A G3P2 woman delivers a healthy neonate. After placental delivery, the uterus fails to contract despite oxytocin 10 IU IM. Bimanual compression and methylergometrine are given with partial response. Bleeding continues at 1500 mL. What is the MOST appropriate next pharmacological agent according to WHO recommendations for atonic PPH refractory to first-line uterotonics?
- A Misoprostol 800 mcg sublingual
- B Carboprost 250 mcg IM (PGF2α analogue)
- C Tranexamic acid 1 g IV over 10 minutes ✓
- D Dinoprostone 20 mg vaginal suppository
Explanation
Tranexamic acid (TXA) 1 g IV, given within 3 hours of delivery, significantly reduces PPH-related mortality (WOMAN trial, 2017). After first-line uterotonics fail, TXA should be administered as it addresses the fibrinolytic component of hemorrhage. Carboprost is a valid uterotonic for atony but contraindicated in asthma; TXA has broader applicability and direct mortality benefit proven in a large RCT of 20,000 women. Misoprostol sublingual is actually effective for primary prevention but less so as rescue therapy. Dinoprostone has largely been replaced by carboprost and misoprostol in practice.
Reference: Williams Obstetrics, 26th ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.