Download oxytocin for post partum hemorrhage

ANNE ARUNDEL MEDICAL CENTER
Guidelines for Use of Intravenous
Oxytocin (Pitocin®) in Emergency Department
Indication
For the management of postpartum hemorrhage due to presumed uterine atony, when
an immediate contractile response is desired.
Mechanism of Action
Oxytocin indirectly stimulated contraction of uterine smooth muscle by increasing the
sodium permeability of uterine myometrial tissue. The drug increases the amplitude
and frequency of uterine contractions.
Oxytocin produces vasodilation of vascular smooth muscle, increasing renal, coronary,
and cerebral blood flow.
Special Administration and Monitoring Techniques
 Oxytocin has pressor and antidiuretic activity which may be exhibited with high
doses.
 The drug should be diluted in NSS or LR to minimize the risk of water intoxication.
 Monitor blood pressure, heart rate, uterine response, reduction in uterine bleeding.
Total fluid intake, estimated blood loss and urine output should be carefully
monitored.
Dosage and Administration
Intravenous doses of oxytocin should be administered as a continuous infusion. The
drug can be diluted in Lactated Ringer or normal saline.
10 to 40 units of oxytocin added to 1000 ml of I.V. solution, adjust infusion rate to
sustain uterine contractions and control uterine atony.
Oxytocin
20 units per 1000 ml
40 units per 1000 ml
Infusion Rate
200 milliunit/min = 600 ml/hr
200 milliunit/min = 300 ml/hr
Precautions
1. Continuous observation by trained personnel is necessary for all patients receiving
I.V. oxytocin
2. Cautious use of Oxytocin for the treatment of postpartum hemorrhage is
recommended in hypertensive and cardiac patients.
Adverse Effects
Gastrointestinal – nausea, vomiting
Cardiovascular – arrhythmias and premature ventricular contractions have been
reported. The cardiovascular effects of oxytocin used postpartum consist of
Hypotension followed by a period of Hypertension.
Endocrine metabolic – water intoxication, dilutional hyponatremia
Neurologic – headache, seizure, subarachnoid hemorrhage
Hematologic – afibrinogenemia (fatal)
Miscellaneous – anaphylaxis
Comments
Pharmacologic Agents Used in Postpartum Hemorrhage
Medication
Oxytocin
Dose
Route of Administration
and Frequency
10–40 units in 500–1000 mL I.V.
parenteral fluids.
Continuous infusion
given at ~200 milliunits/min
Comment
Avoid undiluted rapid IV
infusion, which causes
hypotension.
Methylergonovine 0.2 mg
(Methergine)
I.M. or intramyometrial
Every 2–4 hr
Avoid if patient is
hypertensive
Carboprost
tromethamine
(Hemabate)
0.25 mg (250 microgram)
I.M. or intramyometrial
Every 15–90 min
(not to exceed 8 doses)
Avoid in asthmatic patients;
relative contraindication if
hepatic, renal, and cardiac
disease. Diarrhea, fever,
tachycardia can occur.
Misoprostol
(Cytotec)
800-1000 microgram
Rectal
Single dose
Reference:
ACOG Practice Bulletin: Clinical Management Guideline for Obstetrician-Gynecologists. #76 Oct 2006: Postpartum
Hemorrhage
Obstetric drug therapy. In: Koda-Kimble MA, et al., eds. Applied therapeutics: the clinical use of drugs. 8th ed.
Philadelphia: Lippincott Williams & Wilkins; 2005.
Postpartum Hemorrhage Kit
“Postpartum Hemorrhage” kit will be created in the Emergency Department Pyxis.
When drugs are needed, nursing can withdraw meds under “kit”, and then pick
“Postpartum Hemorrhage kit”. Each pocket will open sequentially, allowing nurse to
access the drugs.
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5
Oxytocin: 10 units per ml vial
Methylergonovine: 0.2 mg per ml ampule (Refrigerated)
Carboprost: 250 microgram per ml ampule (Refrigerated)
Misoprostol: 200 microgram per tablet
Pharmacy Department/Clinical Services
IV Additive Service
________________________________________________________________
DRUG
NAME
STORAGE
REQUIREMENTS
PREPARATION
RESULTING
CONCENTRATION
STABILITY
Oxytocin
40 units
per 1000ml
Room temperature
Add 40 units (4 ml) of
Oxytocin to 1000 ml of
LR or NSS
40 milliunits/ml
(0.04 units/ml)
24 hrs
Room temperature
Add 20 units (2 ml) of
Oxytocin to 1000 ml of
LR or NSS
Oxytocin
20 units
per 1000ml
Premix
20 units in 1000 ml LR
24 hrs
20 milliunits/ml
(0.02 units/ml)