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Three Part Question

In patients with massive postpartum haemorrhage what is the appropriate dose of syntocinon and what is the maximum dose that can be used safely, to arrest haemorrhage or prevent further uterine bleeding?

Clinical Scenario

In patients suffering with massive postpartum haemorrhage syntocinon is often used intravenously to control atonic uterine bleeding. Currently, clinical units have protocols for administering up to 10 units intravenously stat, repeated up to once, followed by an infusion of 40 units in 40 mls of diluent administered over 4 hours and repeated if required. There are variations of this protocol in use in different hospitals. There is a need to support the use of such doses of syntocinon / oxytocin with evidence from proper studies on the effectiveness of different uterotonics and reports of any adverse effects.

Search Strategy

OVID interface through BMA site 1966 to date included Embase. PUBmed through world wide web. CINAHL, Biological absracts, SIGLE (grey literature in europe), hand search and cross references.
exp (third stage OR 3rd stage) OR (post partum h$emorrhage OR postpartum h$emorrhage OR post-partum h$emorrhage) OR PPH OR blood loss OR blood-loss AND (exp oxytocin OR syntocinon)AND NOT (induc* OR rip* OR prelab* or cerv* or dystocia OR augment*)

Search Outcome

There were three case reports from 1970-75 about water intoxication following the use of syntocinon. The pharmaceutical company Alliance, which manufactures syntocinon sent us their protocol for the use of a syntocinon infusion and the rate of administration but no evidence on which it was based. There is one systematic review on the use of uterotonics in the control of postpartum haemorrhage but does not have any information about evidence for the most appropriate dosage of syntocinon to be used or any known complications from currently used dosages.

Comment(s)

Syntocinon / oxytocin is a widely used parenteral uterotonic for the control of post partum haemorrhage. In massive haemorrhage, protocols with infusions of up to 40 units over 4 hours have been advocated. There have been no large studies (observational or otherwise) to quantify the actual amount or rate that is effective in controlling atonic uterine haemorrhage or preventing uterine atony once it has been controlled. Case reports about water intoxication following large doses of syntocinon suggested that Dextrose infusion in large quantities was to blame but this was never proven. There is a need for further studies looking at the effectiveness of current protocols of syntocinon used in the post partum period and especially in cases with massive postpartum haemorrhage where there is great complexity in managing infused fluid volumes and monitoring output.

Clinical Bottom Line

The recommended rate of infusion in post partum haemorrhage of 5 IU syntocinon slowly IV followed by intravenous infusion at a rate of 20 - 40 mU/min or higher is stated by the Clinical guideline for induction of labour (NICE 2001) and by the RCOG evidence based clinical guideline 2001. There is no evidence that is quoted to support the current protocols in use for massive post partum haemorrhage.