Standard Medical Therapy for Postpartum Hemorrhage

Failure of the uterus to contract and retract following childbirth has for centuries been recognized as the most striking cause of postpartum hemorrhage (PPH) and complicates up to 10% of pregnancies globally. In the developing world, PPH is responsible for one maternal death every 7 minutes1. In the 19th century, uterine atony was treated by intrauterine placement of various agents with the aim of achieving a tamponade effect. ‘A lemon imperfectly quartered’ or ‘a large bull’s bladder distended with water’ were employed for this purpose, with apparent success. Douching with vinegar or iron perchloride was also reported2,3. Historically, the first uterotonic drugs were ergot alkaloids, followed by oxytocin and, finally, prostaglandins. Ergot, the alkaloid-containing product of the fungus Claviceps purpurea that grows on rye, was recognized for centuries as having uterotonic properties and is the substance referred to by John Stearns in 1808 as ‘pulvis parturiens’ (a powder [for] childbirth), at which time it was used as an agent to accelerate labor4. By the end of the 19th century, however, recognition of the potential hazards associated with ergot use in labor, namely its ability to cause uterine hyperstimulation and stillbirth, had tempered enthusiasm for its use. Focus was diverted toward its role in preventing and treating PPH at a time when, according to an 1870 report, maternal mortality in England approached one in 20 births5. Attempts to isolate the active alkaloids from ergot were not successful until the early 20th century, when Barber and Dale isolated ergotoxine in 19063. Initially thought to be a pure substance, this agent was subsequently found to comprise four alkaloids, and in 1935 Moir and Dudley were credited with isolating ergometrine, the active aqueous extract ‘to which ergot rightly owes its long-established reputation as the pulvis parturiens’6,7. Moir reported on its clinical use in 1936, stating7: