In an asthmatic postpartum woman with hemorrhage unresponsive to oxytocin and uterine massage, what is the next uterotonic to give?

Next Uterotonic for Asthmatic Patient with Refractory Postpartum Hemorrhage

In an asthmatic woman with postpartum hemorrhage unresponsive to oxytocin and uterine massage, avoid methylergonovine and prostaglandin F2α (carboprost) due to severe bronchospasm risk; instead, proceed directly to uterine balloon tamponade while considering tranexamic acid if not already given. 1, 2, 3

Critical Contraindications in Asthma

Methylergonovine (Option A) is absolutely contraindicated in this asthmatic patient because:

• Ergometrine causes bronchospasm, particularly when associated with general anesthetics 1
• Methylergonovine carries significant risk (>10%) of vasoconstriction and hypertension 2
• European Respiratory Society/TSANZ guidelines explicitly recommend against its use in women with asthma 1

Carboprost (Option D) is also contraindicated in this patient because:

• Prostaglandin F2α causes bronchoconstriction in asthmatic patients 1
• Although not associated with clinical exacerbations in some studies, it is specifically recommended not to be used in women with asthma 1
• The risk of severe bronchospasm outweighs potential benefits 3

Recommended Management Algorithm

Immediate Next Steps (Option B - Uterine Balloon):

Uterine balloon tamponade is the appropriate next intervention because:

• It achieves 90% success rate when properly placed and should be implemented after failure of uterotonic medications 4
• Success rates of 79.4% to 88.2% specifically in uterine atony cases 4
• This is a conservative mechanical intervention that avoids pharmacologic bronchospasm triggers 4

Concurrent Medical Management:

Tranexamic acid should be administered immediately if not already given:

• 1 g IV over 10 minutes, must be given within 3 hours of birth 2, 4
• Reduces bleeding-related mortality and is safe in asthmatic patients 1, 4
• Can repeat 1 g dose if bleeding continues after 30 minutes 4

If Balloon Tamponade Fails:

Hysterectomy (Option C) is reserved for refractory cases only after:

• Balloon tamponade failure 4
• Consideration of other surgical interventions (brace sutures, arterial ligation) 2, 4
• This represents the final step in the escalation algorithm 4

Key Clinical Pitfalls to Avoid

• Never use ergometrine or prostaglandin F2α for postpartum hemorrhage in asthma patients - both cause severe bronchospasm 1, 3
• Oxytocin remains the uterotonic of choice for active management in asthmatic patients 3
• Do not delay mechanical interventions (balloon tamponade) while attempting additional contraindicated uterotonics 4
• Ensure tranexamic acid is given early (within 3 hours) as effectiveness decreases 10% for every 15 minutes of delay 4

Answer: B. Uterine balloon is the correct next step, with concurrent tranexamic acid if not already administered.