The Labor and Delivery Quality and Safety Committee at your institution has been evaluating strategies to decrease their higher-than-desired rate of postpartum hemorrhage (PPH). They have initiated the administration of prophylactic intramuscular (IM) methylergonovine in women undergoing cesarean delivery while in labor, provided they have no contraindication to the medication. Based on a recent study, which of the following outcomes is MOST likely to occur with this initiative?

  • □ (A) No change in the rate of PPH
  • □ (B) Fewer patients requiring additional uterotonic agents
  • □ (C) Higher rate of maternal hypertension

PPH is a leading cause of maternal morbidity and mortality in the United States and worldwide. It accounts for approximately 11% of maternal deaths in the U.S., most of which are preventable. The rate of PPH has also been increasing, especially PPH related to uterine atony. Thus, strategies are needed to decrease the rate of atonic PPH. Investigators recently conducted a randomized controlled trial evaluating the efficacy of prophylactic methylergonovine in a group considered at higher risk for PPH – laboring women who require an intrapartum cesarean delivery.

In this study, 160 women who met inclusion criteria were enrolled and randomized to receive intravenous oxytocin and either 0.2 mg of IM methylergonovine or placebo (1 mL of IM normal saline). Women with chronic or pregnancy-induced hypertension were excluded because this condition is a relative contraindication to methylergonovine administration. Upon delivery, the oxytocin infusion was initiated; it consisted of 30 units in 500 mL administered at 300 mL/h for the first hour after delivery and then 150 mL/h for the next hour. The methylergonovine or normal saline was injected immediately after the oxytocin infusion began. The primary outcome of the study was administration of additional uterotonics, a clinically relevant outcome that is considered an indicator for uterine atony. Secondary outcomes of the study included rate of PPH (defined as blood loss >1 L), blood transfusion rate, quantitative blood loss, satisfactory uterine tone as assessed by an obstetrician, and difference between preoperative and postoperative day one hemoglobin level. Since hypertension may be an adverse effect of methylergonovine administration, this outcome was also evaluated.

Improvement in all outcomes was found in the methylergonovine group compared with the placebo group. The percentage of women requiring additional uterotonics was 20% in the methylergonovine group and 55% in the placebo group (relative risk [RR], 0.4; 95% CI, 0.2-0.6) with a calculated number needed to treat of 2.9 (95% CI, 2.0-4.8). Compared with the placebo group, the methylergonovine group had lower rates of PPH (35% vs. 59%; RR, 0.6; 95% CI, 0.4-0.9) and blood transfusion (5% vs. 23%; RR, 0.2; 95% CI, 0.1-0.6). Obstetricians rated uterine tone as satisfactory in 80% of the women receiving methylergonovine and in 41% of the women receiving placebo. Mean quantitative blood loss was 967 mL in the methylergonovine group and 1,315 mL in the placebo group. No notable difference was found in the rate of hypertension between the two groups.

In conclusion, these investigators found that prophylactic administration of methylergonovine in women undergoing intrapartum cesarean delivery improved outcomes associated with uterine atony and PPH. Adoption of this management strategy by labor and delivery units has the potential to decrease the risk of uterine atony and associated PPH, outcomes that have been shown to be increasing among parturients.

Answer: B