Objectives: Use of prostaglandins, including sulprostone (an E2 analog), is recommended for second-line uterotonic treatment of atonic postpartum hemorrhage and might be considered as an indicator of quality of care in severe atonic postpartum hemorrhage management. Our objective was to estimate whether sulprostone was appropriately used and how it was tolerated in women with atonic postpartum hemorrhage.
Methods: This large population-based study (146,781 deliveries) included 4,038 women with clinically assessed atonic postpartum hemorrhage in 106 French hospitals during 1 year. Severe postpartum hemorrhage was defined as one of the following: hemoglobin decline of 4 g/dL or more, transfusion, arterial embolization, surgical procedures, transfer to intensive care unit, or death. Sulprostone use in severe atonic postpartum hemorrhage was analyzed according to the mode of delivery and the characteristics of the maternity units.
Results: Rates of sulprostone use were only 33.9% (n = 1,370) and 53.5% (n = 657) among women with atonic (n = 4 ,038) and severe atonic (n = 1,227) postpartum hemorrhage, respectively. In the latter population, sulprostone administration was less frequent after vaginal delivery than after cesarean delivery (45.6% compared with 86.5%, P<.01) in units performing fewer than 1,500 annual deliveries in public nonuniversity hospitals and in units where the obstetrician or anesthesiologist was not present 24 hours per day, 7 days per week. Fifty-one of the 1,370 women with sulprostone-treated atonic postpartum hemorrhage (3.7%, 95% confidence interval [CI] 2.7-4.7) experienced side effects, including seven (0.5%, 95% CI 0.2-1.0) with severe cardiovascular or respiratory symptoms that resolved when the hypovolemic shock was corrected and drug administration was stopped.
Conclusion: Sulprostone is underused for treating severe atonic postpartum hemorrhage after vaginal delivery, despite low rates of severe side effects in this population-based study.
Level of evidence: : III.