Bibliographic information
GuidelineConsolidated guidelines for the prevention, diagnosis and treatment of postpartum haemorrhage
Year of Publication2025
Issuing InstitutionWorld Health Organization
Recommendation
New
Uterotonics for the treatment of postpartum haemorrhage. If intravenous oxytocin is unavailable, or if the bleeding does not respond to oxytocin, the use of intravenous ergometrine, oxytocin-ergometrine fixed dose, or a prostaglandin drug (including sublingual misoprostol, 800 µg) is recommended
Recommended
Notes and Remarks
- In settings where intravenous oxytocin is unavailable to women who have received prophylactic intramuscular oxytocin during the third stage of labour, the GDG considered misoprostol to be a valid alternative for the treatment of PPH.
- If PPH prophylaxis with misoprostol has been administered and if injectable uterotonics are unavailable, there is insufficient evidence to guide additional misoprostol dosing. Providers should weigh the potential for toxicity when considering repeated doses.
- There is no added benefit to offering misoprostol simultaneously to women receiving oxytocin for the treatment of PPH (i.e. adjunct misoprostol).
- The GDG noted that the two largest trials of misoprostol for the treatment of PPH reported the use of a 800-μg dose administered sublingually (56, 57). Most of the GDG members agreed that 800 μg is an acceptable sublingual misoprostol dose for the treatment of PPH, although some members of the GDG expressed concern related to the risk of hyperpyrexia associated with this dosage.
- If intravenous oxytocin has been used for the treatment of PPH and the bleeding does not stop, there is paucity of data to recommend preferences for second-line uterotonic drug treatment. Decisions in such situations must be guided by the experience of the provider, the availability of the drugs and by the known contraindications.
- In situations in which intramuscular oxytocin can be administered and there is no possibility of intravenous treatment with ergot alkaloids/injectable prostaglandins, there is a paucity of data to recommend a preference for intramuscular oxytocin over misoprostol or other uterotonics. Decisions in such situations must be guided by the experience of the provider, the availability of the drugs and by the known contraindications.
- Carbetocin (heat-stable and non-heat-stable formulations), although recommended for PPH prevention, has not been adequately studied for repeated dosing for PPH treatment, when carbetocin has been used for PPH prophylaxis. Therefore, the use of carbetocin (heat-stable and non-heat-stable formulations) in this context should be discouraged until robust evidence on safety and efficacy for PPH treatment becomes available.
- While there is no evidence to suggest that carbetocin is less safe or less effective than the injectable uterotonics recommended here for PPH treatment, its use in this context has not been adequately studied. In contrast, ergometrine and the fixed-dose oxytocin and ergometrine combination have a longer history of clinical use for both the prevention and treatment of PPH, and their safety concerns are known and can be mitigated in clinical practice.