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Postpartum Haemorrhage — FRCA Final MCQ

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ModerateObstetric AnaesthesiaPostpartum HaemorrhageFRCA Final

A 28-year-old woman at 36 weeks' gestation undergoes emergency caesarean birth under general anaesthesia. Immediately after delivery she bleeds 2.5 litres from an atonic uterus. The major obstetric haemorrhage protocol is active, transfusion has started and the surgeon is preparing further mechanical measures. She has already received oxytocin 5 units slow IV followed by an oxytocin infusion, ergometrine 500 micrograms IM, misoprostol 800 micrograms PR and tranexamic acid 1 g IV, and bimanual compression with uterine massage has been performed. She has no significant past medical history and no history of asthma or bleeding disorder. The uterus remains atonic. Which is the most appropriate next pharmacological step?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: A — Carboprost 250 micrograms IM

Explanation lettering: E = shown as B · B = shown as C · C = shown as D · D = shown as E

Carboprost (A) is correct. It is a 15-methyl prostaglandin F2-alpha analogue acting at myometrial FP receptors via Gq–phospholipase C–IP3, raising intracellular calcium and producing sustained uterine contraction. UK guidance lists carboprost 250 micrograms IM, repeatable at intervals of 15 minutes or more to a maximum of eight doses, for atony persisting after oxytocin, ergometrine and misoprostol; bronchoconstriction makes asthma a key caution, excluded here. Ergometrine (B) has already been given and repeat dosing is not advised, with added hypertensive and emetic risk. Tranexamic acid (C) is an essential antifibrinolytic adjunct but is not a uterotonic and should only be repeated after at least 30 minutes. Adrenaline (D) is for cardiac arrest or anaphylaxis, not atony. Desmopressin (E) is reserved for von Willebrand disease or uraemic platelet dysfunction.

Reference: NICE, Intrapartum care (NG235) — Management of postpartum haemorrhage, visual summary (uterotonic options including carboprost 250 micrograms IM), 2023. https://www.nice.org.uk/guidance/ng235/resources/management-of-postpartum-haemorrhage-visual-summary-pdf-13187003437