What is the best next step in managing a postpartum woman with severe vaginal bleeding, uterine atony, and tachycardia, unresponsive to uterine massage and high-dose oxytocin?

From the Guidelines

The best next step in management for this patient with postpartum hemorrhage unresponsive to uterine massage and high-dose oxytocin is administration of tranexamic acid 1 gram intravenously, as recommended by the most recent guidelines 1. This patient presents with heavy vaginal bleeding, a boggy fundus, and failure to respond to first-line treatments, indicating uterine atony as the likely cause of bleeding. Given the patient's asthma, caution should be exercised with certain medications, but tranexamic acid is not contraindicated in asthma and has been shown to reduce maternal morbidity and mortality in postpartum hemorrhage 2, 1.

The patient's symptoms, including dizziness, nausea, and a pulse of 102/min, suggest hemodynamic instability, which necessitates prompt intervention. The use of tranexamic acid within 3 hours of birth, as suggested by the WHO 2 and more recently supported by guidelines for urgent obstetric situations 1, is crucial in managing postpartum hemorrhage effectively.

Key considerations in this case include:

• The patient's asthma, which may influence the choice of uterotonic agents but does not preclude the use of tranexamic acid.
• The need for rapid control of bleeding to prevent further hemodynamic instability and potential organ dysfunction.
• The importance of monitoring for adverse effects of any administered medications, including tranexamic acid, although it is generally well-tolerated.

Alternative options, such as methylergonovine, carboprost, or misoprostol, may be considered based on specific patient factors and the availability of medications, but tranexamic acid is the preferred next step given its efficacy and safety profile, as supported by the highest quality and most recent evidence 1.

From the FDA Drug Label

Carboprost tromethamine injection is indicated for the treatment of postpartum hemorrhage due to uterine atony which has not responded to conventional methods of management. Prior treatment should include the use of intravenously administered oxytocin, manipulative techniques such as uterine massage and, unless contraindicated, intramuscular ergot preparations In a high proportion of cases, carboprost tromethamine injection used in this manner has resulted in the cessation of life threatening bleeding and the avoidance of emergency surgical intervention.

The best next step in management of this patient is the administration of carboprost tromethamine (IM), as the patient's postpartum hemorrhage due to uterine atony has not responded to conventional methods of management, including oxytocin and uterine massage 3.

From the Research

Management of Postpartum Hemorrhage

The patient is experiencing heavy vaginal bleeding after a forceps-assisted vaginal delivery, with a boggy and palpable uterus above the umbilicus, indicating uterine atony. The best next step in management would be to administer a second-line uterotonic agent, as oxytocin has not resolved the bleeding.

• Uterotonic agents, such as methylergonovine or carboprost, can be used to treat uterine atony, as they have been shown to be effective in reducing bleeding and improving uterine tone 4, 5, 6.
• Methylergonovine and carboprost have been compared in a randomized controlled trial, which found no significant difference in their efficacy in treating uterine atony, suggesting that either agent can be used 6.
• The use of tranexamic acid, an antifibrinolytic agent, may also be considered, as it has been shown to reduce maternal mortality and the need for blood transfusions in women with postpartum hemorrhage 4, 7.

Considerations for Treatment

When choosing a second-line uterotonic agent, it is essential to consider the patient's medical history and current condition. In this case, the patient has asthma, which may affect the choice of uterotonic agent.

• Methylergonovine may be contraindicated in patients with hypertension, but there is no mention of hypertension in this patient's history.
• Carboprost may cause bronchospasm, which could be a concern for patients with asthma, but it can still be used with caution 5.
• The patient's oxygen saturation is 98%, which suggests that she is not experiencing significant respiratory distress at present.

Next Steps

Given the patient's condition and the lack of response to oxytocin, the next step would be to administer a second-line uterotonic agent, such as methylergonovine or carboprost, while closely monitoring the patient's vital signs and uterine tone. Additionally, consideration should be given to the use of tranexamic acid, as it may help reduce bleeding and improve outcomes 4, 7.