Pregnancy Complications: Management of Uterine Atony Health Article

Before Delivery

If you are at risk for uterine atony, your doctor or nurse should make the following preparations in case excessive bleeding occurs during or after delivery:

• at least one large intravenous line should be established;
• medication to induce contractions of the uterus--oxytocin (Pitocin), methylergonovine (Methergine), and/or prostaglandins--should be on hand; and
• appropriate nursing and anesthesia personnel should be available.

In addition, the blood bank should be notified of the possible need for a blood transfusion for certain high-risk patients.

After Delivery

Uterine atony is diagnosed after delivery when there is excessive bleeding and a large, relaxed uterus. The doctor first rules out other potential causes of the bleeding (tears in the vagina or cervix and fragments of the placenta remaining in the uterus); these problems should be resolved if they are present. If the bleeding continues, the uterus may be stimulated to contract with use of massage and intravenous oxytocin. Many studies show this technique reduces postpartum hemorrhage and the need for blood transfusions. If heavy bleeding from atony occurs despite the use of oxytocin after delivery, then two additional medications may be used to help control hemorrhage:

• Methylergonovine, a strong vasoconstrictor derived from ergot, is injected into a muscle. It is not given to patients with preeclampsia or a history of high blood pressure because it can cause high blood pressure.
• Prostaglandin F-2-alpha (Hemabate) is injected under the skin and also directly into the uterus. Frequent side effects include diarrhea and vomiting. It can cause bronchial constriction and is usually avoided in patients with asthma.

Emergency surgery should be performed if atony persists despite these measures to control the bleeding. This may be accomplished by tying off the blood vessels that supply the uterus. If successful, this procedure should not affect future pregnancies. In a more involved procedure, the doctor uses x-rays to guide a small catheter through blood vessels in the mother's leg and into the blood vessels supplying the uterus. These blood vessels are then injected with gelatin sponge particles or spring coils to obstruct blood flow to the uterus. Although successful control of hemorrhage has been reported with this technique, the equipment necessary to perform it may not be available in most emergency situations.

If bleeding persists in spite of all conservative measures to control it, a hysterectomy (removal of the uterus) may be necessary.

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