What medication is indicated for a postpartum patient with significant blood loss (500cc) after delivery, who has already received the maximum dose of oxytocin (Oxytocin), aside from another uterotonic agent?

Tranexamic Acid is Indicated

For a postpartum patient with 500cc blood loss after delivery who has already received maximum dose oxytocin, tranexamic acid (option d) is the indicated medication aside from additional uterotonics. 1

Rationale Based on WHO Guidelines

The WHO strongly recommends early use of intravenous tranexamic acid (within 3 hours of birth) in addition to standard care for women with clinically diagnosed postpartum hemorrhage, which is defined as blood loss of more than 500 mL after vaginal birth. 1

Critically, the 2018 WHO guideline explicitly states that tranexamic acid should be given in all cases of postpartum hemorrhage, regardless of whether bleeding is thought to be due to genital tract trauma or uterine atony, and this recommendation is broader than the previous 2012 recommendation which advised tranexamic acid only if oxytocin and other treatments were not effective. 1

Dosing and Administration

• Administer 1 g tranexamic acid (100 mg/mL) intravenously at 1 mL/min (over 10 minutes) as soon as possible. 1
• Give a second dose of 1 g intravenously if bleeding continues after 30 minutes or restarts within 24 hours of completing the first dose. 1

Critical Timing Considerations

Time is of the essence: effectiveness decreases by 10% for every 15-minute delay, with no benefit seen after 3 hours post-delivery. 1

• Tranexamic acid must be given within 3 hours of birth. 1
• Giving tranexamic acid beyond 3 hours after birth is suspected to be potentially harmful. 1

Why Not the Other Options?

While carbetocin (option b) and methylergonovine (option c) are both uterotonics that could be considered, the question specifically asks for a medication "other than another uterotonic." 2, 3

• Aspirin (option a) has no role in acute postpartum hemorrhage management. 1
• Carbetocin and methylergonovine are both uterotonics, which the question explicitly excludes. 2, 3, 4

Contraindications to Consider

Avoid tranexamic acid in women with active thromboembolic disease, history of thrombosis, or known thromboembolic events during pregnancy. 1, 5, 6

Integration with Standard PPH Management

Tranexamic acid should be part of a comprehensive treatment package that includes fluid replacement, monitoring of vital signs, and sequential use of non-surgical interventions (bimanual compression, intrauterine balloon tamponade) moving toward more invasive interventions as required. 1