What is the dosing for methergine (methylergonovine) in postpartum hemorrhage?

Methylergonovine (Methergine) Dosing for Postpartum Hemorrhage

For postpartum hemorrhage management, methylergonovine (Methergine) should be administered at a dose of 0.2 mg intramuscularly as a second-line uterotonic agent after first-line treatment with oxytocin has failed to control bleeding.

Dosing Regimen

• Initial dose: 0.2 mg intramuscularly
• Route: Intramuscular (IM) is the preferred route for postpartum hemorrhage
• Timing: Administered after first-line oxytocin therapy fails to control uterine atony
• Repeat dosing: May be repeated every 2-4 hours as needed, not to exceed 5 doses

Clinical Algorithm for Postpartum Hemorrhage Management

1. First-line treatment:

   • Oxytocin 10 IU IV infusion
   • Uterine massage

2. If bleeding continues (second-line treatment):

   • Methylergonovine 0.2 mg IM
   • OR Carboprost (Hemabate) 250 mcg IM

3. If bleeding still continues:

   • Consider tranexamic acid 1 g IV (given over 10 minutes) within 3 hours of birth 1
   • A second dose of tranexamic acid 1 g IV may be given if bleeding continues after 30 minutes or restarts within 24 hours 1

Efficacy Considerations

• Methylergonovine appears to be more effective than carboprost as a second-line uterotonic agent, with lower risk of hemorrhage-related morbidity (RR 1.7; 95% CI 1.2-2.6 favoring methylergonovine) 2
• Methylergonovine is comparable to rectal misoprostol as second-line therapy for primary postpartum hemorrhage 3

Important Contraindications and Precautions

• Absolute contraindications:

  • Hypertension
  • Preeclampsia
  • Cardiovascular disease
  • Known hypersensitivity

• Relative contraindications:

  • Hepatic or renal impairment
  • Sepsis

Monitoring Requirements

• Blood pressure and pulse should be monitored before administration and at 15-minute intervals for at least 30 minutes after administration
• Monitor uterine tone and vaginal bleeding
• Observe for signs of peripheral vasospasm or hypertension

Potential Adverse Effects

• Hypertension (most common serious side effect)
• Nausea and vomiting
• Headache
• Dizziness
• Chest pain
• Dyspnea
• Peripheral vasospasm

Clinical Pearls and Pitfalls

• Do not administer intravenously as this can cause sudden hypertensive crisis, stroke, or myocardial infarction
• Methylergonovine is particularly useful when uterine atony is the cause of postpartum hemorrhage
• In cases where methylergonovine is contraindicated, consider alternative second-line agents like carboprost or misoprostol
• Oral methylergonovine prescriptions for delayed or secondary postpartum hemorrhage are uncommon (less than 1% of overall prescriptions) and should be used cautiously 4
• Always consider tranexamic acid as an adjunct to uterotonics in cases of ongoing postpartum hemorrhage 1

By following this evidence-based approach to methylergonovine dosing in postpartum hemorrhage, clinicians can effectively manage this potentially life-threatening condition while minimizing risks associated with the medication.