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Second Line Uterotonic Agents and the Risk of Hemorrhage-Related Morbidity
Abstract Number: O1-05
Abstract Type: Original Research
Introduction: Uterine atony is a leading cause of postpartum hemorrhage (PPH).(1) Second line uterotonic agents, notably methylergonovine maleate (methergine) and carboprost (hemabate) are recommended to treat severe or refractory uterine atony in patients who fail to respond to first line therapy such as uterine massage and oxytocin.(2) However, there are few data comparing outcomes in patients with uterine atony who receive either methergine or hemabate.
Methods: We performed a retrospective cohort study using data from the NIH-MFMU Cesarean Registry. We identified 1,335 patients who underwent cesarean delivery (CD) and received methergine or hemabate. Patients with hypertensive disorders or asthma were excluded as they would not be eligible for both medications. The primary study outcome was hemorrhage-related morbidity (HRM), defined as the presence of at least one of the following: intraoperative or postoperative RBC transfusion, uterine artery or hypogastric artery ligation. We performed propensity score (PS) matching using a 1:1 ratio to account for potential confounders which included: maternal age, gestational age, race, BMI at delivery, diabetes, multiple gestation, repeat CD, previa, presence of labor or labor induction, chorioamnionitis, and neonatal birthweight.
Results: Within our cohort, 1,335 of 57,182 (2.3%) patients received either methergine (n=870) or hemabate (n=465) after failing to respond to first line therapy (uterine massage and oxytocin). The PS matched cohort comprised 369 pairs of patients who received either methergine or hemabate. In the matched cohort, the incidence of HRM was 16.0% in the hemabate group and 9.2% in the methergine group (Table). After accounting for measured confounders, hemabate was associated with an increased risk of HRM (odds ratio 1.88, 95% confidence interval 1.19 to 2.94) (Table).
Discussion: In this retrospective cohort study, those patients treated with the second-line uterotonic agent hemabate were at increased risk for progression to HRM compared to those treated with methergine, independent of measured confounders. These data suggest that methergine may be a more effective second line uterotonic agent than hemabate. Randomized-controlled trials should be conducted to confirm these findings.
References: (1) Anesth Analg 2010;110:1368-73 (2) Obstet Gynecol 2006;108:1039-47.