What is the best next step in managing a postpartum woman with persistent vaginal bleeding, a firm uterine fundus, and mild anemia (low hemoglobin), following a forceps-assisted vaginal delivery with a third-degree perineal laceration?

From the Guidelines

The best next step in management for this patient is administration of tranexamic acid 1 g intravenously, as it has been shown to reduce maternal death due to hemorrhage in cases of postpartum hemorrhage 1. This patient is experiencing postpartum hemorrhage, most likely due to uterine atony despite having a firm fundus on examination. The patient's presentation with continuous dark red vaginal bleeding requiring frequent pad changes suggests abnormal bleeding beyond what would be expected for normal lochia. Her vital signs are stable and her hemoglobin is only mildly decreased at 10 g/dL, indicating that while she is bleeding more than normal, she is not yet hemodynamically compromised. The intact perineal repair and minimal blood in the vagina suggest the bleeding source is likely from the uterus rather than the laceration site. Key points to consider in management include:

• The use of uterotonic agents such as methylergonovine or oxytocin to stimulate uterine contractions and reduce bleeding
• The potential need for blood product transfusion, including packed red blood cells, fresh frozen plasma, or platelets, depending on laboratory values and clinical status
• The role of imaging, such as pelvic ultrasound or contrast-enhanced CT, in evaluating the cause of postpartum hemorrhage and guiding management 1. If tranexamic acid is ineffective, additional interventions such as additional uterotonics, uterine curettage, or other surgical interventions may be necessary. The patient should be advised to return immediately if bleeding increases, she develops fever above 100.4°F, or experiences lightheadedness or other signs of hemodynamic instability.

From the FDA Drug Label

INDICTIONS AND USAGEFor routine management after delivery of the placenta; postpartum atony and hemorrhage; subinvolution. The patient's presentation of continuous, dark red vaginal bleeding with small clots, a firm and nontender uterine fundus, and minimal dark red blood in the vagina does not directly indicate postpartum atony and hemorrhage or subinvolution that would be managed with methergine.

• The patient's hemoglobin is 10 g/dL, which is low, but the uterine fundus is firm, which suggests that uterine atony is not the primary cause of the bleeding.
• The best next step in management is not directly addressed by the methergine drug label 2. The FDA drug label does not answer the question.

From the Research

Patient Evaluation

The patient is a 27-year-old woman, gravida 1 para 1, presenting with postpartum bleeding after a forceps-assisted vaginal delivery. She has a history of a third-degree perineal laceration that was repaired and has been experiencing continuous, dark red vaginal bleeding with small clots.

Laboratory Results

The patient's laboratory results show:

• Hemoglobin: 10 g/dL
• Platelets: 140,000/mm3
• Leukocytes: 11,000/mm3

Management Options

Based on the patient's symptoms and laboratory results, the best next step in management would be to consider the use of tranexamic acid (TXA) to reduce bleeding.

• TXA has been shown to be effective in reducing blood loss and improving hemoglobin levels in patients with heavy menstrual bleeding 3 and postpartum hemorrhage 4.
• The use of TXA has also been studied in patients undergoing surgery, where it has been shown to reduce intraoperative blood loss and perioperative blood transfusion 5.
• Additionally, TXA has been found to be safe and effective in preventing or decreasing blood loss across different surgical interventions or medical conditions characterized by excessive bleeding 6.

Uterotonic Medications

Other options for managing postpartum bleeding include the use of uterotonic medications such as oxytocin, methylergonovine, carboprost, and misoprostol.

• Oxytocin is the first-line agent for preventing and treating uterine atony, which is a common cause of primary postpartum hemorrhage 7.
• However, the patient's uterine fundus is firm and nontender, which suggests that uterine atony may not be the primary cause of her bleeding.

Next Steps

Given the patient's symptoms and laboratory results, the best next step in management would be to consider the use of TXA to reduce bleeding, in addition to monitoring her vital signs and laboratory results closely.

• The patient's hemoglobin level is low, and TXA has been shown to improve hemoglobin levels in patients with heavy menstrual bleeding 3 and postpartum hemorrhage 4.
• The use of TXA may help to reduce the patient's bleeding and improve her hemoglobin level, and its safety and efficacy have been well established in the literature 6.