# Situation: The nurse works in the labor, operating, and postpartum units of a government hospital. A 32-year-old multipara with preeclampsia and moderate persistent asthma gave birth vaginally 40 minutes ago. Bleeding continues despite fundal massage and an oxytocin infusion. The uterus is soft, the bladder is empty, no lacerations are found, and quantified blood loss is 900 mL. Which additional medication is MOST appropriate to prepare?

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> subject: Nursing Practice II — Maternal and Child Health Nursing

## 문제

Situation: The nurse works in the labor, operating, and postpartum units of a government hospital.

A 32-year-old multipara with preeclampsia and moderate persistent asthma gave birth vaginally 40 minutes ago. Bleeding continues despite fundal massage and an oxytocin infusion. The uterus is soft, the bladder is empty, no lacerations are found, and quantified blood loss is 900 mL. Which additional medication is MOST appropriate to prepare?

## 보기

1. Methylergonovine 0.2 mg intramuscularly every 2 to 4 hours
2. Tranexamic acid 1 g intravenously over 10 minutes **✔ 정답**
3. Carboprost 250 mcg intramuscularly every 15 to 90 minutes
4. Oxytocin 10 units undiluted by rapid intravenous push

**정답: 2**

## 해설

Methylergonovine is contraindicated in hypertension and preeclampsia because it can cause severe hypertension and stroke, and carboprost is contraindicated in asthma because it causes bronchospasm. Tranexamic acid 1 g intravenously over 10 minutes, given within 3 hours of birth, is part of the first response to postpartum hemorrhage and is safe for her. She is 40 minutes after birth, well within that window.

## 심화 해설

Clinical situation

A multiparous patient with preeclampsia and moderate persistent asthma is 40 minutes postpartum after vaginal delivery. Uterine atony is suspected because the uterus remains soft despite fundal massage and an ongoing oxytocin infusion, the bladder is empty, and no lacerations are identified. Quantified blood loss is 900 mL, which meets the threshold for postpartum hemorrhage. The question asks which additional medication is most appropriate to prepare.

Why the other uterotonics are unsafe here

The two classic second-line uterotonics are both contraindicated in this patient. Methylergonovine causes vasoconstriction and can precipitate dangerous hypertension; in a patient with preeclampsia, this raises the risk of hypertensive crisis and stroke. Carboprost, a prostaglandin F2-alpha analogue, can induce bronchospasm and is therefore contraindicated in asthma. Oxytocin is already infusing, and giving 10 units undiluted by rapid IV push is never appropriate because it can cause severe hypotension, arrhythmia, and cardiovascular collapse.

Why tranexamic acid is the correct choice

Tranexamic acid is an antifibrinolytic agent that inhibits plasminogen activation and stabilizes clot formation, making it a safe adjunct when uterine atony is the suspected cause of ongoing bleeding. It does not cause hypertension or bronchospasm, so it is compatible with both preeclampsia and asthma. The recommended dose for postpartum hemorrhage is 1 g intravenously over 10 minutes, and it should be given as early as possible, ideally within 3 hours of birth. This patient is only 40 minutes postpartum, well within the therapeutic window.

Evidence supporting early tranexamic acid use

A systematic review and individual patient data meta-analysis of randomized trials found that tranexamic acid is a recommended treatment for women with a clinical diagnosis of postpartum hemorrhage, and early administration is emphasized [1]. A multinational systematic review of six placebo-controlled trials involving 54,934 participants observed that tranexamic acid lowered the risk of bleeding-related mortality and reduced further blood loss when used in postpartum hemorrhage management [4]. Although some trials focused on prophylactic use after vaginal delivery or before cesarean incision, the consistent finding is that tranexamic acid reduces blood loss by inhibiting fibrinolysis without the hemodynamic or respiratory risks seen with ergot alkaloids and prostaglandins .

Key distinctions for the licensure exam

| Medication | Mechanism | Contraindication in this patient | Nursing implication |
| --- | --- | --- | --- |
| Methylergonovine | Uterine vasoconstriction and sustained contraction | Preeclampsia (risk of severe hypertension and stroke) | Check blood pressure before administration; avoid in hypertensive disorders |
| Carboprost | Prostaglandin F2-alpha analogue causing strong uterine contraction | Asthma (risk of bronchospasm) | Assess respiratory status; have bronchodilator available if used in other patients |
| Tranexamic acid | Antifibrinolytic; inhibits plasminogen activation | No contraindication with preeclampsia or asthma | Give 1 g IV over 10 minutes within 3 hours of birth |
| Oxytocin IV push | Uterotonic via oxytocin receptor stimulation | Rapid undiluted push causes hypotension and arrhythmia | Never administer undiluted oxytocin by rapid IV push |

Watch out! Uterine atony is the most common cause of postpartum hemorrhage, but the choice of additional medication must account for maternal comorbidities. A soft uterus after oxytocin and fundal massage points to atony, yet the patient’s preeclampsia and asthma rule out the usual second-line uterotonics. Tranexamic acid is the safest and most evidence-supported adjunct in this scenario because it targets fibrinolysis rather than vascular or bronchial smooth muscle.

Key point! The 3-hour window for tranexamic acid is critical. Giving it after 3 hours is less effective and not recommended for postpartum hemorrhage. This patient at 40 minutes postpartum is an ideal candidate for early administration.References (research sources)

- [1]Tranexamic acid for postpartum bleeding: a systematic review and individual patient data meta-analysis of randomised controlled trials.Meta-analysis/systematic reviewKer K, Sentilhes L, Shakur-Still H, Madar H, Deneux-Tharaux C, Saade G (2024) · DOI: 10.1016/S0140-6736(24)02102-0

- [4]Tranexamic Acid in Postpartum Hemorrhage Management: A Multinational Systematic Review of Efficacy and Safety in Both Vaginal and Cesarean Births.Meta-analysis/systematic reviewAli N (2025) · DOI: 10.7759/cureus.85712

## 임상 시나리오

Postpartum Hemorrhage Medication SafetyChoosing an adjunct when standard uterotonics are contraindicated
In postpartum hemorrhage with suspected uterine atony, tranexamic acid 1 g IV over 10 minutes is a safe adjunct when given within 3 hours of birth.

Methylergonovine is contraindicated in preeclampsia because it can precipitate hypertensive crisis and stroke.

Carboprost is contraindicated in asthma because it can trigger bronchospasm.

CautionNever give oxytocin 10 units undiluted by rapid IV push; it can cause severe hypotension, arrhythmia, and cardiovascular collapse.

## 핵심 개념

- **Postpartum hemorrhage** — Cumulative blood loss of 1000 mL or more, or bleeding with signs of hypovolemia, within 24 hours of birth.
- **Tranexamic acid** — Antifibrinolytic that inhibits plasminogen activation and stabilizes clot; given 1 g IV over 10 minutes within 3 hours of birth for PPH.
- **Uterine atony** — Failure of the uterus to contract after delivery, the most common cause of postpartum hemorrhage.
- **Methylergonovine** — Uterotonic contraindicated in hypertension and preeclampsia due to risk of hypertensive crisis and stroke.
- **Carboprost** — Prostaglandin F2-alpha analogue contraindicated in asthma because it can cause bronchospasm.

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