, or if the bleeding does not respond to oxytocin, the use of intravenous ergometrine, oxytocin-ergometrine fixed dose, or a prostaglandin drug (including sublingual misoprostol, 800 μg) is recommended. (Strong recommendation, low-quality evidence)”

eMedicine. Postpartum Hemorrhage Treatment & Management. (Smith, JR. 2012)

“Management of the underlying cause of PPH.

Use other uterotonic agents if the uterus remains atonic despite oxytocin administration and bimanual massage. The traditional second-line agent for uterine atony has been ergonovine (or ergotrate) given as an initial dose of 100 or 125 mcg intravenously or intramyometrially or 200 or 250 mcg intramuscularly. The maximum total dose is 1.25 mg”

Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Management of Postpartum haemorrhage (PPH). 2011.

“Tone - uterine atony is the most common cause of primary PPH but clinical assessment should be used to exclude other causes. The following interventions have all been used to stop the bleeding, generally in the stepwise progression as presented here.

i. Mechanical:

  • Uterine massage or bimanual uterine compression.
  • Empty bladder.

ii. Pharmacological:

  • Syntocinon by slow intravenous injection or infusion.
  • Ergometrine by slow intravenous injection, in the absence of contraindications......”

Queensland Maternity and Neonatal Clinical Guideline. Primary postpartum haemorrhage (2012).

A PPH Drug table in appendix E, has the order of administration as oxytocin first end ergometrine second. Information for ergometrine is:

Dose: 250 microgram. Repeat as required, after 15 minutes to a maximum total dose of 500 micrograms

Route: IV slowly over 1-2 minutes

RCOG Green-top guideline. Management of postpartum haemorrhage. 2009.

“When uterine atony is perceived to be a cause of the bleeding, the following mechanical and pharmacological measures should be instituted, in turn, until the bleeding stops:

  • Bimanual uterine compression (rubbing up the fundus) to stimulate contractions.
  • Ensure bladder is empty (Foley catheter, leave in place).
  • Syntocinon 5 units by slow intravenous injection (may have repeat dose).
  • Ergometrine 0.5 mg by slow intravenous or intramuscular injection (contraindicated in women with hypertension).
  • Syntocinon infusion (40 units in 500ml Hartmann’s solution at 125ml/hour) unless fluid restriction is necessary.
  • Carboprost 0.25 mg by intramuscular injection repeated at intervals of not less than 15 minutes to a maximum of 8 doses (contraindicated in women with asthma).
  • Direct intramyometrial injection of carboprost 0.5 mg (contraindicated in women with asthma), with responsibility of the administering clinician as it is not recommended for intramyometrial use.
  • Misoprostol 1000 micrograms rectally.”

Society of Obstetricians and Gynaecologists of Canada. Active management of the third stage of labour: prevention and treatment of postpartum haemorrhage. 2009

“Uterine Massage and Additional Uterotonic Administration

“Since the most common cause of PPH is uterine atony, the clinician’s initial efforts should be directed at preventing ongoing blood loss by performing the initial basic maneuvres of uterine massage and administering additional uterotonics, which include the following”. .....

“5. Ergonovine

  • 0.25 mg IM or IV, can be repeated every 2 hours
  • Contraindicated in women with hypertension and those taking certain drugs (e.g., proteases for HIV infection).”

American College of Obstetricians and Gynecologists. Postpartum hemorrhage. 2006

A table for the medical management of postpartum hemorrhage lists the dose/route for Methylergonovine (Methergine) as intramuscularly 02.mg, and the frequency as every 2-4h.

The British National Formulary section on prevention and treatment of haemorrhage says:

“Oxytocic drugs are used to treat postpartum haemorrhage caused by uterine atony; treatment options are as follows:

  • oxytocin 5 units by slow intravenous injection (dose may be repeated), followed in severe cases by intravenous infusion of oxytocin 40 units in 500 mL infusion fluid (prolonged administration—see Appendix 4) at a rate that controls uterine atony or
  • ergometrine 250–500 micrograms by intramuscular injection or
  • ergometrine 250–500 micrograms by slow intravenous injection (use with caution—risk of hypertension) or
  • ergometrine 500 micrograms with oxytocin 5 units (Syntometrine® 1 mL) by intramuscular injection”

The summary of product characteristics for Ergometrine Injection BP 0.05% w/v (hameln) says:

“Prevention and Treatment of Postpartum Haemorrhage:

Doses of 200 micrograms to 500 micrograms of Ergometrine are given intramuscularly, following expulsion of the placenta or when bleeding occurs. In emergencies, Ergometrine Injection may be given intravenously at a dose of 250 micrograms to 500 micrograms.”

(Evidence level IV)

References

Search date

August 2013

Classification of evidence levels

  • Ia: Evidence obtained from meta-analysis of randomised controlled trials.
  • Ib: Evidence obtained from at least one randomised controlled trial.
  • IIa: Evidence obtained from at least one well-designed controlled study without randomisation.
  • IIb: Evidence obtained from at least one other type of well-designed quasi-experimental study.
  • III: Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies.
  • IV: Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities.

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