Primary postpartum haemorrhage due to uterine atony — MRCEM SBA MCQ

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EasyObstetric and gynaecological emergenciesPrimary postpartum haemorrhage due to uterine atonyMRCEM SBA

A 31-year-old woman with pre-eclampsia has a vaginal birth in an obstetric unit. She received oxytocin 10 units intramuscularly for management of the third stage. Following delivery of an intact placenta, measured blood loss reaches 850 mL and brisk bleeding continues. The uterus remains soft despite massage; examination finds no genital tract laceration. Her pulse is 118/min and blood pressure is 164/106 mmHg. She has no history of asthma. The obstetric team is present, intravenous access and resuscitation are established, and tranexamic acid has been given. Which additional uterotonic is the most appropriate first-line choice?

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Correct answer: D — Carboprost by intramuscular injection

The continuing blood loss after delivery, together with a soft uterus and no evident retained placenta or laceration, points to primary postpartum haemorrhage from uterine atony. NICE specifies that first-line uterotonic treatment should take account of the drug already given for the third stage. After oxytocin alone, its table lists intramuscular ergometrine, **carboprost if ergometrine is contraindicated**, or an oxytocin infusion. Pre-eclampsia contraindicates ergometrine, making **D** the appropriate choice among those offered. An oxytocin infusion would also be a guideline-supported first-line option, but is not listed. ([nice.org.uk](https://www.nice.org.uk/guidance/ng235/chapter/Recommendations)) **A** initially fits the prior-oxytocin pathway, but is contraindicated here. **B** is a recognised uterotonic combination, but it too contains ergometrine; it could be considered in a patient without an ergometrine contraindication who had received no prophylactic uterotonic. **C** can be used as an additional treatment and may be used earlier if intravenous administration is unavailable; it is not the best first-line choice with access established. **E** is used for prevention after caesarean birth, not for treatment of this haemorrhage. Uterotonic treatment must proceed alongside resuscitation, ongoing blood-loss assessment and obstetric-led care; tranexamic acid is an adjunct rather than a substitute. ([nice.org.uk](https://www.nice.org.uk/guidance/ng235/chapter/Recommendations))

Reference: NICE NG235, Intrapartum care: recommendation 1.10.34 and table 12 (9 June 2026) — https://www.nice.org.uk/guidance/ng235/chapter/Recommendations Ergometrine Injection BP: Summary of Product Characteristics, section 4.3 (5 May 2026) — https://www.medicines.org.uk/emc/medicine/20884 NICE NG235, Intrapartum care: recommendations 1.10.13 and 1.10.33–1.10.35 (9 June 2026) — https://www.nice.org.uk/guidance/ng235/chapter/Recommendations