From the Guidelines
For intraoperative C-section bleeding, tranexamic acid 1 gram IV over 10 minutes (can repeat after 30 minutes if needed) is recommended as a first-line treatment to help stabilize clots, in addition to standard care for women with clinically diagnosed post-partum haemorrhage following cesarean section 1.
Medications for Intraoperative C-section Bleeding
The following medications can be used to manage intraoperative bleeding during a C-section:
- Oxytocin, administered as a 10 IU IV bolus followed by 20-40 IU infusion over 4-8 hours
- Methylergonovine (Methergine) 0.2 mg IM every 2-4 hours, but should be avoided in hypertensive patients
- Carboprost (Hemabate) 250 mcg IM every 15-90 minutes (maximum 8 doses) is effective for atonic uterus
- Misoprostol (Cytotec) 600-1000 mcg can be administered rectally or sublingually as another option ### Blood Product Replacement For severe hemorrhage, consider fibrinogen concentrate 2-4 grams IV or cryoprecipitate, and blood product replacement as needed, with a 1:1:1 to 1:2:4 strategy of packed red blood cells: fresh frozen plasma: platelets 2.
Antifibrinolytic Therapy
Tranexamic acid inhibits fibrin degradation and decreases bleeding complications and mortality in nonobstetric patients, and its use is recommended in cases of postpartum hemorrhage 2.
Key Considerations
Prompt administration of these medications is crucial, and they should be used alongside surgical interventions and blood product replacement as needed. The use of hemorrhage checklists is also strongly encouraged to ensure all options are considered and no details are neglected 2.
From the FDA Drug Label
For Refractory Postpartum Uterine Bleeding: An initial dose of 250 micrograms of carboprost tromethamine injection (1 mL of carboprost tromethamine injection) is to be given deep, intramuscularly. The total dose of carboprost tromethamine injection should not exceed 2 milligrams (8 doses)
- Carboprost tromethamine (IM): 250 micrograms initially, with optional additional doses of 250 micrograms at 15 to 90 minute intervals, not to exceed a total dose of 2 milligrams (8 doses) 3
- No specific dosage for tranexamic acid (IV) is provided in the context of managing intraoperative bleeding during a C-section 4
From the Research
Medications for Managing Intraoperative Bleeding during C-Section
- Oxytocin: + A study published in 2020 5 found that starting an IV oxytocin infusion early before uterine incision reduces intraoperative blood loss. + Another study from 2023 6 compared the effects of oxytocin administration timing on postpartum hemorrhage during cesarean section and found that administering oxytocin before placenta removal significantly reduced intraoperative blood loss. + A 2016 study 7 compared two oxytocin administration protocols (5 IU vs 10 IU) and found that 5 IU was effective for uterine tone without increased bleeding risk and guaranteed better hemodynamic stability and fewer side effects.
- Carbetocin: + A 2009 study 8 found that a single IV injection of carbetocin was as effective as a continuous 2-h infusion of oxytocin in controlling intraoperative blood loss after placental delivery. + A 2020 study 9 found that carbetocin was more effective than oxytocin in preventing postpartum hemorrhage in twin pregnancies undergoing cesarean section.
Dosages
- Oxytocin: + 3-10 IU as an IV push or infusion 6, 7 + 10 IU in 1000 cc isotonic fluid given as an IV infusion at a rate of 250 cc/h 6
- Carbetocin: + 100 µg as a single IV dose 8, 9