Pharmacologic interventions |
Drug | Dosing |
Oxytocin (first-line) | 10 to 40 units in 500 to 1000 mL normal saline infused at a rate sufficient to control atony or 5 to 10 units IM. |
Tranexamic acid (adjunctive agent) | 1 g (10 mL of a 100 mg/mL solution) is infused over 10 to 20 minutes; if bleeding persists after 30 minutes, a second 1 g dose is administered. |
Ergots (second-line) | Methylergonovine 0.2 mg IM or ergonovine 0.2 mg IM every 2 to 4 hours. |
Carboprost (second-line) | 0.25 mg IM every 15 to 90 minutes up to 8 doses. |
Misoprostol | 400 to 800 mcg sublingually as a single dose. Most useful in settings where injectable uterotonics are unavailable or contraindicated (eg, hypertension, asthma) |
Recombinant human factor VIIa (adjunctive agent) | 50 to 100 mcg/kg. It is preferable to start with a low dose (40 or 60 mcg/kg). The dose may be repeated once in 15 to 30 minutes if there is no response. Additional doses are unlikely to be effective. |
Surgical interventions |
- Repair lacerations
- Curettage
- Uterine compression suture (eg, B-Lynch suture)
- Uterine artery ligation
- Utero-ovarian artery ligation or cross clamp
- Pelvic packing
- Uterine tourniquet
- Focal myometrial excision
- Use of fibrin glues and patches to cover areas of oozing and promote clotting
- Placement of figure 8 sutures or other hemostatic sutures directly into the placental bed
- Resuscitative endovascular balloon occlusion of the aorta (REBOA)
- Internal iliac artery (hypogastric artery) ligation
- Aortic/iliac artery compression
- Hysterectomy, supracervical
- Hysterectomy, total
|
Interventional endovascular procedures |
- Selective arterial embolization
- Intermittent aortic balloon occlusion
- Common iliac artery balloon occlusion
|
Blood bank |
- Packed red blood cells
- Platelets
- Fresh frozen plasma
- Cryoprecipitate
|
Nonsurgical interventions |
- Uterine massage
- Intravenous fluids
- Intrauterine tamponade
- Intrauterine balloon or alternative device (eg, bladder catheter bulb, Sengstaken-Blakemore tube)
- Intrauterine vacuum
- Uterine packing (eg, 4-inch gauge packing)
|
Consultations |
- General surgery
- Trauma surgery
- Anesthesia team
- Interventional radiology
- Gynecologic oncology
- Urology
|