What medication should be avoided in a postpartum patient with chronic hypertension (high blood pressure), tachycardia, and profuse vaginal bleeding due to a soft uterine fundus and distended lower uterine segment with blood clots, who is being managed with labetalol (labetalol)?

From the Guidelines

Methylergonovine should be avoided in this patient. The patient is experiencing postpartum hemorrhage due to uterine atony, as evidenced by her soft uterine fundus and profuse vaginal bleeding. While uterotonic medications are indicated to treat this condition, methylergonovine (Methergine) is contraindicated in patients with hypertension because it can cause severe hypertension through its vasoconstrictive effects. This patient already has poorly controlled chronic hypertension with a blood pressure of 148/102 mm Hg, putting her at increased risk for complications like stroke or seizures if methylergonovine were administered, as highlighted in the management of hypertensive disorders in the peripartum period 1. Alternative uterotonic medications that would be safer for this patient include oxytocin, misoprostol, or carboprost tromethamine. First-line management should include bimanual uterine massage and intravenous oxytocin to promote uterine contraction while monitoring her blood pressure closely. The patient's history of multiple pregnancies (this being her eighth delivery) is a risk factor for uterine atony, which explains her current postpartum hemorrhage.

Key considerations in managing this patient's condition include:

• Monitoring and controlling her blood pressure to prevent complications associated with hypertension, as emphasized in guidelines for the prevention, detection, evaluation, and management of high blood pressure in adults 1.
• Avoiding medications that could exacerbate hypertension, such as certain antidepressants, atypical antipsychotics, and nonsteroidal anti-inflammatory drugs (NSAIDs), as listed in tables of frequently used medications and other substances that may cause elevated blood pressure 1.
• Ensuring the patient receives appropriate uterotonic therapy that is safe given her hypertensive condition, prioritizing medications like oxytocin that are effective for uterine atony without significantly increasing blood pressure.

Given the potential for severe hypertension and its complications, the choice of uterotonic agent is critical, and methylergonovine's potential to worsen hypertension makes it an inappropriate choice for this patient.

From the FDA Drug Label

Except in unusual circumstances, oxytocin should not be administered in the following conditions: ... grand multiparity The patient in question is a grand multipara (having had eight vaginal deliveries).

• Oxytocin should be avoided in this patient due to her grand multiparity, as stated in the precautions section of the oxytocin drug label 2.

From the Research

Medication to Avoid in Postpartum Hemorrhage

The patient in question has chronic hypertension and is experiencing postpartum hemorrhage. Given her condition, it's crucial to consider the potential effects of uterotonic medications on her cardiovascular system.

• Methylergometrine and carboprost are uterotonic agents that should be avoided in patients with certain cardiovascular pathologies, including hypertension, due to their potential to exacerbate these conditions 3.
• The patient's history of chronic hypertension, managed with labetalol, indicates that medications with significant cardiovascular side effects should be used with caution.
• Oxytocin is generally considered the first-line uterotonic agent, but in cases where oxytocin is not effective, alternative uterotonics with different mechanisms of action may be chosen, taking into account the patient's comorbidities 3, 4.
• Carbetocin, a long-acting oxytocin analogue, may be an appropriate alternative in some cases, given its efficacy and heat stability, but the decision should be based on the patient's specific clinical scenario and institutional preferences 3, 5.
• Misoprostol, another uterotonic option, has shown limited efficacy in recent studies for uterine atony, making it a less favorable choice in this context 5, 6.

Considerations for Uterotonic Medication Choice

When selecting a uterotonic medication for this patient, it's essential to consider her chronic hypertension and the potential for exacerbating this condition. The choice of medication should be guided by the need to balance effective management of postpartum hemorrhage with the risk of worsening her hypertension. Given the information provided, methylergometrine and carboprost should be avoided due to their potential to worsen hypertension 3.