A 27-year-old woman, gravida 3, para 2, at 41 weeks' gestation is admitted to the hospital in active labor. Her pregnancy has been uncomplicated. Both of her prior children were delivered by vaginal birth. She has a history of asthma. Current medications include iron and vitamin supplements. After a prolonged labor, she undergoes vaginal delivery. Shortly afterwards, she begins to have heavy vaginal bleeding with clots. Her temperature is 37.2°C (98.9°F), pulse is 90/min, respirations are 17/min, and blood pressure is 130/72 mm Hg. Examination shows a soft, enlarged, and boggy uterus on palpation. Laboratory studies show: Hemoglobin 10.8 g/dL Hematocrit 32.3% Leukocyte Count 9,000/mm3 Platelet Count 140,000/mm3 Prothrombin time 14 seconds Partial thromboplastin time 38 seconds Her bleeding continues despite bimanual uterine massage and administration of oxytocin. Which of the following is the most appropriate next step in management?

Administer carboprost tromethamine

A 24-year-old primigravida presents at 36 weeks gestation with vaginal bleeding, mild abdominal pain, and uterine contractions that appeared after bumping into a handrail. The vital signs are as follows: blood pressure 130/80 mm Hg, heart rate 79/min, respiratory rate 12/min, and temperature 36.5℃ (97.7℉). The fetal heart rate was 145/min. Uterine fundus is at the level of the xiphoid process. Slight uterine tenderness and contractions are noted on palpation. The perineum is bloody. The gynecologic examination shows no vaginal or cervical lesions. The cervix is long and closed. Streaks of bright red blood are passing through the cervix. A transabdominal ultrasound shows the placenta to be attached to the lateral uterine wall with a marginal retroplacental hematoma (an approximate volume of 150 ml). The maternal hematocrit is 36%. What is the next best step in the management of this patient?

Admit for maternal and fetal monitoring and observation

Manage as an outpatient with modified rest

Corticosteroid administration and schedule a cesarean section after

A 24-year-old woman, gravida 1, at 35 weeks gestation is admitted to the hospital with regular contractions and pelvic pressure for the last 5 hours. Her pregnancy has been uncomplicated and she has attended many prenatal appointments and followed the physician's advice about screening for diseases, laboratory testing, diet, and exercise. She has had no history of fluid leakage or bleeding. At the hospital, her temperature is 37.2°C (99.0°F), blood pressure is 108/60 mm Hg, pulse is 88/min, and respirations are 16/min. Cervical examination shows 60% effacement and 5 cm dilation with intact membranes. Cardiotocography shows a contraction amplitude of 220 MVU in 10 minutes. Which of the following is the most appropriate pharmacotherapy at this time?

No pharmacotherapy at this time

A 34-year-old G5P5 woman gave birth to a healthy infant 30 minutes ago by vacuum-assisted vaginal delivery and is now experiencing vaginal bleeding. The placenta was delivered spontaneously and was intact upon examination. The infant weighed 5.2 kg and had Apgar scores of 8 and 9. No perineal tear or intentional episiotomy occurred. The patient has type 1 diabetes. She had good glycemic control throughout her pregnancy. She took a prenatal vitamin daily. Blood pressure is 135/72 mmHg, pulse is 102/min, and respirations are 18/min. Upon physical examination, the uterine fundus is soft and palpated 4 cm above the umbilicus. There are 3-cm blood clots on the patient’s bed pad. Which of the following is the next best step in management for the patient’s bleeding?

Perform uterine massage and administer oxytocin

Manually remove retained placental fragments

Perform uterine artery embolization

A 37-year-old woman presents to the clinic to discuss various options for contraception. The patient has a past medical history of hypertension, Wilson's disease, and constipation-dominant irritable bowel syndrome. The patient takes rivaroxaban and polyethylene glycol. The blood pressure is 152/98 mm Hg. On physical examination, the patient appears alert and oriented. The heart auscultation demonstrates regular rate and rhythm, and it is absent of murmurs. The lungs are clear to auscultation bilaterally without wheezing. The first day of the last menstrual period was 12 days ago. The urine hCG is negative. Given the patient's history and physical examination, which of the following forms of contraception is the most appropriate?

levonorgestrel/ethinyl estradiol

Depot-medroxyprogesterone acetate

A 36-year-old primigravid woman at 34 weeks' gestation comes to the physician because of a 1-week history of upper abdominal discomfort, nausea, and malaise. She had a mild upper respiratory tract infection a week ago. She has a 10-year history of polycystic ovarian syndrome and a 3-year history of hypertension. Her medications include metformin, labetalol, folic acid, and a multivitamin. Her pulse is 92/min, respirations are 18/min, and blood pressure is 147/84 mm Hg. Examination shows a nontender uterus consistent in size with a 34-week gestation. There is mild tenderness of the right upper quadrant of the abdomen. The fetal heart rate is reactive with no decelerations. Which of the following is the most appropriate next step in management?

Serum transaminase levels and platelet count

HBsAg and IgM anti-HBc serology

Stool antigen assay for H. pylori

A 26-year-old primigravida presents to her physician’s office at 35 weeks gestation with new onset lower leg edema. The course of her pregnancy was uneventful up to the time of presentation and she has been compliant with the recommended prenatal care. She reports a 4 pack-year history of smoking prior to her pregnancy. She also used oral contraceptives for birth control before considering the pregnancy. Prior to pregnancy, she weighed 52 kg (114.6 lb). She gained 11 kg (24.3 lb) during the pregnancy thus far, and 2 kg (4.4 lb) during the last 2 weeks. Her height is 169 cm (5 ft 7 in). She has a family history of hypertension in her mother (diagnosed at 46 years of age) and aunt (diagnosed at 51 years of age). The blood pressure is 145/90 mm Hg, the heart rate is 91/min, the respiratory rate is 15/min, and the temperature is 36.6℃ (97.9℉). The blood pressure is unchanged 15 minutes and 4 hours after the initial measurement. The fetal heart rate is 144/min. The examination is remarkable for 2+ pitting lower leg edema. The neurologic examination shows no focality. A urine dipstick test shows 2+ proteinuria. Which of the following factors is a risk factor for her condition?

BMI < 18.5 kg/m2 prior to pregnancy

Medical management of PPH | Postpartum hemorrhage

Uterotonics - The Tone Tighteners

First-Line: Oxytocin (Pitocin)
- Stimulates upper uterine segment to contract.
- Dose: 20-40 units in 1L crystalloid IV infusion.
Second-Line Agents:
- Methylergonovine (Methergine)
  - Ergot alkaloid; causes generalized smooth muscle contraction.
  - Dose: 0.2 mg IM.
  - ⚠️ Contraindication: Hypertension, preeclampsia.
- Carboprost Tromethamine (Hemabate)
  - Prostaglandin F2α analog.
  - Dose: 0.25 mg IM.
  - ⚠️ Contraindication: Asthma.
- Misoprostol (Cytotec)
  - Prostaglandin E1 analog.
  - Dose: 800-1000 mcg per rectum.
Adjunct Therapy: Tranexamic Acid (TXA)
- Antifibrinolytic; prevents clot breakdown.
- Dose: 1 g IV, given within 3 hours of delivery.

⭐ Methylergonovine is contraindicated in patients with hypertension or preeclampsia due to its potent vasoconstrictive effects, which can precipitate a hypertensive crisis.

Uterotonic Medication Table for PPH

Adjunctive Meds - The Backup Brigade

When oxytocin isn't enough, these second-line agents are crucial. Administer sequentially if bleeding persists.

Medication	Class	Dose & Route	Key Contraindication
Methylergonovine	Ergot Alkaloid	0.2 mg IM	Hypertension / Preeclampsia
Carboprost (Hemabate)	Prostaglandin F2α	0.25 mg IM/Intramyometrial	Asthma ⚠️
Misoprostol (Cytotec)	Prostaglandin E1	800-1000 mcg PR	-
Tranexamic Acid (TXA)	Antifibrinolytic	1 g IV over 10 min	Hx of thromboembolic disease
%%{init: {'flowchart': {'htmlLabels': true}}}%%
flowchart TD

A["🩺 Persistent Atony
• Uterine hemorrhage• Failure to contract"]

B["📋 Oxytocin Failed
• 1st line failed• Bleeding persists"]

C["💊 2nd Line Step
• Start uterotonics• Escalate therapy"]

D["💊 Specific Meds
• Methylergonovine• Carboprost dose"]

E["📋 Still Bleeding?
• Vital assessment• Ongoing PPH"]

F["💊 Add TXA
• Tranexamic acid• Antifibrinolytic"]

A --> B B --> C C --> D D --> E E -->|Yes| F

style A fill:#F7F5FD, stroke:#F0EDFA, stroke-width:1.5px, rx:12, ry:12, color:#6B21A8 style B fill:#FEF8EC, stroke:#FBECCA, stroke-width:1.5px, rx:12, ry:12, color:#854D0E style C fill:#F1FCF5, stroke:#BEF4D8, stroke-width:1.5px, rx:12, ry:12, color:#166534 style D fill:#F1FCF5, stroke:#BEF4D8, stroke-width:1.5px, rx:12, ry:12, color:#166534 style E fill:#FEF8EC, stroke:#FBECCA, stroke-width:1.5px, rx:12, ry:12, color:#854D0E style F fill:#FDF4F3, stroke:#FCE6E4, stroke-width:1.5px, rx:12, ry:12, color:#B91C1C


> ⭐ **Exam Favorite:** Always check for a history of asthma before administering Carboprost (Hemabate). Prostaglandin F2α is a potent bronchoconstrictor and can trigger a severe asthma attack.



## Management Algorithm - PPH Playbook

*   **Initial Steps:** Fundal massage, IV access, call for help.
*   Administer Tranexamic Acid (TXA) **1g** IV within **3 hours** of birth.

```mermaid
%%{init: {'flowchart': {'htmlLabels': true}}}%%
flowchart TD

    START["<b>⚠️ PPH Confirmed</b><br><span style='display:block; text-align:left; color:#555'>• Maternal bleeding</span><span style='display:block; text-align:left; color:#555'>• Postpartum hemorrhage</span>"]
    
    OXY["<b>💊 1st Line: Oxytocin</b><br><span style='display:block; text-align:left; color:#555'>• Uterotonic agent</span><span style='display:block; text-align:left; color:#555'>• Promote contraction</span>"]
    
    PERSIST{"<b>📋 Bleeding?</b><br><span style='display:block; text-align:left; color:#555'>• Evaluate response</span><span style='display:block; text-align:left; color:#555'>• Assess stability</span>"}
    
    MONITOR["<b>👁️ Monitor</b><br><span style='display:block; text-align:left; color:#555'>• Vital signs check</span><span style='display:block; text-align:left; color:#555'>• Ongoing assess</span>"]
    
    SECOND["<b>💊 2nd Line Drugs</b><br><span style='display:block; text-align:left; color:#555'>• Uterotonic options</span><span style='display:block; text-align:left; color:#555'>• Check CI's first</span>"]
    
    METHYL["<b>💊 Methylergonovine</b><br><span style='display:block; text-align:left; color:#555'>• CI: Hypertension</span><span style='display:block; text-align:left; color:#555'>• Ergot alkaloid</span>"]
    
    CARBO["<b>💊 Carboprost</b><br><span style='display:block; text-align:left; color:#555'>• CI: Asthma</span><span style='display:block; text-align:left; color:#555'>• Prostaglandin F2a</span>"]
    
    MISO["<b>💊 Misoprostol</b><br><span style='display:block; text-align:left; color:#555'>• PGE1 analogue</span><span style='display:block; text-align:left; color:#555'>• Rectal or subling</span>"]

    START --> OXY
    OXY --> PERSIST
    PERSIST -->|No| MONITOR
    PERSIST -->|Yes| SECOND
    
    SECOND --> METHYL
    SECOND --> CARBO
    SECOND --> MISO

    style START fill:#FDF4F3, stroke:#FCE6E4, stroke-width:1.5px, rx:12, ry:12, color:#B91C1C
    style OXY fill:#F1FCF5, stroke:#BEF4D8, stroke-width:1.5px, rx:12, ry:12, color:#166534
    style PERSIST fill:#FEF8EC, stroke:#FBECCA, stroke-width:1.5px, rx:12, ry:12, color:#854D0E
    style MONITOR fill:#EEFAFF, stroke:#DAF3FF, stroke-width:1.5px, rx:12, ry:12, color:#0369A1
    style SECOND fill:#F1FCF5, stroke:#BEF4D8, stroke-width:1.5px, rx:12, ry:12, color:#166534
    style METHYL fill:#F1FCF5, stroke:#BEF4D8, stroke-width:1.5px, rx:12, ry:12, color:#166534
    style CARBO fill:#F1FCF5, stroke:#BEF4D8, stroke-width:1.5px, rx:12, ry:12, color:#166534
    style MISO fill:#F1FCF5, stroke:#BEF4D8, stroke-width:1.5px, rx:12, ry:12, color:#166534

📌 Mnemonic (Uterotonics): Oh My Heavy Menses (Oxytocin, Methylergonovine, Hemabate, Misoprostol)

⭐ In cases of uterine atony, if oxytocin fails, the next step is typically a second-line uterotonic like methylergonovine or carboprost, keeping their contraindications (hypertension and asthma, respectively) in mind.

High‑Yield Points - ⚡ Biggest Takeaways

Uterine atony is the #1 cause of PPH; always start with uterine massage and oxytocin.

Refractory atony requires second-line agents like methylergonovine, carboprost, or misoprostol.

Methylergonovine is contraindicated in hypertension and preeclampsia due to its vasoconstrictive effects.

Carboprost tromethamine (a prostaglandin) is contraindicated in asthma due to the risk of bronchoconstriction.

Tranexamic acid (TXA), an antifibrinolytic, is crucial if initial uterotonics fail to control the bleeding.