Postpartum hemorrhage

Postpartum hemorrhage US Medical PG Question 1: A 38-year-old woman, gravida 2, para 1, at 35 weeks' gestation comes to the emergency department because of an episode of vaginal bleeding that morning. The bleeding has subsided. She has had no prenatal care. Her previous child was delivered with a caesarean section because of a breech presentation. Her temperature is 37.1°C (98.8°F), pulse is 88/min, respirations are 14/min, and blood pressure is 125/85 mm Hg. The abdomen is nontender and the size of the uterus is consistent with a 35-week gestation. No contractions are felt. The fetal heart rate is 145/min. Her hemoglobin concentration is 12 g/dL, leukocyte count is 13,000/mm3, and platelet count is 350,000/mm3. Transvaginal ultrasound shows that the placenta covers the internal os. Which of the following is the most appropriate next step in management?

• A. Schedule elective cesarean delivery (Correct Answer)
• B. Observation only
• C. Perform bimanual pelvic examination
• D. Perform emergency cesarean delivery
• E. Administer oxytocin to induce labor

Postpartum hemorrhage Explanation: ***Schedule elective cesarean delivery*** - The ultrasound finding of the **placenta covering the internal os** confirms **placenta previa**. Given the patient is at **35 weeks' gestation** and has experienced **vaginal bleeding**, an elective cesarean delivery is the safest management to avoid further bleeding episodes and ensure maternal and fetal well-being. - An elective cesarean delivery is typically scheduled between **36 and 37 weeks' gestation** for placenta previa to minimize the risk of spontaneous labor and potentially catastrophic hemorrhage. *Observation only* - This is inappropriate given the diagnosis of **placenta previa** and the history of **vaginal bleeding**. Observation alone carries a significant risk of recurrent, potentially severe hemorrhage. - While the bleeding has subsided, the underlying condition remains and warrants active management to prevent future complications. *Perform bimanual pelvic examination* - A **bimanual pelvic examination** is **contraindicated** in cases of suspected or confirmed **placenta previa**. - Performing such an examination can **disrupt the placenta** and precipitate a massive, life-threatening hemorrhage. *Perform emergency cesarean delivery* - An emergency cesarean delivery is indicated if the patient presents with **severe, active bleeding** or signs of **fetal distress**. - In this case, the bleeding has subsided, the patient is hemodynamically stable, and the fetal heart rate is normal, so an immediate emergency delivery is not warranted. *Administer oxytocin to induce labor* - **Induction of labor with oxytocin** is **contraindicated** in **placenta previa**. - Stimulating contractions would lead to **cervical dilation**, causing further placental separation and severe hemorrhage, putting both mother and fetus at extreme risk.

Postpartum hemorrhage US Medical PG Question 2: A 29-year-old G2P2 female gives birth to a healthy baby boy at 39 weeks of gestation via vaginal delivery. Immediately after the delivery of the placenta, she experiences profuse vaginal hemorrhage. Her prior birthing history is notable for an emergency cesarean section during her first pregnancy. She did not receive any prenatal care during either pregnancy. Her past medical history is notable for obesity and diabetes mellitus, which is well controlled on metformin. Her temperature is 99.0°F (37.2°C), blood pressure is 95/50 mmHg, pulse is 125/min, and respirations are 22/min. On physical examination, the patient is in moderate distress. Her extremities are pale, cool, and clammy. Capillary refill is delayed. Which of the following is the most likely cause of this patient’s bleeding?

• A. Chorionic villi invading into the myometrium
• B. Placental implantation over internal cervical os
• C. Chorionic villi attaching to the decidua basalis
• D. Chorionic villi invading into the serosa
• E. Chorionic villi attaching to the myometrium (Correct Answer)

Postpartum hemorrhage Explanation: ***Chorionic villi attaching to the myometrium*** - This describes **placenta accreta**, where the **chorionic villi adhere directly to the myometrium** without invading beyond it. This condition is strongly associated with a history of **prior C-sections**, as the scar tissue increases the risk of abnormal placental implantation. - The profuse hemorrhage immediately following placental delivery, despite the placenta being delivered, suggests a problem with normal placental separation from the uterine wall. **Placenta accreta** can lead to massive postpartum hemorrhage when the placenta attempts to separate, tearing the maternal vessels. *Chorionic villi invading into the myometrium* - This describes **placenta increta**, where the **chorionic villi invade deeper into the myometrium**. While also causing severe hemorrhage, the term "attaching to the myometrium" (accreta) is a more common and slightly less severe form often seen with prior C-sections. - Both accreta and increta present similarly with hemorrhage, but accreta is the initial and most common form of abnormal adherence to the myometrium. *Placental implantation over internal cervical os* - This describes **placenta previa**, which is characterized by **painless vaginal bleeding** typically in the **second or third trimester**, before delivery. - While a prior C-section is a risk factor for placenta previa, the hemorrhage in this case occurred *after* the delivery of the placenta, not before or during labor, ruling out active previa. *Chorionic villi invading into the serosa* - This describes **placenta percreta**, the most severe form where **chorionic villi invade through the myometrium and into the uterine serosa**, potentially involving adjacent organs. - While it causes massive hemorrhage, "attaching to" or even "invading into" the myometrium (accreta/increta) are more probable, given the description, than invasion *through* to the serosa, though all are part of the placenta accreta spectrum. *Chorionic villi invading beyond the serosa* - This is an alternative description for **placenta percreta**, indicating invasion through the uterus and potentially into surrounding structures like the bladder. - While this is a severe cause of postpartum hemorrhage, the provided option "Chorionic villi attaching to the myometrium" (placenta accreta) is the most common form of abnormally adherent placenta in the spectrum and is highly consistent with the patient's history of prior C-section and the clinical presentation of hemorrhage after placental delivery.

Postpartum hemorrhage US Medical PG Question 3: A 30-year-old woman, gravida 2, para 1, at 42 weeks' gestation is admitted to the hospital in active labor. Pregnancy has been complicated by gestational diabetes, for which she has been receiving insulin injections. Her first child was delivered by lower segment transverse cesarean section because of a nonreassuring fetal heart rate. Her pulse is 90/min, respirations are 18/min, and blood pressure is 135/80 mm Hg. The fetal heart rate tracing shows a baseline heart rate of 145/min and moderate variation with frequent accelerations and occasional early decelerations. She undergoes an elective repeat lower segment transverse cesarean section with complete removal of the placenta. Shortly after the operation, she starts having heavy uterine bleeding with passage of clots. Examination shows a soft uterus on palpation. Her bleeding continues despite fundal massage and the use of packing, oxytocin, misoprostol, and carboprost. Her pulse rate is now 120/min, respirations are 20/min, and blood pressure is 90/70 mm Hg. Her hemoglobin is 8 g/dL, hematocrit is 24%, platelet count is 120,000 mm3, prothrombin time is 11 seconds, and partial thromboplastin time is 30 seconds. Mass transfusion protocol is activated and a B-Lynch uterine compression suture is placed to control her bleeding. Which of the following is the mostly likely cause of her postpartum complication?

• A. Adherent placenta to myometrium
• B. Uterine inversion
• C. Infection of the endometrial lining of the uterus
• D. Uterine rupture
• E. Lack of uterine muscle contraction (Correct Answer)

Postpartum hemorrhage Explanation: ***Lack of uterine muscle contraction*** - The presentation of a **soft uterus** on palpation and continued severe bleeding despite fundal massage and uterotonics (**oxytocin, misoprostol, carboprost**) is highly indicative of **uterine atony**, which is a lack of effective uterine muscle contraction. - Uterine atony is the most common cause of **postpartum hemorrhage**, and risk factors include **macrosomia** (due to gestational diabetes), **multiparity**, and a prolonged labor or rapid delivery, though the latter two are less clear here. *Adherent placenta to myometrium* - While a history of prior C-section and **macrosomia** (due to gestational diabetes) could increase the risk of an **abnormally adherent placenta** (accreta, increta, percreta), the description notes **complete removal of the placenta**. - If the placenta were morbidly adherent and not completely removed, bleeding would likely stem from retained placental tissue, and this would typically be explicitly noted or suspected due to difficulty with manual removal. *Uterine inversion* - **Uterine inversion** involves the uterus turning inside out, which would present with a **mass protruding from the vagina** or a visible inversion of the fundus upon examination, along with sudden onset of severe pain and shock. - The description of a **soft uterus** and an absence of a physical description of uterine inversion makes this diagnosis less likely. *Infection of the endometrial lining of the uterus* - **Endometritis** (infection of the endometrial lining) typically presents with fever, foul-smelling lochia, uterine tenderness, and prolonged postpartum bleeding, usually occurring a few days postpartum rather than immediately following delivery. - The acute, massive hemorrhage immediately following delivery, coupled with a normal initial temperature, does not align with the typical presentation of endometritis. *Uterine rupture* - **Uterine rupture** is a serious complication, especially with a history of prior C-section, but it typically presents with **sudden severe abdominal pain**, fetal heart rate abnormalities (if it occurs before delivery), and **hemodynamic instability**, often with cessation of contractions. - While the patient is hemodynamically unstable, the primary issue described is heavy uterine bleeding with a soft uterus, and no mention of severe abdominal pain or clear signs of rupture during the C-section make uterine atony a more direct explanation for the described symptoms.

Postpartum hemorrhage US Medical PG Question 4: A 32-year-old woman, gravida 2, para 1, at 38 weeks' gestation comes to the emergency department because of vaginal bleeding for the past hour. The patient reports that she felt contractions prior to the onset of the bleeding, but the contractions stopped after the bleeding started. She also has severe abdominal pain. Her first child was delivered by lower segment transverse cesarean section because of a nonreassuring fetal heart rate. Her pulse is 110/min, respirations are 17/min, and blood pressure is 90/60 mm Hg. Examination shows diffuse abdominal tenderness with no rebound or guarding; no contractions are felt. The fetal heart rate shows recurrent variable decelerations. Which of the following is the most likely diagnosis?

• A. Uterine inertia
• B. Amniotic fluid embolism
• C. Uterine rupture (Correct Answer)
• D. Vasa previa
• E. Abruptio placentae

Postpartum hemorrhage Explanation: ***Uterine rupture*** - The patient's history of a prior **cesarean section**, sudden onset of **vaginal bleeding** and **severe abdominal pain**, resolution of contractions, and signs of **hypovolemic shock** (tachycardia, hypotension) coupled with fetal distress (variable decelerations) are highly indicative of uterine rupture. - Diffuse abdominal tenderness without rebound or guarding, and no palpable contractions, are also consistent with rupture. *Uterine inertia* - This condition is characterized by **weak or uncoordinated uterine contractions** leading to prolonged labor, but it does not typically present with acute vaginal bleeding, sudden severe abdominal pain, or hypovolemic shock. - Fetal distress in uterine inertia would more likely be due to prolonged labor rather than acute compromise following a sudden event. *Amniotic fluid embolism* - This is a rare, life-threatening obstetric emergency characterized by sudden **cardiovascular collapse, respiratory distress**, and **coagulopathy**, often occurring during labor or immediately postpartum. - While it can cause fetal distress, vaginal bleeding and severe abdominal pain are not primary presenting symptoms. *Vasa previa* - Characterized by **painless vaginal bleeding** when fetal vessels within the membranes cross the internal cervical os, making them vulnerable to rupture during cervical dilation or amniotomy. - The bleeding is typically fetal blood, and fetal distress occurs rapidly, but the mother would not experience severe abdominal pain or signs of hypovolemic shock unless the bleeding is substantial and prolonged. *Abruptio placentae* - This involves the **premature separation of the placenta**, causing painful vaginal bleeding, uterine tenderness, and frequent, strong contractions. - While it can cause hypovolemic shock and fetal distress, the description of contractions stopping after bleeding started, along with a previous C-section scar, points more specifically to uterine rupture rather than an abruption.

Postpartum hemorrhage US Medical PG Question 5: A 29-year-old G1P0 female at 32 weeks gestation presents to the emergency department with vaginal bleeding. She has had minimal prenatal care to-date with only an initial visit with an obstetrician after a positive home pregnancy test. She describes minimal spotting that she noticed earlier today that has progressed to larger amounts of blood; she estimates 30 mL of blood loss. She denies any cramping, pain, or contractions, and she reports feeling continued movements of the baby. Ultrasound and fetal heart rate monitoring confirm the presence of a healthy fetus without any evidence of current or impending complications. The consulted obstetrician orders blood testing for Rh-status of both the mother as well as the father, who brought the patient to the hospital. Which of the following represents the best management strategy for this situation?

• A. After 28 weeks gestation, administration of RhoGAM will have no benefit
• B. If mother is Rh-positive and father is Rh-negative then administer RhoGAM
• C. If mother is Rh-negative and father is Rh-negative then administer RhoGAM
• D. If mother is Rh-negative and father is Rh-positive, RhoGAM administration is not needed
• E. If mother is Rh-negative and father is Rh-positive then administer RhoGAM (Correct Answer)

Postpartum hemorrhage Explanation: ***If mother is Rh-negative and father is Rh-positive then administer RhoGAM*** - This combination creates a risk for **Rh incompatibility**, meaning the fetus could be Rh-positive and the mother's immune system could form antibodies against fetal red blood cells, which can harm the fetus in future pregnancies. - **RhoGAM (Rh immunoglobulin)** administration prevents the mother from forming these antibodies when there's a risk of maternal-fetal blood mixing, as indicated by vaginal bleeding. *After 28 weeks gestation, administration of RhoGAM will have no benefit* - This statement is incorrect; **RhoGAM is routinely administered around 28 weeks gestation** as prophylaxis in Rh-negative mothers, even without bleeding episodes, to prevent sensitization. - In cases of potential fetal-maternal hemorrhage, such as vaginal bleeding, RhoGAM is indicated regardless of gestational age beyond the first trimester. *If mother is Rh-positive and father is Rh-negative then administer RhoGAM* - This scenario does not pose a risk for **Rh incompatibility hemolytic disease of the newborn**, as the mother already possesses the Rh antigen. - RhoGAM is specifically given to Rh-negative mothers to prevent their immune system from reacting to an Rh-positive fetus. *If mother is Rh-negative and father is Rh-negative then administer RhoGAM* - In this case, both parents are **Rh-negative**, meaning the fetus will also be Rh-negative. - There is no risk of **Rh incompatibility** or sensitization, so RhoGAM administration is not indicated. *If mother is Rh-negative and father is Rh-positive, RhoGAM administration is not needed* - This statement is incorrect and represents a critical misunderstanding of **Rh incompatibility prophylaxis**. - This specific genetic combination creates the highest risk for **Rh sensitization** during pregnancy, especially with events like vaginal bleeding, making RhoGAM administration essential.

Postpartum hemorrhage US Medical PG Question 6: A 27-year-old woman, gravida 2, para 1, at 38 weeks' gestation comes to the emergency department in active labor. She received all of her prenatal care for this pregnancy. Pregnancy and delivery of her first child were uncomplicated. The patient's blood type is Rh-negative. Four hours after arrival, a healthy 3650-g (8-lb) female newborn is delivered. Delivery of the fetus is followed by placental retention and heavy vaginal bleeding. One hour later, the placenta is manually removed and the bleeding ceases. The mother's temperature is 36.7°C (98.1°F), pulse is 90/min, and blood pressure is 110/60 mm Hg. Examination shows blood on the vulva, the introitus, and on the medial aspect of each thigh. The neonate's blood type is Rh-positive. A single dose of anti-D immune globulin is administered. Which of the following is the most appropriate next step in management?

• A. Perform Kleihauer-Betke test
• B. Administer additional dose of anti-D immune globulin
• C. Perform rosette test (Correct Answer)
• D. Perform flow cytometry
• E. Perform Coombs test

Postpartum hemorrhage Explanation: ***Perform rosette test*** - The **rosette test** is a qualitative screening test used to detect the presence of **fetal Rh-positive red blood cells** in the maternal Rh-negative blood circulation. - It helps determine if a significant fetomaternal hemorrhage (FMH) has occurred, which would necessitate further quantification with a Kleihauer-Betke test to guide additional anti-D immune globulin dosing. *Perform Kleihauer-Betke test* - The **Kleihauer-Betke test** is a quantitative test used to determine the exact volume of **fetal Rh-positive red blood cells** in the maternal circulation. - While necessary for determining the precise dose of anti-D immune globulin if FMH is suspected, it is usually performed *after* a positive screening test like the rosette test. *Administer additional dose of anti-D immune globulin* - Administering an additional dose without quantifying the extent of **fetomaternal hemorrhage (FMH)** is not the most appropriate immediate next step. - The initial standard dose of anti-D immune globulin is a prophylactic measure, and further doses depend on the amount of fetal blood that entered maternal circulation. *Perform flow cytometry* - Flow cytometry is a highly sensitive method for detecting **fetal red blood cells** in maternal blood, but it is typically reserved for cases where other screening methods are inconclusive or a very precise quantification is needed. - The rosette test is a more common and readily available initial screening test for significantly sized fetomaternal hemorrhage. *Perform Coombs test* - The **Coombs test** (both direct and indirect) is used to detect antibodies on the surface of red blood cells or free in the serum. - It is primarily used to diagnose **hemolytic disease of the newborn** or **autoimmune hemolytic anemia**, not to determine the volume of fetomaternal hemorrhage for anti-D immune globulin dosing.

Postpartum hemorrhage US Medical PG Question 7: A 25-year-old G2P1001 at 32 weeks gestation presents to the hospital with painless vaginal bleeding. The patient states that she was taking care of laundry at home when she experienced a sudden sensation of her water breaking and saw that her groin was covered in blood. Her prenatal history is unremarkable according to the clinic records, but she has not seen an obstetrician for the past 14 weeks. Her previous delivery was by urgent cesarean section for placenta previa. Her temperature is 95°F (35°C), blood pressure is 125/75 mmHg, pulse is 79/min, respirations are 18/min, and oxygen saturation is 98% on room air. Cervical exam shows gross blood in the vaginal os. The fetal head is not palpable. Fetal heart rate monitoring demonstrates decelerations and bradycardia. Labs are pending. IV fluids are started. What is the best next step in management?

• A. Cesarean section (Correct Answer)
• B. Betamethasone
• C. Red blood cell transfusion
• D. Vaginal delivery
• E. Lumbar epidural block

Postpartum hemorrhage Explanation: ***Cesarean section*** - This patient presents with signs highly suggestive of **placenta previa with possible vasa previa or placental abruption**, with life-threatening complications for both mother and fetus. The presence of **painless vaginal bleeding**, a prior **cesarean section for placenta previa**, and **fetal heart rate decelerations/bradycardia** necessitate immediate delivery via cesarean section to prevent **fetal demise** and severe **maternal hemorrhage**. - The rapid deterioration of the fetal status, indicated by **decelerations and bradycardia**, confirms the urgency. A **cesarean section** is the quickest and safest way to deliver the baby and address the underlying obstetric emergency. *Betamethasone* - **Betamethasone** is administered to promote **fetal lung maturity** in cases of preterm delivery. While this patient is preterm at 32 weeks, the critical nature of the fetal distress and bleeding requires immediate delivery, making the delay for betamethasone administration inappropriate. - The benefits of steroids for lung maturity are outweighed by the **immediate risk of fetal demise** and severe maternal complications if delivery is delayed. *Red blood cell transfusion* - While the patient is actively bleeding and may eventually require a **blood transfusion**, starting IV fluids and proceeding with an **immediate cesarean section** are higher priorities to stabilize the mother and rescue the fetus. - Transfusions are supportive measures once the source of hemorrhage is addressed and vital signs are stabilized during or after surgery. *Vaginal delivery* - Given the patient's history of **placenta previa**, current **painless vaginal bleeding**, and signs of **fetal distress**, a vaginal delivery is contraindicated due to the high risk of **exsanguinating hemorrhage** for the mother and severe fetal compromise. - The prior **cesarean section for placenta previa** also increases the risk of recurrent previa and **placenta accreta spectrum**, further contraindicating vaginal delivery. *Lumbar epidural block* - A **lumbar epidural block** is used for pain management during labor, but in this emergent situation with active bleeding and fetal distress, immediate delivery is paramount. - The time required to safely administer an **epidural**, along with the potential for **hypotension** in a hypovolemic patient, makes it an inappropriate next step.

Postpartum hemorrhage US Medical PG Question 8: Two days after being admitted to the hospital because of severe peripartum vaginal bleeding during a home birth, a 40-year-old woman, gravida 3, para 3, has a 30-second generalized convulsive seizure followed by unconsciousness. Prior to the event she complained of acute onset of sweating and uncontrollable shivering. She was hemodynamically unstable and required several liters of intravenous fluids and 5 units of packed red blood cells in the intensive care unit. The patient's two prior pregnancies, at ages 33 and 35, were uncomplicated. She is otherwise healthy. Prior to admission, her only medication was a daily prenatal vitamin. Temperature is 37.5°C (99.5°F), pulse is 120/min, respirations are 18/min, blood pressure is 101/61 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 96%. Examination shows very little milk expression from the breasts bilaterally. Finger-stick glucose level is 36 mg/dL. Which of the following is the most likely underlying cause of this patient's condition?

• A. Lactotrophic adenoma
• B. Hypothalamic infarction
• C. Pituitary ischemia (Correct Answer)
• D. Adrenal hemorrhage
• E. Hypoactive thyroid

Postpartum hemorrhage Explanation: ***Pituitary ischemia*** - The patient's history of **severe peripartum hemorrhage** followed by **hypotension** and **seizure** is highly suggestive of **Sheehan syndrome**, which is caused by pituitary ischemia and necrosis. - The inability to lactate (**little milk expression**) and **hypoglycemia** (finger-stick glucose 36 mg/dL) are consistent with deficiencies of **prolactin** and **adrenocorticotropic hormone (ACTH)**, respectively, due to pituitary damage. *Lactotrophic adenoma* - A lactotrophic adenoma would typically cause **hyperprolactinemia** leading to **galactorrhea** (excessive milk production), not decreased milk expression. - While it can cause headaches and visual field defects, it does not explain the peripartum onset with hemorrhage or the subsequent hypoglycemia. *Hypothalamic infarction* - While hypothalamic damage can lead to endocrine dysfunction, an isolated hypothalamic infarction is a less common cause of this constellation of symptoms immediately following severe hemorrhage. - **Pituitary infarction** is a more direct and common consequence of profound peripartum hypotension. *Adrenal hemorrhage* - **Adrenal hemorrhage** can lead to adrenal insufficiency with symptoms like hypotension, hypoglycemia, and shock. - However, it does not explain the specific symptom of **agalactorrhea** (little milk expression), which points to pituitary involvement. *Hypoactive thyroid* - A **hypoactive thyroid (hypothyroidism)** can cause fatigue, bradycardia, and sometimes hypoglycemia, but it typically does not present with an acute seizure or agalactorrhea in the immediate postpartum period following hemorrhage. - The acute presentation here is more consistent with a sudden and severe endocrine insult affecting multiple axes.

Postpartum hemorrhage US Medical PG Question 9: A 31-year-old G6P6 woman with a history of fibroids gives birth to twins via vaginal delivery. Her pregnancy was uneventful, and she reported having good prenatal care. Both placentas are delivered immediately after the birth. The patient continues to bleed significantly over the next 20 minutes. Her temperature is 97.0°F (36.1°C), blood pressure is 124/84 mmHg, pulse is 95/min, respirations are 16/min, and oxygen saturation is 98% on room air. Continued vaginal bleeding is noted. Which of the following is the most appropriate initial step in management?

• A. Oxytocin
• B. Blood product transfusion
• C. Uterine artery embolization
• D. Hysterectomy
• E. Bimanual massage (Correct Answer)

Postpartum hemorrhage Explanation: ***Bimanual massage*** - The patient is experiencing **postpartum hemorrhage (PPH)**, indicated by significant bleeding post-delivery. **Uterine atony** is the most common cause of PPH, and bimanual massage helps stimulate uterine contractions to reduce bleeding. - This is a **first-line, non-pharmacological intervention** that can be rapidly initiated to manage uterine atony. *Oxytocin* - While **oxytocin** is a uterotonic agent used to treat PPH, the initial step is typically **bimanual massage** to physically stimulate the uterus while preparing for medication administration. - Oxytocin infusion would be administered concurrent with or immediately following bimanual massage, but manual compression is often initiated first. *Blood product transfusion* - Blood product transfusion is indicated for significant blood loss and hemodynamic instability, but it is a **supportive measure** rather than an initial intervention to stop the bleeding. - The patient's current **blood pressure (124/84 mmHg)** and **pulse (95/min)** do not immediately suggest severe hypovolemic shock requiring immediate transfusion as the *first* step before attempting to control the source of bleeding. *Uterine artery embolization* - **Uterine artery embolization** is a highly invasive procedure typically reserved for cases where conservative measures, including uterotonic agents and bimanual compression, have failed to control PPH. - It is not an appropriate initial step, as it requires specialized equipment and personnel and would delay immediate management of active bleeding. *Hysterectomy* - **Hysterectomy** is a last-resort intervention for intractable PPH that cannot be controlled by all other methods, including uterotonics, uterine massage, and other surgical or interventional radiology techniques. - It is a highly invasive procedure with significant morbidity and is not considered an initial management step.

Postpartum hemorrhage US Medical PG Question 10: A 30-year-old woman, gravida 2, para 1, abortus 1, comes to the physician because of failure to conceive for 12 months. She is sexually active with her husband 2–3 times per week. Her first child was born at term after vaginal delivery 2 years ago. At that time, the postpartum course was complicated by hemorrhage from retained placental products, and the patient underwent dilation and curettage. Menses occur at regular 28-day intervals and previously lasted for 5 days with normal flow, but now last for 2 days with significantly reduced flow. She stopped taking oral contraceptives 1 year after the birth of her son. Her vital signs are within normal limits. Speculum examination shows a normal vagina and cervix. The uterus is normal in size, and no adnexal masses are palpated. Which of the following is the most appropriate next step in management?

• A. Hysteroscopy with potential adhesiolysis (Correct Answer)
• B. Measurement of serum FSH and LH concentrations
• C. Measurement of antisperm antibody concentration
• D. Dilation and curettage
• E. Estrogen/progestin withdrawal test

Postpartum hemorrhage Explanation: ***Hysteroscopy with potential adhesiolysis*** - The patient's history of **postpartum hemorrhage** requiring D&C, followed by significantly **reduced menstrual flow**, strongly suggests **intrauterine adhesions (Asherman's syndrome)**. - **Hysteroscopy** is the definitive diagnostic and therapeutic procedure for Asherman's syndrome, allowing direct visualization and surgical lysis of adhesions. *Measurement of serum FSH and LH concentrations* - This step is typically used to evaluate **ovarian reserve** or **hypothalamic-pituitary-ovarian axis dysfunction** in cases of anovulation or primary ovarian insufficiency. - Given the patient's regular menstrual cycles, ovulatory dysfunction is less likely to be the primary cause of her infertility symptoms. *Measurement of antisperm antibody concentration* - **Antisperm antibodies** are a cause of infertility in a small percentage of couples, affecting sperm function or fertilization. - This test is usually pursued after more common causes of infertility have been ruled out, as there are stronger indicators for Asherman's syndrome in this case. *Dilation and curettage* - A **D&C** was previously performed and is the likely iatrogenic cause of her current symptoms (Asherman's syndrome). - Performing another D&C without addressing the adhesions would likely worsen her condition and lead to further scarring. *Estrogen/progestin withdrawal test* - This test assesses the integrity of the **endometrium** and the presence of sufficient endogenous estrogen if a patient has **amenorrhea**, as bleeding after withdrawal indicates a responsive endometrium. - The patient has regular, albeit reduced, menstrual cycles, making this test less relevant for her specific symptoms.

Postpartum hemorrhage Flashcard 1 of 10

Question: Pregnancy-related infarction of the pituitary gland (Sheehan syndrome) often occurs following _____

Answer: postpartum bleeding

Postpartum hemorrhage Flashcard 2 of 10

Question: What is the treatment for postpartum blues? _____

Answer: Supportive

Postpartum hemorrhage Flashcard 3 of 10

Question: retained placental tissue

Answer:

Extra Information: postpartum hemorrhage or infection

Postpartum hemorrhage Flashcard 4 of 10

Question: Identify 2

Answer: uterine artery and vein

Postpartum hemorrhage Flashcard 5 of 10

Question: What sexual changes are common in elderly women?

Answer: vaginal shortening, thinning, and dryness

Postpartum hemorrhage Flashcard 6 of 10

Question: Placenta accreta often requires _____ after delivery due to attachment of the placenta to the uterus

Answer: hysterectomy

Extra Information:   * Hysterectomy is the surgical removal of the uterus Watch Gestational Disorders [https://dashboard.sketchy.com/study/medical/courses/medical-pathophysiology/units/medical-pathophysiology-reproductive-gu/videos/medical-pathophysiology-reproductive-and-gu-gestational-disorders-gestational-disorders?utm_source=anki&utm_medium=partnership&utm_campaign=february_update&utm_content=medical]Watch associated Bootcamp video [https://app.bootcamp.com/med-school/reproduction/videos/pathology-of-pregnancy?index=8] https://onlinemeded.org?ref=anki 

Postpartum hemorrhage Flashcard 7 of 10

Question: Acute (lactational) mastitis is associated with _____

Answer: breast feeding

Extra Information:   Watch Benign Breast Disorders [https://dashboard.sketchy.com/study/medical/courses/medical-pathophysiology/units/medical-pathophysiology-reproductive-gu/videos/medical-pathophysiology-reproductive-and-gu-breast-benign-breast-disorders?utm_source=anki&utm_medium=partnership&utm_campaign=february_update&utm_content=medical] https://onlinemeded.org?ref=anki 

Postpartum hemorrhage Flashcard 8 of 10

Question: Treatment for acute (lactational) mastitis is _____ plus _____

Answer: continued drainage (e.g. feeding)

Extra Information:   Watch Benign Breast Disorders [https://dashboard.sketchy.com/study/medical/courses/medical-pathophysiology/units/medical-pathophysiology-reproductive-gu/videos/medical-pathophysiology-reproductive-and-gu-breast-benign-breast-disorders?utm_source=anki&utm_medium=partnership&utm_campaign=february_update&utm_content=medical] https://onlinemeded.org/spa/obgyn?ref=anki Clogged milk ducts → flu-like symptoms, focal unilateral breast pain with erythema/induration and axillary lymphadenopathy 

Postpartum hemorrhage Flashcard 9 of 10

Question: What is the likely diagnosis in a 6-month postpartum woman that presents with irregular vaginal bleeding, an enlarged uterus, and dyspnea with multiple infiltrates on CXR? _____

Answer: Choriocarcinoma

Extra Information:  Watch Hydatidiform Mole & Choriocarcinoma [https://dashboard.sketchy.com/study/medical/courses/medical-pathophysiology/units/medical-pathophysiology-reproductive-gu/videos/medical-pathophysiology-reproductive-and-gu-gestational-disorders-hydatidiform-mole-and-choriocarcinoma?utm_source=anki&utm_medium=partnership&utm_campaign=february_update&utm_content=medical] Watch Hydatidiform Mole & Choriocarcinoma [https://dashboard.sketchy.com/study/medical/courses/medical-pathophysiology/units/medical-pathophysiology-reproductive-gu/videos/medical-pathophysiology-reproductive-and-gu-gestational-disorders-hydatidiform-mole-and-choriocarcinoma?utm_source=anki&utm_medium=partnership&utm_campaign=february_update&utm_content=medical] https://onlinemeded.org?ref=anki 

Postpartum hemorrhage Flashcard 10 of 10

Question: Severe hemorrhage during pregnancy or after delivery may lead to _____ and/or hypovolemic shock

Answer: DIC

Extra Information:  Watch Gestational Disorders [https://dashboard.sketchy.com/study/medical/courses/medical-pathophysiology/units/medical-pathophysiology-reproductive-gu/videos/medical-pathophysiology-reproductive-and-gu-gestational-disorders-gestational-disorders?utm_source=anki&utm_medium=partnership&utm_campaign=february_update&utm_content=medical] Watch Gestational Disorders [https://dashboard.sketchy.com/study/medical/courses/medical-pathophysiology/units/medical-pathophysiology-reproductive-gu/videos/medical-pathophysiology-reproductive-and-gu-gestational-disorders-gestational-disorders?utm_source=anki&utm_medium=partnership&utm_campaign=february_update&utm_content=medical] https://onlinemeded.org?ref=anki