What is the diagnosis for a 39-year-old primigravida (first pregnancy) at 38 weeks gestation with a history of hypertension treated with nifedipine (calcium channel blocker) and asthma treated with albuterol (beta-2 adrenergic receptor agonist), who develops postpartum hemorrhage (PPH) with a soft uterus after a forceps-assisted vaginal delivery and manual placental extraction?

From the Guidelines

The patient is experiencing postpartum hemorrhage due to uterine atony, and immediate management should begin with bimanual uterine massage and administration of uterotonics, starting with oxytocin 10-40 units in 1L of IV fluid at a rate of 500 mL/hour, as recommended by the most recent guidelines 1.

Initial Management

The patient's history of hypertension and asthma should be taken into consideration when selecting uterotonics.

• Oxytocin is the first-line treatment for uterine atony, and its administration should be guided by the patient's blood pressure and overall clinical condition.
• If bleeding persists, additional uterotonics such as carboprost (Hemabate) 250 mcg IM every 15-90 minutes up to 8 doses, or misoprostol 800-1000 mcg rectally can be considered.
• Methylergonovine 0.2 mg IM is contraindicated in hypertension, so it should be used cautiously given her history.

Fluid Resuscitation and Monitoring

• Fluid resuscitation with crystalloids should be initiated to maintain adequate blood volume and prevent shock.
• The patient's vital signs should be monitored closely, and a complete blood count should be obtained to assess the degree of blood loss.
• The soft, boggy uterus positioned 4 cm above the umbilicus indicates inadequate uterine contraction, which is the most common cause of postpartum hemorrhage.

Risk Factors and Additional Considerations

• Risk factors in this case include prolonged labor, forceps-assisted delivery, large infant (4.1 kg), manual extraction of the placenta, and possibly hypertension.
• If medical management fails, surgical interventions such as uterine tamponade, arterial embolization, or hysterectomy may be necessary.
• The goal is to achieve a firm, contracted uterus to stop the bleeding and stabilize the patient's hemodynamic status.

Additional Treatment Options

• Tranexamic acid 1 g IV can be administered within 3 hours of birth, in addition to standard care, to reduce the risk of postpartum hemorrhage, as recommended by the WHO 1.
• The patient's blood pressure should be closely monitored, and labetalol or nifedipine can be used to control hypertension if necessary, as recommended by the ESC guidelines 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. In patients with a history of asthma, hypo- or hypertension, cardiovascular, renal, or hepatic disease, anemia, jaundice, diabetes, or epilepsy, carboprost tromethamine should be used cautiously.

The patient has a history of hypertension and asthma, and is experiencing postpartum hemorrhage due to uterine atony.

• The use of carboprost tromethamine may be considered in this case, but it should be used cautiously due to the patient's medical history.
• The patient's hypertension may be a concern, as carboprost tromethamine can cause increased blood pressure in some cases 2.
• However, the patient's current blood pressure is 140/80 mm Hg, which is not significantly elevated.
• The patient's asthma may also be a concern, but there is no indication that carboprost tromethamine is contraindicated in patients with asthma 2.
• The patient has not responded to conventional methods of management for postpartum hemorrhage, and carboprost tromethamine may be considered as a treatment option 2.

From the Research

Postpartum Hemorrhage Management

The patient's situation, with a soaked perineal pad and 1,000 mL of clotted blood expressed from the lower uterine segment, indicates potential postpartum hemorrhage (PPH). Key points to consider in managing PPH include:

• Uterine atony is the most common cause of PPH, accounting for 70% to 80% of cases 3.
• Pharmacotherapy, including uterotonic agents, is the first-line preventative therapy for PPH 3, 4, 5, 6, 7.
• Oxytocin is the first-line uterotonic agent for preventing PPH, with carbetocin being a long-acting analog that may be more effective in some cases 3, 4, 5, 6, 7.

Uterotonic Agents

Available uterotonic agents for PPH prevention and treatment include:

• Oxytocin: first-line agent, effective but may require repeated administration 3, 4, 5, 6, 7.
• Carbetocin: long-acting oxytocin analog, potentially more effective than oxytocin alone 3, 5, 6.
• Methylergonovine and carboprost: second-line agents with potential side effects, particularly in patients with cardiovascular conditions 4, 5, 7.
• Misoprostol: may be used when oxytocin is not available, but its effectiveness is debated 4, 6, 7.

Clinical Considerations

In the patient's case, with a history of hypertension and asthma, careful selection of uterotonic agents is necessary to avoid exacerbating these conditions. The use of oxytocin or carbetocin may be preferred, given their relatively safer side effect profiles compared to methylergonovine and carboprost 5. Additionally, the patient's prolonged labor and forceps-assisted vaginal delivery may increase the risk of uterine atony, emphasizing the need for effective uterotonic management 4.