What is the next step for an asthma patient with postpartum hemorrhage (PPH) who has not responded to oxytocin and uterine massage?

Next Step: Carboprost IM

In an asthma patient with postpartum hemorrhage unresponsive to oxytocin and uterine massage, carboprost (prostaglandin F2α) should be administered intramuscularly at 250 mcg, despite the asthma diagnosis, as it is FDA-approved for this exact indication and the bronchospasm risk is manageable compared to the life-threatening hemorrhage. 1

Why Carboprost is the Correct Choice

The FDA label explicitly states that carboprost is indicated "for the treatment of postpartum hemorrhage due to uterine atony which has not responded to conventional methods of management," specifically including oxytocin and uterine massage. 1 This matches your clinical scenario precisely.

Contraindicated Options in Asthma Patients

• Methylergonovine (Option A) is contraindicated in women with asthma due to significant bronchospasm risk and should be avoided 2, 3
• Ergometrine may cause bronchospasm, particularly when combined with general anesthetics 3

Why Not Balloon or Hysterectomy Yet

• Intrauterine balloon tamponade (Option B) should be implemented AFTER pharmacological uterotonics fail, not before exhausting medical management 2, 4
• The stepwise approach is: oxytocin → second-line uterotonic (carboprost or sulprostone) → balloon tamponade → surgery/embolization 2, 4
• Hysterectomy (Option D) is reserved as the absolute last resort when all other measures have failed 5

Clinical Management Algorithm

Immediate Actions with Carboprost

1. Administer carboprost 250 mcg IM as the second-line uterotonic 1
2. Continue uterine massage and bimanual compression 2
3. Administer tranexamic acid 1 g IV over 10 minutes if not already given (must be within 3 hours of delivery) 2, 5
4. Initiate fluid resuscitation with physiologic electrolyte solutions 2

Monitoring for Bronchospasm

• While prostaglandin F2α (carboprost) may theoretically cause bronchoconstriction, the guideline notes it is "not associated with clinical exacerbations" in practice 3
• Have bronchodilators immediately available 3
• The life-threatening nature of uncontrolled PPH outweighs the theoretical bronchospasm risk

If Carboprost Fails (Within 30 Minutes)

• Proceed to intrauterine balloon tamponade before considering surgery or interventional radiology 2, 4
• Consider sulprostone if available (though not mentioned in your options) 4
• Initiate massive transfusion protocol if blood loss exceeds 1,500 mL 2

Resuscitation Priorities

• Target hemoglobin >8 g/dL and fibrinogen ≥2 g/L during active hemorrhage 2
• Transfuse packed RBCs, FFP, and platelets in fixed ratio without waiting for laboratory results in severe bleeding 2
• Maintain normothermia: warm all infusion solutions and blood products; use active skin warming 2
• Administer oxygen in severe PPH 2

Common Pitfalls to Avoid

• Do not use methylergonovine in asthma patients - this is a critical contraindication 2, 3
• Do not proceed directly to balloon tamponade without trying second-line uterotonics first 2, 4
• Do not delay carboprost administration while arranging for balloon or surgery - pharmacological management should be exhausted first 1, 4
• Do not forget tranexamic acid - it must be given within 3 hours of birth, with effectiveness declining 10% every 15 minutes 2, 5

Answer: C - Carboprost