What is the recommended dose and administration of carboprost tromethamine (Inj corboprost) for treating severe postpartum hemorrhage?

Carboprost Tromethamine for Severe Postpartum Hemorrhage

For refractory postpartum hemorrhage due to uterine atony, administer carboprost tromethamine 250 micrograms (1 mL) deep intramuscularly, with repeat doses every 15-90 minutes as needed, not exceeding a total dose of 2 milligrams (8 doses). 1

Initial Dosing and Administration

• Give 250 micrograms (1 mL) as a deep intramuscular injection when uterine atony persists despite oxytocin therapy 1
• In clinical trials, 73% of successful cases responded to a single injection 1
• Use a tuberculin syringe for accurate dosing 1

Repeat Dosing Protocol

• Administer additional 250 microgram doses at intervals of 15-90 minutes based on clinical response and ongoing bleeding 1
• The interval between doses should be determined by the attending physician based on uterine contractility and hemodynamic status 1
• Maximum total dose is 2 milligrams (8 doses total) 1

Clinical Efficacy

• Carboprost demonstrates superior efficacy compared to oxytocin alone, with significant reduction in blood loss and duration of third stage when used prophylactically 2
• When used as second-line therapy for refractory uterine atony, carboprost achieves comparable uterine tone scores to methylergonovine (mean 7.6±2.1 on 0-10 scale at 10 minutes) 3
• Combined therapy with oxytocin plus second-line agents like carboprost provides additive or synergistic effects for postpartum hemorrhage prevention 4

Common Adverse Reactions and Management

Expect gastrointestinal and cardiovascular side effects:

• Nausea and vomiting occur in approximately 51% of patients 5
• Diarrhea is the most common side effect requiring no intervention 2
• Transient hypertension and tachycardia may occur 6
• Facial flushing and chest congestion are common 5
• Transient mild temperature elevation may be observed 6

Consider low-dose remifentanil (1.5 ng/mL target effect-site concentration) to reduce adverse reactions during cesarean delivery under neuraxial anesthesia, which decreases vomiting incidence from 51% to 14% 5

Critical Contraindications and Precautions

• Do not use in patients with preexisting hypertension or cardiovascular disease without careful blood pressure monitoring, though patients with preeclampsia did not demonstrate serious blood pressure elevations in studies 6
• Carboprost may be less effective in patients with chorioamnionitis, as both treatment failures in one series had this condition 6
• Inspect the solution visually for particulate matter and discoloration before administration 1

Integration with Hemorrhage Protocol

• Carboprost serves as second-line therapy after oxytocin failure for uterine atony 3
• Concurrent use of tranexamic acid (1 gram IV within 3 hours of birth) reduces maternal death from hemorrhage and should be administered alongside uterotonic therapy 7
• Maintain 1:1:1 to 1:2:4 ratio of packed red blood cells:fresh frozen plasma:platelets for massive transfusion 7
• Monitor fibrinogen levels, targeting >200 mg/dL, as hypofibrinogenemia predicts severe postpartum hemorrhage 7

When Carboprost Fails

• If bleeding persists after maximum carboprost dosing (2 mg total), proceed to surgical interventions including uterine compression sutures, hypogastric artery ligation, or interventional radiology embolization 7
• Consider recombinant factor VIIa only for posthysterectomy bleeding with failed standard therapy, given thrombosis risk (3% in case series) and high cost 7