A woman delivers vaginally and has 1200 mL blood loss. The uterus is soft, central, and atonic on examination. Oxytocin 10 units IV has been given. What is the NEXT appropriate uterotonic to administer for medical management of uterine atony?

• A Ergometrine 0.2 mg IM or IV (slowly)
• B Carboprost (15-methyl PGF2α) 250 mcg IM ✓
• C Misoprostol 200 mcg sublingual
• D Tranexamic acid 1 g IV

Explanation

After failed oxytocin, the next step in uterotonic escalation for PPH due to atony is carboprost (15-methyl PGF2α) 250 mcg IM, which can be repeated every 15 minutes up to 8 doses. Ergometrine is second-line but contraindicated in hypertension; misoprostol 800 mcg sublingual is an alternative when carboprost is unavailable. Tranexamic acid addresses fibrinolysis rather than atony and should be given concurrently but does not replace uterotonic escalation.

Reference: Williams Obstetrics, 26th ed.

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