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Post-partum haemorrhage

Most country guidelines recommend use of prophylactic oxytocics for the third stage and all recommend their use in high risk labours. The choice between oxytocin, ergometrine, misoprostol and carbetocin, and the recommended doses of each vary widely.

Available guidelines

 

Region Country Date Source url Active treatment of 3rd stage labour PPH prophylaxis
Europe Austria 2011 n/a • Oxytocin and carbetocin Vaginal deliveries
1. Oxytocin (3–5 IU IV)
Europe Czech Republic 2011 Link 1. Oxytocin, carbetocin or methylergometrine Caesarean sections
1. Oxytocin or carbetocin
2. Controlled cord traction
3. Cord clamping and cutting
Europe Denmark 2013 n/a 1. Syntocinon (40–80 IU diluted and administered via infusion pump at a rate of 180 mL/hour)
2. Cytotec (0.4 mg sublingual/rectal)
3. Methylergometrine (0.2 mg IM)
4. Carboprost (Prostinfenem; 0.25 mg/mL IM)
5. Carbetocin (100 mcg slow IV)

 

Vaginal and caesarean deliveries
1. Syntocinon (40–80 IU diluted and administered via infusion pump at a rate of 180 mL/hour)
2. Cytotec (0.4 mg sublingual/rectal)
3. Methylergometrine (0.2 mg IM)
4. Carboprost (0.25 mg/mL IM)
5. Carbetocin (100 mcg slow IV)
Europe Finland n/a n/a • Oxytocin (50 IU) or Cytotec (600–1200 mcg) administered rectally every 3–4 hours n/a
Europe France 2014 Link

• Oxytocin

Vaginal and caesarean deliveries
• Prophylaxis: in Caesarian section, carbetocin listed (not first recommendation)
Europe Germany 2016 Link • Oxytocin 3-5 IE slowly i.v. or short infusion • Oxytocin (Syntocinon ®)3-5 IE as short infusion or slowly i.v. or Carbetocin (PABAL ® 100 µg) as short infusion or slowly i.v.
Europe Greece 2014 Link

1. Oxytocin
2. Methylergonovine 0.2 mg IM or Ergometrine 0.25 mg IM (Grade of recommendation Β).
3. Prostaglandines allowed only if oxytocin or alkaloids have failed

Vaginal and caesarean deliveries
• In the third stage of vaginal delivery oxytocin (5 iu or 10 iu, Grade of recommendation Α). In Caesarian section oxytocin (5 - 10 iu, Grade of recommendation C). Misiprostol can be used only in deliveries at home or in lack of oxytocin (Grade of recommendation Α)
Europe Hungary 2008 Link

First line: Oxytocin (5-20 IU IV or  IM , 2-3 hours after birth: 10 IU IV infusion in 500 mL)
+  ergot alkaloide in selected cases (rarely)
+ misoprostol, if necessary an injectable uterotonic (rarely)

carbetocin (only in caesarean deliveries)

1. Uterotonics:
Oxytocin (10 IU IM, 5 IU IV or 10 IU IV infusion in 500 mL of liquid at a rate of 100–150 mL/hour)
Non-responsive cases: prostaglandines (Sulprostone, carboprost, misoprostol)

2. Controlled cord traction, cord clamping and cutting

3. Uterine massage

Europe Italy 2009 n/a

1. Carbetocin
2. Oxytocin 
3. Syntometrin
4. Misoprostol

  • Vaginal delivery: oxytocin or syntometrine
  • Cesarean delivery: carbetocin or oxytocin or syntometrine
Europe The Netherlands 2013 Link • Oxytocin as first choice

Vaginal and caesarean deliveries:
• There is evidence that in caesarean section the use of carbetocin reduces the risk of PPH (18), however, the comparative studies difference in terms of duration and dose of oxytocin in the control groups. However carbetocin is not more cost-effective than oxytocin as maintenance dose, and also the WHO does not support the use of carbetocin above a maintenance dose of oxytocin (1, 19).

1. WHO Recommendations for the prevention and treatment of postpartum hemorrhage and retained placenta. Versie 2009, update 2012
18. Su. LL Chong YS, Samuel M Carbetocin for preventing postpartum haemorrhage. Cochrane Database Syst Rev. 2012 Feb 15;2:CD005457.
19. Higgins L et al. Does carbotocin for prevention of postpartum haemorrhage at caesarean section provide clinical or Financial benefit. J Obstet Gynaecol 2011 Nov;31(8):732-9

Europe Norway 2014 Link

• Oxytocin 5 IU IM (repeat once, if necessary)

Vaginal and caesarean deliveries
• Oxytocin 5 IU IM
Europe Poland 2013 link 1. Oxytocin
2. Carbetocin
n/a
Europe Portugal n/a n/a • Oxytocin n/a
Europe Romania 2009 Link • Oxytocin or methylergometrine Vaginal and caesarean deliveries
• Oxytocin or methylergometrine
Europe

Russia

2013

Link

 

Link

1. Carbetocin 100 mcg IM or oxytocin 20 IU IM
2. Misoprostol is used in approximately 20% cases of PPH

 

 

Vaginal and caesarean deliveries
1. Carbetocin 100 mcg and oxytocin (5–10 IU IV infusion)

Carbetocin is included in the EDL 2015. EDL is list of vital and essential medicines that includes 608 drugs from diversified areas and which guided all hospitals in Russia

Europe Slovakia 2014 Link 1. Oxytocin, carbetocin or methylergometrine

Elective Caesarean sections
1. Carbetocin
2. Methylergometrine 
3. Cord clamping and cutting

 

Slovak National guidelines for prevention, diagnosis and treatment of PPH was approved by Ministry of health on October , 2014. http://www.health.gov.sk/?VestnikyMzSr2014

Recommendation for prevention of PPH:

- In elective Caesarean section Carbetocin, 100 μg is given as an IV bolus over 1 minute, within woman is monitored. In case of uterine atony occurrence after Carbetocin administered, another therapeutic uterotonics, ( like Methylergometrin or Prostin 15Mcarboprost) are given.

- In acute Caesarean section, prevention is managed by administration of Oxytocin. If Oxytocin was not administered, Carbetocin 100μg/1 ml would be given as an IV bolus over 1 minute. If Oxytocin was administered, Oxytocin 5IU would be given as an i.v. bolus + 5IU in 500ml FR and methylergometrin 0,2mg i.u.

Europe Spain 2006 Link

1. Oxytocin
2. Methylergometrine
3. Carboprost (Hemabate) or misoprostol

Vaginal and caesarean deliveries
• Oxytocin
Europe Sweden n/a n/a • Oxytocin n/a
Europe Turkey n/a n/a • Oxytocin (40–60 IU IV infusion)
• Methylergometrine (0.2 mg IM every 3–4 hours, 4–6 times)
• Misoprostol tablets (1000 mcg rectally or 400–800 mcg sublingually)
Vaginal and caesarean deliveries
• Oxytocin (5–10 IU IM or IV Infusion)
• Methylergometrine (0.2 mg IM)
Europe Ukraine 2014 Link 1. Oxytocin
2. Carbetocin
Vaginal deliveries
• Oxytocin (5 IU or 10 IU by IM)

Caesarean deliveries
• Oxytocin (5 IU slow IV bolus)
• carbetocin 
• misoprostol
Europe United Kingdom 2009 Link

• Syntocinon (5 IU slow IV bolus)
• Ergometrine (0.5 mg slow IV or IM bolus)
• Syntocinon (40 IU IV infusion in 500 mL Hartmann's solution at a rate of 125 mL/hour)
• Carboprost (0.25 mg IM repeated at intervals of no less than 15 min). Maximum of 8 doses (2 mg)
• Carboprost (0.5 mg intramyometrial injection)
• Misoprostol (1000 mcg rectally)

Vaginal deliveries
• Oxytocin (5 IU or 10 IU by IM)

Caesarean deliveries
• Oxytpocin (5 IU slow IV bolus)
• Syntometrine (in the absence of hypertension)
• Misoprostol (if oxytocin is not available, such as home-birth setting)

Latin America Argentina n/a n/a • Oxytocin (10/20 IU IM)
• Ergometrine (0.2 mg IM)
• Syntometrine
• Misoprostol (400–600 mcg)

n/a

Latin America Brazil 2010 n/a

1. Oxytocin (10 IU IM, 20–40 IU IV in 6 hours). Maintenance dose of 20 IU IV over 8 hours)
2. Ergometrine (0.2 mg IM). A second dose can be give after 15 min if required. Maintenance dose of 0.2 mg IM over 4 hours (total dosage should not exceed 1 mg)
3. Misoprostol (200–800 mcg sublingual). Do not exceed 800 mcg

Vaginal and caesarean deliveries
1. Oxytocin (10 IU IV or IM after delivery)
Latin America Chile 2015 Link

First-line recommendation

  • Oxytocin
  • Carbetocin, in elective C-section, to reduce the need for further uterotonics
  • Misoprostol, when oxytocin is not available

Second-line recommendation

  • Ergometrine

*Misoprostol (600 to 800 mcg oral, sublingual or rectal) can be used as an alternative for the prevention of postpartum hemorrhage when oxytocin is not available.

n/a
Latin America Mexico 2010 Link

• Oxytocin (10–40 IU IV in 1000 mL saline)
• Ergometrine (0.2 mg IM or IV)
• Carbetocin (100 mcg single IV bolus)
• Misoprostol (800 mg sublingually or rectally)
• Tranexamic acid acid

Caesarean deliveries
• Oxytocin (10–40 IU IV in 1000 mL saline)
• Carbetocin 100 mcg/min IV can be used in elective caesarean section instead of oxytocin
Asia China 2009 Link • Oxytocin (10 IU IM, 5 IU IV or 10 IU IV infusion in 500 mL of liquid at a rate of 100–150 mL/hour) Vaginal and caesarean deliveries
1. Oxytocin (10 IU IM, 5 IU IV or 10 IU IV infusion in 500 mL of liquid at a rate of 100–150 mL/hour)
2. Controlled cord traction, cord clamping and cutting
3. Uterine massage
Asia Japan 2014 n/a

Vaginal and caesarean deliveries;

Uterine massage, Controlled cord traction, cord clamping and cutting

1st line
- Oxytocin (5-10 IU IM, 5-20IU IV drip)
- PGF2က (250mcg IM)
- Ergometrine (0.2mg IM)

Uterine massage, Controlled cord traction, cord clamping and cutting

2nd line
- PGE1 (600-1000mcg Oral)

n/a
Asia Malaysia 2015 n/a

1. IV bolus oxytocin 5IU, follow by infusion up to 40IU for next 24 hours
2. IM Syntometrine 1 ampoule
3. IM Carborprost 250mg
4. PR Mistroprostol

Vaginal delivery and C-section:
1. Uterine massage
2. Expel all blood clots and ensure bladder empty
3. IV bolus oxytocin 5IU, follow by infusion up to 40IU for next 24 hours
4. IM Syntometrine 1 ampoule
Asia South Korea 2010 Link
1st line recommendation: Oxytocin 
2nd: Misoprostol
1st line recommendation: Oxytocin 
2nd: Misoprostol 
*Carbetocin, in elective C-section, is listed but not recommended as 1st choice of drug
Asia Thailand 2011 n/a 1. Oxytocin (10 IU IM, 5 IU IV or 10–20 IU IV infusion in 1000 mL saline at a rate of 100–150 mL/hour) 2. Methylergometrine n/a
Asia The Philippines 2014 n/a

1. Oxytocin – 5 IU slow IV or 5-10 IU IM/IV infusion
2. Carbetocin – 100 ug IM or IV over 1 minute
3. Methylergometrine – 0.2mg IM, can be repeated at an interval 2-4 hours up to 1mg (5 doses) for a 24  hour period
4. Tranexamic Acid – if oxytocin and other uterotonics failed to stop the bleeding

1. Oxytocin – 10 IU/mL IM or 5IU slow IV push within the first minute after delivery
2. Carbetocin – 100 ug IM or IV over 1 minute
3. Methylergometrine – 0.2mg IM, can be repeated at an interval 2-4 hours up to 1mg (5 doses) for a 24  hour period
Asia Vietnam 2012

n/a

1. Controlled cord traction
2. Carbetocin 100 mcg IM or IV in high-risk patient groups
Caesarean deliveries
• Uterine massage
• Oxytocin (5 IU IV infusion in 500 mL solvent). Maximum of 80 IU
• Methylergometrine (0.2 mg IV or IM). Maximum of 5 doses (1 mg). Contraindicated for hypertension and Raynaud symptom
• Carbetocin (100 mcg)
• PGEF2α (250 mcg IM). Total dose 2 mg. Contraindicated for asthma and hypertension
• PGE1 (800 mcg rectally)
Australasia Australia 2012 Link

• Syntocinon, ergometrine or misoprostol (rectally)

Elective caesarean deliveries
• Consider using carbetocin 100 mcg IV in 1 mL, given slowly over 1 min after birth of the baby

Carbetocin is currently not indicated in emergency caesarean section or after vaginal birth

Australasia New Zealand 2011 n/a • Syntocinon, ergometrine, misoprostol (rectally) or prostaglandins n/a
North America Canada 2010 Link

1. Oxytocin (10 IU IM or 20–40 IU IV infusion at a rate of 500–1000 mL/hour)
2. Hemabate
3. Carbetocin (100 mcg IM or IV over 1 min)
4. Misoprostol (400–1000 mcg)

Caesarean deliveries
• Carbetocin (100 mcg IV bolus over 1 min)

Vaginal deliveries
• Carbetocin (100 mcg IM)

North America United States 2006 Link 1. Oxytocin (10 IU IM or 10–40 IU IV infusion in 1000 mL saline)
2. Methylergometrine (0.2 mg IM every 2–4 hours)
3. Hemabate (0.25 mg IM every 15–90 min). Maximum of 8 doses (2 mg)
4. Prostin (20 mg vaginally or rectally every 2 hours)
5. Cytotec (800–1000 mcg rectally)
Vaginal and caesarean deliveries
1. Oxytocin (10 IU IM or 10–40 IU IV infusion in 1000 mL saline)
2. Methylergometrine (0.2 mg IM every 2–4 hours)
3. Carboprost (Hemabate; 0.25 mg IM every 15–90 min). Maximum of 8 doses (2 mg)
4. Prostin (20 mg vaginally or rectally every 2 hours)
5. Cytotec (800–1000 mcg rectally)
Middle East Israel 2013 n/a • Oxytocin or prostaglandins Vaginal and caesarean deliveries
• Oxytocin or prostaglandins
Middle East Lebanon 2012 n/a 1. Oxytocin Vaginal and caesarean deliveries
1. Oxytocin (5–10 IU IV followed by continuous IV infusion of 20–30 IU)
2. Misoprostol (200 mcg)
3. Methylergometrine
4. Prostin
Middle East Saudi Arabia 2013 Link n/a Use oxytocic drugs that can be given together or sequentially for vaginal and caesarean deliveries
• Oxytocin (10 IU IM or 20 IU IV infusion in 1000 mL fluid at a rate of 60 drops/min)
• Ergometrine (0.2 mg IM or slow IV). A second dose of 0.2 mg IM can be given after 15 minutes if required or a second dose of 0.2 mg slow IV given every 4 hours. Maximum of 5 doses (1 mg)
• PGFα (0.25 mg IV given every 15 min). Maximum total dose of 2 mg
Africa South Africa n/a n/a n/a

Caesarean deliveries
• Oxytocin (10 IU IV bolus, followed by a continuous infusion of 20–30 IU IV infusion)

Vaginal deliveries
• Oxytocin (10 IU IM)

Worldwide World Health Organization 20112 Link

Pharmacological methods
1. Oxytocin IV
2. Ergometrine IV, syntometrine or prostaglandin (including misoprostol 800 mcg sublingual)
3. Tranexamic acid

Vaginal and caesarean deliveries
1. Oxytocin (10 IU IV or IM)
2. Ergometrine/methylergometrine, syntometrine or misoprostol (600 mcg orally)
Worldwide International Federation of Gynecology and Obstetrics 2012 Link

• Oxytocin (10 IU IM, 5 IU slow IV bolus or 20–40 IU IV infusion)
• Misoprostol (800 mcg sublingually)
• Ergometrine/methylergometrine (0.2 mg IM). Repeat dose every 2–4 hours if required. Maximum total dose of 1 mg per 24-hour period
• Syntometrine IM
• Carbetocin (100 mcg IM or IV over 1 min)
• Carboprost (0.25 mg every 15 min). Maximum of 8 doses (2 mg)

1. Oxytocin (10 IU IM or 5 IU slow IV bolus)
2. Ergometrine/methylergometrine (0.2 mg IM)
3. Misoprostol (600 mcg orally)