One versus two uterotonics: Which is better for minimizing postpartum blood loss?
A Cochrane network meta-analysis concluded that the two highest-ranked interventions for reducing the rate of postpartum blood loss ≥ 500 mL were misoprostol plus oxytocin and ergonovine plus oxytocin. However, administering two agents significantly increases the rate of adverse effects.
The bottom line
PPH is a major cause of maternal morbidity, and in low-resource settings, mortality. Oxytocin is the standard for reducing postpartum blood loss, but rates of blood loss ≥ 500 mL are high following this monotherapy. To reduce postpartum blood loss beyond what is possible with oxytocin alone, clinicians can more rapidly transition to administering a second uterotonic when they suspect blood loss is becoming excessive or they can use two uterotonic agents with all births or in those at high risk for excess bleeding. If blood loss does become excessive, clinicians need to pivot rapidly from prevention with oxytocin to treatment with our entire therapeutic armamentarium.
