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?

Chorionic villi attaching to the myometrium

Chorionic villi invading into the myometrium

Placental implantation over internal cervical os

Chorionic villi attaching to the decidua basalis

Chorionic villi invading into the serosa

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?

Administer carboprost tromethamine

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?

Lack of uterine muscle contraction

Adherent placenta to myometrium

Infection of the endometrial lining of the uterus

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?

Perform uterine massage and administer oxytocin

Manually remove retained placental fragments

Perform uterine artery embolization

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?

Hysteroscopy with potential adhesiolysis

Measurement of serum FSH and LH concentrations

Measurement of antisperm antibody concentration

Estrogen/progestin withdrawal test

A 25-year-old woman comes to the emergency department one hour after the sudden onset of diffuse abdominal pain and nausea. She has no history of serious illness. Menses occur at regular 27-day intervals and last 4 to 6 days with moderate flow. Her last menstrual period was 6 weeks ago. She is sexually active with two sexual partners and uses oral contraceptive pills inconsistently. She appears pale and diaphoretic. Her temperature is 37.7°C (99.9°F), pulse is 120/min, respirations are 20/min, and blood pressure is 85/70 mm Hg. Abdominal examination shows diffuse abdominal tenderness. Pelvic examination shows a normal appearing vagina, cervix, and uterus, with right adnexal tenderness. Her hemoglobin concentration is 13 g/dL, leukocyte count is 10,000/mm3, and platelet count is 350,000/mm3. Results of a pregnancy test are pending. Which of the following is the most appropriate next step in management?

Administer intravenous normal saline fluids

Perform exploratory laparoscopy

Perform CT scan of the abdomen and pelvis with contrast

Transfuse O negative packed red blood cells

Surgical management of PPH for USMLE Step 3: High-Yield OB/GYN Lessons

Indications & Escalation - When to Cut

Trigger: Failure of medical/conservative management or persistent hemodynamic instability despite resuscitation.
Key Indications:
- Refractory uterine atony.
- Suspected uterine rupture.
- Placenta accreta spectrum.
- Significant genital tract trauma requiring surgical repair.

B-Lynch Suture Placement for Postpartum Hemorrhage

⭐ The B-Lynch suture is a uterine compression technique that can avert hysterectomy in cases of atony, thus preserving fertility. It is contraindicated in uterine rupture.

Uterine Preservation - Suture & Squeeze

Uterine Compression Sutures: A key surgical step when uterotonics and intrauterine tamponade (e.g., Bakri balloon) fail to control atonic PPH. The primary goal is mechanical compression of the myometrium to stop bleeding and preserve the uterus.
B-Lynch Suture: The most common technique.
- A single "brace-like" suture is passed from the anterior to the posterior uterine wall, compressing the fundus.
- Requires a lower segment hysterotomy for placement.
Modifications & Alternatives:
- Hayman Suture: Does not require hysterotomy; involves vertical sutures from anterior to posterior wall.
- Pereira Sutures: Uses a series of transverse and longitudinal sutures.

⭐ High-Yield: While successful in over 90% of cases, potential complications of compression sutures include uterine ischemia/necrosis, erosion of sutures into the uterine cavity, and Asherman syndrome (intrauterine adhesions).

Vascular Ligation & Hysterectomy - The Final Stops

Stepwise Devascularization: When conservative measures fail, surgical control is essential. The goal is to sequentially reduce arterial pulse pressure to the uterus.
Uterine Compression Sutures:
- The B-Lynch suture is a key technique to mechanically compress an atonic uterus, often tried before ligation.
Vascular Ligation Sequence:
- Uterine Artery Ligation: Bilateral ligation is the primary step.
- Ovarian Artery Ligation: Performed if bleeding persists after uterine artery ligation.
Hysterectomy:
- The definitive, last-resort treatment for intractable PPH.
- Ensures 100% cessation of uterine bleeding but results in permanent sterility.

⭐ The B-Lynch suture is a vital, fertility-sparing surgical technique that physically compresses the uterus, acting like an "internal bimanual massage" to control atonic PPH.

Interventional Radiology - The Embo Option

A minimally invasive option for persistent PPH in hemodynamically stable patients, preserving the uterus.

Primary Indication: Ongoing bleeding unresponsive to medical therapy & conservative surgical methods in a stable patient who desires future fertility.
Technique:
- Femoral artery access → selective catheterization of internal iliac arteries.
- Angiography identifies bleeding source (often uterine artery).
- Embolization with absorbable gelatin sponge (Gelfoam), particles, or coils.
Success Rate: >90% in controlling hemorrhage.

⭐ High-Yield: Post-embolization syndrome (fever, pain, leukocytosis) is a common, self-limiting complication that mimics infection but is managed conservatively with analgesics.

High‑Yield Points - ⚡ Biggest Takeaways

Surgical management is indicated for PPH unresponsive to medical therapy.

Uterine compression sutures (e.g., B-Lynch) are a primary uterus-preserving method.

Stepwise devascularization follows a sequence: uterine, then utero-ovarian, then internal iliac artery ligation.

Uterine artery embolization is a minimally invasive option in stable patients.

Hysterectomy is the definitive last-resort treatment, especially for placenta accreta.

Intrauterine balloon tamponade (e.g., Bakri) is a less invasive surgical step.

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