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Difficulty: HardPharmacologic Interventions

A 32-year-old woman, gravida 3, para 3, is evaluated on the labor and delivery unit for excessive vaginal bleeding 20 minutes after a spontaneous vaginal delivery of a 4200-g (9.3-lb) neonate. The placenta was delivered intact 5 minutes after the neonate. Her past medical history is significant for chronic hypertension and moderate persistent asthma. Current medications include oral nifedipine and a budesonide-formoterol inhaler. Her blood pressure is 168/105 mmHg, and heart rate is 112/min. Physical examination reveals a large gush of blood from the vagina. The uterus is soft, boggy, and palpable 3 cm above the umbilicus. Careful inspection of the vagina and cervix reveals no lacerations. Bimanual uterine massage is initiated, and a continuous intravenous oxytocin infusion is started. Ten minutes later, the patient continues to have heavy vaginal bleeding, and the uterus remains boggy. Which of the following is the most appropriate next pharmacologic intervention?

  1. A
    Carboprost tromethamine
  2. B
    Intravenous magnesium sulfate
  3. C
    Methylergonovine
  4. MisoprostolAnswer
  5. E
    Transfusion of fresh frozen plasma

Answer

Misoprostol
Misoprostol is a prostaglandin E1 analog that stimulates strong uterine contractions. It is a standard second-line uterotonic for postpartum hemorrhage due to atony. Crucially, it does not possess the smooth muscle bronchoconstricting properties of prostaglandin F2-alpha analogs, nor does it cause the severe systemic vasoconstriction seen with ergot alkaloids. Therefore, it is the safest and most effective choice for a patient with concurrent asthma and chronic hypertension.

Step-by-Step Solution

1
Diagnose the cause of hemorrhage based on physical exam findings.
The soft, boggy uterus palpable above the umbilicus indicates postpartum hemorrhage secondary to uterine atony.
Identifying the mechanism of bleeding is essential for selecting targeted therapy.
2
Evaluate the response to initial first-line interventions.
Bleeding persists despite appropriate bimanual uterine massage and intravenous oxytocin administration.
Failure of first-line therapy necessitates escalation to second-line uterotonic agents.
3
Analyze the patient's medical history for contraindications to second-line uterotonics.
The patient has chronic hypertension (excluding methylergonovine) and moderate persistent asthma (excluding carboprost tromethamine).
Administering contraindicated uterotonics can precipitate life-threatening complications such as hypertensive crisis or severe bronchospasm.
4
Select the safest, most effective alternative uterotonic.
Misoprostol is chosen as the next appropriate intervention.
Misoprostol effectively stimulates uterine contractions and has no absolute contraindications in patients with hypertension or asthma.

Key Concept

Selection of second-line uterotonic agents for postpartum hemorrhage requires careful avoidance of specific contraindications, notably avoiding carboprost in asthma and methylergonovine in hypertension.
Estimated Time:1m 30s
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Pharmacologic Interventions

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