A woman delivers vaginally and has PPH with estimated blood loss 1800 mL. She has received oxytocin 10 IU IM, misoprostol 800 mcg sublingual, and ergometrine 0.5 mg. Uterine tone is good. On examination, a 3 cm laceration of the posterior vaginal wall is identified but already repaired. BP is 80/50 mmHg and pulse 126/min. Despite all measures, bleeding continues from the uterine cavity. Thromboelastography (TEG) shows prolonged clot formation time (K time). What is the most appropriate next pharmacological intervention?

• A Fresh frozen plasma transfusion to replace clotting factors
• B Carboprost (prostaglandin F2α) 0.25 mg IM
• C Recombinant Factor VIIa IV
• D Tranexamic acid 1g IV over 10 minutes ✓

Explanation

The WOMAN trial (2017, Lancet) demonstrated that tranexamic acid (TXA) 1g IV, when given within 3 hours of PPH onset, significantly reduces death due to bleeding (RR 0.81) without increasing thromboembolic complications. WHO now recommends TXA as a standard part of PPH management. The prolonged K time on TEG indicates delayed clot formation, consistent with hypofibrinogenemia and consumption coagulopathy—a state where TXA is particularly beneficial by preventing fibrin clot breakdown. Carboprost is appropriate when uterine atony is the cause, but here tone is good; FFP takes time; rFVIIa is a last resort. TXA should be given early, ideally within 3 hours.

Reference: Williams Obstetrics, 26th ed.

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Written and medically reviewed by the StethoPrep medical team.