Prophylactic methylergonovine stops Caesarean bleeds

Prophylactic administration of methylergonovine following childbirth helps control bleeding in women who underwent Caesarean deliveries, according to a single-centre randomized controlled trial.

Methylergonovine is a semi-synthetic ergot alkaloid that is US FDA-approved for the prevention and control of postpartum haemorrhage.

“Adding prophylactic methylergonovine improved uterine tone, decreased the need for additional uterotonic agents, decreased postpartum haemorrhage risk, and the need for blood transfusions,” said lead author Dr Nicole Masse, assistant professor of maternal-fetal medicine at the University of Iowa Hospitals in Iowa City, Iowa, US.

Uterine atony is a serious condition caused by the inability of the myometrium to contract sufficiently in response to oxytocin which is supposed to stimulate uterine contractions.

“Satisfactory uterine tone following delivery is essential,” pointed out Masse. “When the uterus fails to contract after childbirth, it can lead to postpartum haemorrhage, which is potentially life-threatening.”

Treatment is usually aimed at stopping the bleeding and replacing the blood lost through transfusions. In the study, there was a reduced need for blood transfusions in patients given prophylactic methylergonovine.

“Transfusions should be avoided whenever possible given the risks, which can include disease transmission and allergic reactions,” said Masse.

The study included 160 women undergoing an intrapartum caesarean birth who received either intravenous (IV) oxytocin 300 mU per minute plus 1 mL of intramuscular normal saline (n=80) or IV oxytocin 300 mU per minute plus 0.2 mg (1 mL) of intramuscular methylergonovine (n=80). The study was conducted between June 2019 and February 2021. [SMFM 2022, abstract 40]

Those given the prophylactic methylergonovine required significantly fewer additional uterotonic agents vs those who received oxytocin alone (20 percent vs 55 percent; relative risk [RR] 0.36), according to Masse.

On top of that benefit, those on methylergonovine were more likely to experience improved uterine tone (80 percent vs 41.2 percent; RR, 1.94). They also had a lower incidence of postpartum haemorrhage (35 percent vs 58.8 percent; RR 0.6) and a decreased need for blood transfusions (5 percent vs 22.5 percent; RR, 0.22. Those on methylergonovine also had lower mean quantitative blood loss (996 mL vs 1,315 mL; p=0.004).

“As the majority of postpartum haemorrhages are preventable, this trial is clinically relevant and can help to decrease the morbidity associated with postpartum haemorrhage,” Masse emphasized.

The results prompted the use of prophylactic methylergonovine on top of oxytocin during caesarean deliveries at the Iowa Hospital. However, as prior studies showed no benefit with simultaneous use of oxytocin and ergot alkaloids, caution is also advised.

“As methylergonovine is a known contraindication to hypertensive and cardiovascular disorders, including preeclampsia, patients would have to be carefully screened,” commented Dr Jennifer Choi, clinical assistant professor of maternal-foetal medicine at Stony Brook University Hospital, Stony Brook in  New York, US. “More studies are clearly warranted.”