A 34-year-old woman is evaluated in the postpartum unit for vaginal bleeding. Two hours ago, she underwent an uncomplicated spontaneous vaginal delivery with an estimated blood loss of 250 mL. Bleeding was initially minimal, but there is now profuse vaginal bleeding, and the patient's perineal pad is soaked with blood and large clots. This was her eighth vaginal delivery; her only surgery was a dilation and curettage 4 years ago for a spontaneous abortion. The patient has chronic hypertension that has been managed throughout this pregnancy with labetalol. She has no medication allergies. Blood pressure is 148/102 mm Hg and pulse is 110/min. On pelvic examination, the uterine fundus is soft, and the lower uterine segment is distended with blood clots. Which of the following medications is contraindicated in this patient?

Question

A 34-year-old woman is evaluated in the postpartum unit for vaginal bleeding.  Two hours ago, she underwent an uncomplicated spontaneous vaginal delivery with an estimated blood loss of 250 mL.  Bleeding was initially minimal, but there is now profuse vaginal bleeding, and the patient's perineal pad is soaked with blood and large clots.  This was her eighth vaginal delivery; her only surgery was a dilation and curettage 4 years ago for a spontaneous abortion.  The patient has chronic hypertension that has been managed throughout this pregnancy with labetalol.  She has no medication allergies.  Blood pressure is 148/102 mm Hg and pulse is 110/min.  On pelvic examination, the uterine fundus is soft, and the lower uterine segment is distended with blood clots.  Which of the following medications is contraindicated in this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_da66_cdb8_bc81_4729b6849ca3_MD0003_00 This patient with profuse vaginal bleeding and a soft uterine fundus has uterine atony, the most common cause of postpartum hemorrhage (PPH). Uterine atony occurs because of insufficient uterine contractility after delivery, resulting in continued bleeding from open placental bed vessels. Risk factors include grand multiparity (eg, ≥5 prior deliveries), hypertensive disorders, and uterine overdistension (eg, macrosomia). First-line treatment for uterine atony is bimanual uterine massage and high-dose oxytocin. If heavy bleeding persists, additional medications are administered based on patient-specific contraindications: bimanual uterine massage Tranexamic acid is an antifibrinolytic that prevents blood clot breakdown and significantly decreases blood loss if administered within 3 hours of delivery. Therefore, it is used for PPH of any etiology (eg, uterine atony, retained placenta). Tranexamic acid has no absolute contraindications but is used with caution in patients with hypercoagulability (eg, inherited thrombophilia) due to the potential increased risk of thromboembolism (Choice E). Carboprost tromethamine is a second-line uterotonic agent that stimulates contractions to increase uterine tone and decrease bleeding. It is a synthetic prostaglandin F2α analog that can cause bronchospasm; therefore, it is contraindicated in patients with asthma (Choice A). Methylergonovine is another second-line uterotonic agent that stimulates contractions. It is a potent vasoconstrictor and therefore contraindicated in patients with hypertensive disorders (eg, this patient with chronic hypertension) due to increased risk of stroke. (Choices C and D) Oxytocin is a first-line uterotonic agent administered to all patients after placental delivery for PPH prophylaxis; high-dose oxytocin is used for PPH treatment. Misoprostol is a prostaglandin E1 analog used for the induction of labor or as a second-line uterotonic to treat uterine atony. There are typically no contraindications to the use of either oxytocin or misoprostol in patients with PPH. Educational objective: The most common cause of postpartum hemorrhage is uterine atony, which typically presents with heavy vaginal bleeding and a soft uterine fundus. The choice of medical therapy for atony depends on patient contraindications: Methylergonovine is contraindicated in hypertensive patients, carboprost tromethamine is contraindicated in patients with asthma, and tranexamic acid is used with caution in patients with hypercoagulability. References: ACOG practice bulletin no. 183: postpartum hemorrhage. (http://www.ncbi.nlm.nih.gov/pubmed/28937571) Uterotonic medications: oxytocin, methylergonovine, carboprost, misoprostol. (http://www.ncbi.nlm.nih.gov/pubmed/28526143) Tranexamic acid for prevention and treatment of postpartum hemorrhage: an update on management and clinical outcomes. (http://www.ncbi.nlm.nih.gov/pubmed/30379320) Diagnosis and management of postpartum haemorrhage. (http://www.ncbi.nlm.nih.gov/pubmed/28954732)

A 34-Year-Old Woman Is Evaluated in the Postpartum Unit for Vaginal