Risk factors for postpartum hemorrhage US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Risk factors for postpartum hemorrhage. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Risk factors for postpartum hemorrhage US Medical PG Question 1: 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)
Risk factors for 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.
Risk factors for postpartum hemorrhage US Medical PG Question 2: 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?
- A. Administer methylergonovine (Correct Answer)
- B. Transfuse blood
- C. Perform hysterectomy
- D. Administer carboprost tromethamine
- E. Perform curettage
Risk factors for postpartum hemorrhage Explanation: ***Administer methylergonovine***
- The patient is likely experiencing **postpartum hemorrhage (PPH)** due to **uterine atony**, characterized by a soft, enlarged, and boggy uterus after delivery, with continued bleeding despite initial measures (massage, oxytocin).
- Given her history of **asthma**, carboprost tromethamine (prostaglandin F2-alpha) is **contraindicated** due to its potential to cause severe bronchospasm, making methylergonovine (an ergot alkaloid) the appropriate next uterotonic agent.
*Transfuse blood*
- While blood transfusions may eventually be necessary if bleeding is severe and leads to significant hemodynamic instability or severe anemia, it is **not the immediate next step** in managing the underlying cause of the hemorrhage (uterine atony).
- **Uterotonic agents** should be tried first to contract the uterus and stop the bleeding, as indicated by the patient's current vital signs being relatively stable (pulse 90/min, BP 130/72 mm Hg).
*Perform hysterectomy*
- **Hysterectomy** is a drastic measure considered only after all less invasive medical and surgical interventions (e.g., uterotonic agents, uterine tamponade, suturing techniques) have failed to control severe PPH.
- It would be **premature** to proceed directly to hysterectomy without attempting additional medical management for uterine atony.
*Administer carboprost tromethamine*
- **Carboprost tromethamine** is a prostaglandin analog that is effective in treating uterine atony but is **contraindicated in patients with asthma** due to its known side effect of inducing bronchospasm.
- The patient's history of asthma makes this a **dangerous option**, and an alternative uterotonic like methylergonovine should be chosen.
*Perform curettage*
- **Curettage** (removing retained placental fragments) would be appropriate if the cause of PPH was **retained placental tissue**.
- However, the examination finding of a **soft, enlarged, and boggy uterus** is characteristic of uterine atony, not retained placenta, and the initial management of atony involves uterotonic agents.
Risk factors for postpartum hemorrhage US Medical PG Question 3: Immediately following prolonged delivery of the placenta at 40 weeks gestation, a 32-year-old multiparous woman develops vaginal bleeding. Other than mild asthma, the patient’s pregnancy has been uncomplicated. She has attended many prenatal appointments and followed the physician's advice about screening for diseases, laboratory testing, diet, and exercise. Previous pregnancies were uncomplicated. She has no history of a serious illness. She is currently on intravenous infusion of oxytocin. Her temperature is 37.2°C (99.0°F), blood pressure is 108/60 mm Hg, pulse is 88/min, and respirations are 17/min. Uterine palpation reveals a soft enlarged fundus that extends above the umbilicus. Based on the assessment of the birth canal and placenta, which of the following options is the most appropriate initial step in patient management?
- A. Intramuscular carboprost
- B. Manual exploration of the uterus
- C. Discontinuing oxytocin
- D. Intravenous methylergonovine
- E. Uterine fundal massage (Correct Answer)
Risk factors for postpartum hemorrhage Explanation: ***Uterine fundal massage***
- The patient presents with **postpartum hemorrhage** indicated by vaginal bleeding and a **soft, enlarged fundus** after placental delivery, suggesting **uterine atony**.
- **Uterine fundal massage** is the **first-line intervention** to encourage uterine contraction and reduce bleeding by expelling clots and compressing vessels.
*Intramuscular carboprost*
- **Carboprost** is a **prostaglandin F2 alpha analog** used to treat **uterine atony** when initial measures like uterine massage and oxytocin are insufficient.
- It is contraindicated in patients with **asthma** due to its bronchoconstrictive effects, which this patient has.
*Manual exploration of the uterus*
- **Manual exploration of the uterus** is indicated when there is suspicion of **retained placental fragments** or **uterine rupture**.
- While these can cause postpartum hemorrhage, the primary finding of a soft, boggy uterus points more strongly to atony, making massage the immediate priority.
*Discontinuing oxytocin*
- The patient is already on an **intravenous oxytocin infusion**, which is a uterotonic agent used to prevent and treat uterine atony.
- Discontinuing it would worsen **uterine atony** and increase blood loss, directly contradicting the goal of management.
*Intravenous methylergonovine*
- **Methylergonovine** is an **ergot alkaloid** used to treat **uterine atony**, but it is contraindicated in patients with **hypertension**, which is not explicitly present here, but it is a potent vasoconstrictor and second-line.
- It is often used as a **second-line agent** if oxytocin and massage are ineffective and there are no contraindications.
Risk factors for postpartum hemorrhage US Medical PG Question 4: 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)
Risk factors for 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.
Risk factors for postpartum hemorrhage US Medical PG Question 5: 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?
- A. Administer misoprostol
- B. Manually remove retained placental fragments
- C. Perform uterine massage and administer oxytocin (Correct Answer)
- D. Perform uterine artery embolization
- E. Perform hysterectomy
Risk factors for postpartum hemorrhage Explanation: ***Perform uterine massage and administer oxytocin***
- The patient's presentation of a **soft, boggy uterus** palpated 4 cm above the umbilicus after delivery, along with significant vaginal bleeding and clots, is highly indicative of **uterine atony**.
- **Uterine massage** and administration of **oxytocin** are the first-line interventions to stimulate uterine contractions and reduce bleeding by compressing placental site blood vessels.
*Administer misoprostol*
- **Misoprostol** is a prostaglandin analog that can be used for uterine atony when oxytocin is insufficient or contraindicated, but it is not the *first-line* treatment.
- Its onset of action may be slower than immediate uterine massage and IV oxytocin, which are preferred for initial management of acute uterine atony.
*Manually remove retained placental fragments*
- The question states that the **placenta was delivered spontaneously and was intact upon examination**, which makes retained placental fragments less likely as the primary cause of bleeding.
- While retained fragments can cause postpartum hemorrhage, the boggy uterus points more strongly to atony, and manual removal is indicated *after* confirming retained placental tissue.
*Perform uterine artery embolization*
- **Uterine artery embolization** is an interventional radiology procedure typically reserved for cases of postpartum hemorrhage that are refractory to conventional medical and surgical management.
- It is an invasive procedure and not the appropriate *next best step* for initial management of suspected uterine atony.
*Perform hysterectomy*
- **Hysterectomy** is a last-resort, life-saving measure for intractable postpartum hemorrhage when all other medical and surgical options have failed.
- It is a highly invasive and irreversible procedure, certainly not the *next best step* in a patient who has just begun to bleed.
Risk factors for postpartum hemorrhage US Medical PG Question 6: A 31-year-old G3P2 woman presents to labor and delivery triage because she has had bleeding over the last day. She is currently 5 months into her pregnancy and has had no concerns prior to this visit. She previously had a delivery through cesarean section and has otherwise had uncomplicated pregnancies. She denies fever, pain, and discomfort. On presentation, her temperature is 99.1°F (37.3°C), blood pressure is 110/70 mmHg, pulse is 81/min, and respirations are 15/min. Physical exam reveals an alert woman with slow, painless, vaginal bleeding. Which of the following risk factors are associated with the most likely cause of this patient's symptoms?
- A. Smoking
- B. Presence of uterine fibroids
- C. Early menarche
- D. Multiparity (Correct Answer)
- E. Pelvic inflammatory disease
Risk factors for postpartum hemorrhage Explanation: ***Multiparity***
- The patient presents with **painless vaginal bleeding** in the second trimester, indicating **placenta previa**. Multiparity is a significant risk factor for placenta previa.
- Placenta previa is more common in women who have had multiple pregnancies due to changes in the **endometrium** and previous uterine scarring.
*Smoking*
- While smoking is a risk factor for several pregnancy complications, including **placental abruption** and **preterm birth**, it is less strongly associated with placenta previa compared to other risk factors presented.
- Smoking can affect placental development and oxygenation but is not the primary risk factor for this specific presentation.
*Presence of uterine fibroids*
- Uterine fibroids (leiomyomas) can cause **bleeding in pregnancy** but are not a primary risk factor for placenta previa.
- Fibroids can interfere with placental implantation if they are submucosal or distort the uterine cavity, but the classic presentation here points more strongly to placenta previa.
*Early menarche*
- Early menarche is not a recognized risk factor for placenta previa.
- It is more commonly associated with conditions like **endometriosis** or increased lifetime exposure to estrogen, rather than placental implantation abnormalities.
*Pelvic inflammatory disease*
- PID is a risk factor for conditions such as **ectopic pregnancy** and **infertility** due to tubal damage.
- It does not directly increase the risk of placenta previa, which is a condition related to abnormal placental implantation in the uterus.
Risk factors for postpartum hemorrhage US Medical PG Question 7: A 62-year-old woman makes an appointment with her primary care physician because she recently started experiencing post-menopausal bleeding. She states that she suffered from anorexia as a young adult and has been thin throughout her life. She says that this nutritional deficit is likely what caused her to not experience menarche until age 15. She used oral contraceptive pills for many years, has never been pregnant, and experienced menopause at age 50. A biopsy of tissue inside the uterus reveals foci of both benign and malignant glandular cells. Which of the following was a risk factor for the development of the most likely cause of her symptoms?
- A. Menopause at age 50
- B. Never becoming pregnant (Correct Answer)
- C. Using oral contraceptive pills
- D. Menarche at age 15
- E. Being underweight
Risk factors for postpartum hemorrhage Explanation: ***Never becoming pregnant***
- **Nulliparity** is a significant risk factor for **endometrial cancer** as it implies longer exposure to unopposed estrogen, which stimulates endometrial proliferation.
- The diagnosis of malignant glandular cells in the context of post-menopausal bleeding strongly suggests **endometrial carcinoma**, where nulliparity contributes to increased estrogen exposure over time.
*Menopause at age 50*
- **Later age of menopause** (e.g., after 52) is a risk factor for endometrial cancer, as it prolongs the duration of estrogen exposure.
- Menopause at age 50 is considered within the **average range**, thus not typically an independent risk factor for endometrial cancer.
*Using oral contraceptive pills*
- **Combined oral contraceptive pills** (estrogen and progestin) actually **reduce the risk** of endometrial cancer.
- The progestin component in OCPs counteracts the proliferative effects of estrogen on the endometrium, offering protection.
*Menarche at age 15*
- **Early menarche** (before age 12) is a risk factor for endometrial cancer due to a longer lifetime exposure to estrogen.
- Menarche at age 15 is considered **later than average**, which would typically be a protective factor against endometrial cancer, as it shortens the duration of estrogen exposure.
*Being underweight*
- **Obesity** is a major risk factor for endometrial cancer because adipose tissue converts androgens to estrogens, leading to higher levels of circulating estrogen.
- Being underweight or having a history of anorexia does not increase the risk of endometrial cancer; in fact, it may be associated with **lower estrogen levels**, which could be protective.
Risk factors for postpartum hemorrhage US Medical PG Question 8: 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)
Risk factors for 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.
Risk factors for postpartum hemorrhage US Medical PG Question 9: 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
Risk factors for 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.
Risk factors for 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
Risk factors for 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.
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