Misoprostol-Cytotec-is a synthetic prostaglandin Ej analogue that is used for prevention and treatment of atony (AbdelAleem, 2001; Ugwu, 2016). Most studies have addressed prevention and have conflicting conclusions. In a Cochrane review, Mousa and associates (2014) reported no added benefits for misoprostol use compared with oxytocin or ergonovine for treatment. Derman and coworkers (2006) compared a 600-l-Lg oral dose given preventively at delivery against placebo. They found that the drug lowered the incidence of hemorrhage from 12 to 6 percent and that of severe hemorrhage from 1.2 to 0.2 percent. In another study, Gerstenfeld and Wing (2001) concluded that 400 ILg misoprostol administered rectally was not superior to intravenous oxytocin given to prevent postpartum hemorrhage. From a systematic review, Villar (2002) found that oxytocin and ergot preparations administered after delivery were more efective than misoprostol for prevention of postpartum hemorrhage (Chap. 27, p. 527). If misoprostol is used to treat atony, the American College of Obstetricians and Gynecologists (2017 d) recommends a dose of 600 to 1000 ILg rectally, orally, or sublingually.
Bleeding Unresponsive to Uterotonic Agents
If bleeding persists after initial measures for atony have been implemented, then the following management steps are performed immediately and simultaneously: 1.
Begin bimanual uterine compression, which is easily done and controls most cases of continuing hemorrhage (Fig. 41-4). This technique is not simply fundal massage. The posterior uterine wall is massaged by one hand on the abdomen, while the other hand is made into a fist and placed into the vagina. his fist kneads the anterior uterine wall through the anterior vaginal wall and the uterus is also compressed between the two hands.
2.
Immediately mobilize the emergent-care obstetrical team to the delivery room and call for whole blood or packed red cells.
3.
Request urgent help from the anesthesia team.
4.
Secure at least two large-bore intravenous catheters so that crystalloid with oxytocin can be continued simultaneously with blood products. Insert an indwelling Foley catheter for continuous urine output monitoring.
5.
Begin volume resuscitation with rapid intravenous infusion of crystalloid (p. 788).
6.
With sedation, analgesia, or anesthesia established and now with optimal exposure, once again manually explore the uterine cavity for retained placental fragments and for uterine abnormalities, including lacerations or rupture.
FIGURE 41-4 Bimanual compression for uterine atony. The uterus is positioned with the fist of one hand in the anterior fornix pushing against the anterior wall, which is held in place by the other hand on the abdomen. The abdominal hand is also used for uterine massage.
7.
Thoroughly inspect the cervix and vagina again for lacerations that may have escaped attention.
8.
If the woman is still unstable or if there is persistent hemorrhage, then blood transfusions are given (p. 788).
At this juncture, after causes other than atony have been excluded and after hypovolemia is reversed, several other measures are considered if bleeding continues. Their use depends on several factors such as parity, desire for sterilization, and experience with each method.