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 for up to four doses |
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 | 800 to 1000 mcg sublingually (preferred) or rectally in a single dose |
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 |
Tamponade |
Intrauterine tamponade with an intrauterine balloon or alternative device (eg, bladder catheter bulb, Sengstaken-Blakemore tube) |
Uterine packing (eg, 4 inch gauge packing) |
Consultations |
General surgery |
Trauma surgery |
Anesthesia team |
Interventional radiology |
Gynecologic oncology |
Urology |