Prophylactic Meds May Prevent Cesarean Bleeding


Methylergonovine is often used to control severe bleeding immediately after cesarean deliveries. But a new study suggests that the ergot alkaloid agent could benefit these women if administered before delivery, researchers from the University of Iowa Hospitals, Iowa City, reported in the January edition of the American Journal of Obstetrics and Gynecology. The data was presented today at the 2022 virtual Pregnancy Meeting of the Society of Maternal-Fetal Medicine.

The findings have prompted the institution to begin administering prophylactic methylergonovine in addition to oxytocin at the time of cesarean deliveries, according to the researchers.

“The addition of prophylactic methylergonovine improved uterine tone, decreased the requirement of additional uterotonic agents, decreased the risk of postpartum hemorrhage, and decreased the need for blood transfusions,” lead author Nicole Masse, MD, assistant professor of maternal-fetal medicine at the University of Iowa, told Medscape Medical News.

Abnormal uterine tone is the leading cause of postpartum hemorrhage, Masse said. “Satisfactory uterine tone following delivery is essential. This study found a decreased need for blood transfusions in patients who received prophylactic methylergonovine. Given the risks of blood transfusions, which can include disease transmission and allergic reactions, transfusions should be avoided whenever possible.”

Conducted between June 2019 and February 2021, the single-center, randomized controlled trial of 160 women undergoing an intrapartum cesarean birth is the largest of its kind to date, Masse said. Women received either intravenous oxytocin at a dose of 300 mU per minute plus 1 mL of intramuscular normal saline (n = 80) or intravenous oxytocin at a dose of 300 mU per minute plus 0.2 mg (1 mL) of intramuscular methylergonovine (n = 80).

Women who received prophylactic methylergonovine required significantly less additional uterotonic agents than those who received oxytocin alone (20% vs. 55%; relative risk [RR] 0.36; 95% CI 0.22 – 0.59), according to the researchers. Those receiving methylergonovine were more likely to experience improved uterine tone (80% vs. 41.2%; RR, 1.94; 95% CI, 1.46 – 2.56), a lower incidence of postpartum hemorrhage (35% vs. 58.8%; RR 0.6; 95% CI, 0.42 – 0.85), decreased need for a blood transfusion (5% vs. 22.5%; RR, 0.22; 95% CI, 0.08 – 0.63), and lower mean quantitative blood loss (996 mL vs. 1315 mL; P = .004), they reported.      

“As the majority of postpartum hemorrhages are preventable, this study is clinically relevant and can serve to decrease the morbidity associated with postpartum hemorrhage,” Masse said.

Jennifer Choi, DO, clinical assistant professor of maternal-fetal medicine at Stony Brook University Hospital, Stony Brook, New York, said the Iowa team’s results are contrary to prior studies showing no benefit with simultaneous use of oxytocin and ergot alkaloids.    

“It would be interesting to see long-term benefits across a diverse population,” she said. “But as methylergonovine is a known contraindication to hypertensive and cardiovascular disorders, including preeclampsia, patients would have to be carefully screened.”

Kecia Gaither, MD, MPH, associate professor of clinical obstetrics and gynecology at Weill Cornell Medicine, New York City, called the study “a novel idea, but more research and higher numbers are needed for a substantive conclusion.”

Additional studies should look at variables such as the number of prior cesarean deliveries, body mass index, presence of uterine myomas, presence of abnormal placentation (placenta accreta, increta, percreta), and presence of multiple gestation, said Gaither, who also is director of perinatal services at NYC Health + Hospitals/Lincoln.

“Methergine [methylergonovine] use is contraindicated in women with hypertension/ preeclampsia spectrum, mitral valve prolapse, history of coronary artery disease, and liver pathology,” she noted.

The researchers reported no relevant financial conflicts of interest.

Society of Maternal-Fetal Medicine 2022 Pregnancy Meeting: Abstract 40. Presented February 4, 2022.

Am J Obstet Gynecol. Published January 2022. Abstract

Howard Wolinsky is a medical writer in Chicago.

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