Oxytocin is routinely administered during the third stage of labor for prophylaxis against postpartum hemorrhage, a leading cause of morbidity and mortality. If the uterus does not adequately contract in response to oxytocin administration, other drugs can be used. Second-line uterotonics include methylergonovine maleate, carboprost, and misoprostol. Which drugs are actually used?
Dr. Brian T. Bateman, Division of Pharmacoepidemiology & Pharmacoeconomics, Department of Medicine, Brigham & Women’s Hospital, Boston, Massachusetts, and the Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, and colleagues used Premier, a hospital-based health care utilization database that contains administrative codes for discharge diagnoses based on the ICD-9 CM, to access the records of patients who delivered a baby between the fourth quarter of 2007 and the third quarter of 2011. The authors further restricted their study cohort to hospitals with more than 100 deliveries in the database and with at least 1 patient charged for a second-line uterotonic. The results of their analysis are discussed in the article titled “Patterns of Second-Line Uterotonic Use in a Large Sample of Hospitalizations for Childbirth in the United States: 2007 – 2011,” which was published in this month’s issue of Anesthesia & Analgesia.
Three hundred and sixty-seven hospitals met inclusion criteria. Over 2 million patients were studied and the rate of second-line uterotonic use varied from 1.7% to 25%. The median hospital level frequency of methylergonovine maleate use was 5.2%, carboprost was 1.0%, and misoprostol was 1.2%. Patient demographics, mode of delivery, medical and obstetrical conditions, year of delivery, and hospital characteristics could not explain the variability of use among hospitals.
The results likely reflect the lack of evidence to guide clinicians as to when to administer second-line uterotonics and which agent to use. Probably, in the absence of this evidence, individual physician or hospital preference, drug availability, or cost is driving choice. We don’t know if outcome is any different depending on how second-line uterotonics are used. However, this study underscores the need for and will help to plan appropriate outcome studies to determine optimal choices of second-line uterotonics.