Postpartum Depression and Psychiatric Disorders — MCQs
Maximum maternal mortality during peripartum period occurs at -
A 30-year-old woman has experienced the loss of her newborn. She is currently producing breast milk leading to discomfort and the risk of developing a breast abscess due to milk stasis and incomplete emptying. Which of the following drugs can be used to prevent this complication?
According to DSM-5 criteria, symptoms of brief psychotic disorder must resolve within what time period to differentiate it from longer-term psychotic conditions like schizophreniform disorder?
Which condition is responsible for approximately a quarter of postnatal maternal deaths?
Commonest cause for puerperal sepsis is :
What is the primary use of prophylactic methergin?
What is the correct order of ligation for devascularization in the management of Postpartum Hemorrhage (PPH)?
In Peripartum cardiomyopathy, cardiac failure occurs at:-
A 24-year-old woman who had a home delivery 2 weeks ago now presents with a complete perineal tear. What is the next line of management?
A 34-year-old lady with 4 children, after her 5th normal vaginal delivery, experiences excessive bleeding after the placenta is removed. What is the cause for this?
Postpartum Depression and Psychiatric Disorders Indian Medical PG Practice Questions and MCQs
Question 1: Maximum maternal mortality during peripartum period occurs at -
- A. Last trimester
- B. During labor
- C. Immediate post-partum (Correct Answer)
- D. Delayed post-partum
Explanation: ***Immediate post-partum*** - The **immediate postpartum period** (first 24 hours after birth) is considered the most critical time for maternal mortality, accounting for approximately **45-50% of all maternal deaths**. - Primary causes include **postpartum hemorrhage** (leading cause, responsible for ~25% of maternal deaths globally), **eclampsia**, and **amniotic fluid embolism**. - This phase involves significant physiological changes and potential complications arising directly from the birthing process, with risks being highest in the first few hours after delivery. *Last trimester* - While the **last trimester** carries risks such as pre-eclampsia, gestational diabetes, and thrombosis, the overall mortality rate is lower compared to the immediate postpartum period. - Many of the complications arising in late pregnancy are either manageable with proper antenatal care or culminate in critical events during or just after delivery. *During labor* - **Maternal mortality during labor** can occur due to complications like obstructed labor, uterine rupture, or severe pre-eclampsia. However, modern obstetric care with active management aims to identify and manage these issues promptly. - Many *intrapartum* complications often lead to adverse outcomes that extend into the immediate postpartum phase, where the majority of deaths are recorded. *Delayed post-partum* - The **delayed postpartum period** (from 24 hours up to 6 weeks after birth) still carries risks such as infections (puerperal sepsis), venous thromboembolism, and peripartum cardiomyopathy, but the incidence of acute, life-threatening events is significantly lower than in the immediate postpartum period. - Mortalities during this period are often related to complications that develop or worsen over time, rather than acute events directly from birth.
Question 2: A 30-year-old woman has experienced the loss of her newborn. She is currently producing breast milk leading to discomfort and the risk of developing a breast abscess due to milk stasis and incomplete emptying. Which of the following drugs can be used to prevent this complication?
- A. Cabergoline (Correct Answer)
- B. Chlorpromazine
- C. Metoclopramide
- D. Mifepristone
Explanation: ***Cabergoline*** - **Cabergoline** is a dopamine agonist that inhibits prolactin secretion, thereby suppressing lactation and preventing breast engorgement and its complications after childbirth. - It has a longer duration of action compared to bromocriptine, allowing for less frequent dosing and better patient compliance in lactation suppression. *Chlorpromazine* - **Chlorpromazine** is an antipsychotic medication primarily used to treat psychotic disorders; it doesn't suppress lactation. - While it can cause hyperprolactinemia as a side effect due to its antidopaminergic action, it is not used to manage lactation or its complications. *Metoclopramide* - **Metoclopramide** is a dopamine receptor antagonist that *increases* prolactin levels, and is sometimes used to *stimulate* lactation, not suppress it. - It enhances gastrointestinal motility and is primarily used as an antiemetic or for gastric emptying disorders. *Mifepristone* - **Mifepristone** is a progesterone receptor antagonist primarily used for medical abortion and induction of labor. - It is not indicated for the suppression of lactation or the prevention of breast engorgement.
Question 3: According to DSM-5 criteria, symptoms of brief psychotic disorder must resolve within what time period to differentiate it from longer-term psychotic conditions like schizophreniform disorder?
- A. 1 week
- B. 3 weeks
- C. 2 weeks
- D. 1 month (Correct Answer)
Explanation: ***1 month*** - According to **DSM-5 criteria**, brief psychotic disorder is characterized by symptoms lasting more than **1 day** but less than **1 month**. - If psychotic symptoms persist for **1 month or longer**, it indicates a different diagnosis, such as schizophreniform disorder or schizophrenia, requiring further evaluation. *1 week* - While psychotic symptoms may be present for 1 week in brief psychotic disorder, this duration is within the disorder's diagnostic window but not its defining upper limit. - The key differentiator for brief psychotic disorder is that symptoms resolve within **1 month**. *2 weeks* - Similar to 1 week, 2 weeks is a duration that can occur within brief psychotic disorder, but it does not represent the minimum duration that distinguishes it from longer-term conditions. - The crucial threshold for duration in brief psychotic disorder is **less than 1 month**. *3 weeks* - Three weeks also falls within the diagnostic duration for brief psychotic disorder. - The essential criteria specify that psychotic symptoms must last **less than 1 month** to be classified as brief psychotic disorder.
Question 4: Which condition is responsible for approximately a quarter of postnatal maternal deaths?
- A. Eclampsia
- B. Anemia
- C. Infection
- D. Postpartum hemorrhage (PPH) (Correct Answer)
Explanation: ***Postpartum hemorrhage (PPH)*** - **Postpartum hemorrhage (PPH)** is the leading cause of maternal mortality worldwide, accounting for roughly a quarter of all postnatal maternal deaths. - PPH is defined as a blood loss of **500 mL or more** within 24 hours after vaginal birth, or **1000 mL or more** after a Cesarean section, and can lead to hypovolemic shock and death if not promptly managed. *Infection* - **Maternal infections**, such as puerperal sepsis, are a significant cause of maternal mortality but typically rank after PPH in overall incidence. - While infections contribute to postnatal deaths, they do not account for as high a proportion as PPH. *Eclampsia* - **Eclampsia** is a severe complication of pre-eclampsia, characterized by seizures, and is a major cause of maternal mortality and morbidity. - Though serious, its contribution to overall maternal deaths, while substantial, is less than that of PPH globally. *Anemia* - **Anemia** in the postpartum period can exacerbate other complications and increase the risk of maternal morbidity, but it is rarely a direct cause of maternal death on its own. - Severe anemia can lower the threshold for adverse outcomes from blood loss or infection but is not a primary cause of death at the same rate as PPH.
Question 5: Commonest cause for puerperal sepsis is :
- A. Gonococci
- B. Staphylococci
- C. Streptococci (Correct Answer)
- D. Anaerobes
Explanation: ***Streptococci*** - **Streptococci**, particularly **Group A Streptococcus (GAS/Streptococcus pyogenes)** and **Group B Streptococcus (GBS)**, are the **most common causative organisms** of puerperal sepsis in modern obstetric practice. - **Group A Streptococcus** causes severe, rapidly progressive puerperal sepsis with high morbidity and is the **leading bacterial cause** historically and currently. - **Group B Streptococcus** commonly colonizes the genital tract and frequently causes postpartum endometritis and sepsis. - These organisms can invade through the **placental site** and **cervical/vaginal lacerations** during delivery. *Anaerobes* - **Anaerobic bacteria** (e.g., *Bacteroides fragilis*, anaerobic streptococci) are important pathogens but typically cause **polymicrobial infections** rather than being the single most common cause. - They thrive in devitalized tissue and are often isolated **in combination with aerobic organisms**. - While significant in complicated cases, they are **not the most common single cause** in contemporary practice. *Staphylococci* - **Staphylococcus aureus** typically causes **wound infections** (cesarean section sites), **mastitis**, and occasionally toxic shock syndrome. - They are less commonly the primary cause of intrauterine puerperal sepsis compared to streptococci. *Gonococci* - **Neisseria gonorrhoeae** causes **pelvic inflammatory disease (PID)** and can lead to postpartum endometritis in untreated cases. - It is **not a common cause** of puerperal sepsis as most pregnant women are screened and treated during antenatal care. - More associated with **sexually transmitted infections** than typical postpartum infections.
Question 6: What is the primary use of prophylactic methergin?
- A. None of the options
- B. Induction of labour
- C. Induction of abortion
- D. To stop excess bleeding from uterus (Correct Answer)
Explanation: ***To stop excess bleeding from uterus*** - **Methergin (Methylergonovine)** is an **ergot alkaloid** that causes strong contractions of the **uterus**. - Its primary prophylactic use is to **prevent or treat postpartum hemorrhage** by contracting the uterus and compressing blood vessels. *Induction of labour* - **Methergin** is generally **contraindicated for labor induction** as its potent, sustained contractions can cause **hypertonic uterine dysfunction** and fetal distress. - **Oxytocin** is the preferred agent for **labor induction** due to its more physiological contraction pattern. *Induction of abortion* - While methergin can cause uterine contractions, it is **not the primary agent for abortion induction**. - **Prostaglandins (e.g., misoprostol)** and other pharmacological agents are typically used in combination for **medical abortion**. *None of the options* - This option is incorrect because **stopping excess uterine bleeding** is indeed a primary use of prophylactic methergin, particularly in the postpartum period. - The other options describe situations where methergin is either not indicated or is a secondary/contraindicated choice.
Question 7: What is the correct order of ligation for devascularization in the management of Postpartum Hemorrhage (PPH)?
- A. Uterine artery, internal iliac, obturator artery
- B. Uterine artery, pudendal artery, vaginal artery
- C. Uterine artery, ovarian artery, vaginal artery
- D. Uterine artery, ovarian artery, internal iliac artery (Correct Answer)
Explanation: ***Uterine artery, ovarian artery, internal iliac artery*** - Ligation of the **uterine artery** is typically the first step due to its primary role in supplying the uterus. It often resolves PPH. - If PPH persists, the next step is typically bilateral ligation of the **ovarian arteries**, followed by the **internal iliac arteries (hypogastric arteries)**. This sequence progressively reduces blood flow to the uterus while preserving collateral circulation as much as possible. *Uterine artery, internal iliac, obturator artery* - While initial ligation of the **uterine artery** is correct, the **obturator artery** is not a primary target for devascularization in PPH management. - The obturator artery mainly supplies the thigh and pelvic floor, and its ligation would not significantly impact uterine blood flow in the context of PPH. *Uterine artery, pudendal artery, vaginal artery* - **Uterine artery** ligation is appropriate, but the **pudendal artery** is not typically ligated for PPH; it supplies the perineum and external genitalia. - While the **vaginal artery** supplies part of the lower uterus and vagina, it is usually addressed after or in conjunction with the hypogastric arteries if uterine and ovarian vessel ligation is insufficient, and not before ovarian arteries. *Uterine artery, ovarian artery, vaginal artery* - Ligation of the **uterine artery** and **ovarian artery** is correct in sequence, but the **vaginal artery** alone is usually insufficient. - The next major supply to be considered if bleeding persists after uterine and ovarian ligation would be the **internal iliac artery** to address collateral supply from other branches, not just the vaginal artery in isolation.
Question 8: In Peripartum cardiomyopathy, cardiac failure occurs at:-
- A. Within 24 months after delivery.
- B. Within 5 months after delivery. (Correct Answer)
- C. Within 6 weeks after delivery.
- D. Within 7 days after delivery.
Explanation: ***Within 5 months after delivery.*** - Peripartum cardiomyopathy (PPCM) is defined as the development of **cardiac failure** in the **last month of pregnancy** or within **5 months after delivery**, in the absence of any other identifiable cause. - Among the given options, "within 5 months after delivery" represents the **postpartum component** of the diagnostic timeframe and is the most complete answer. - This time frame is a key diagnostic criterion recognized by major cardiology societies (some recent guidelines extend this to 6 months postpartum). - **Note:** The complete definition includes both antepartum (last month of pregnancy) and postpartum (up to 5 months) periods. *Within 24 months after delivery.* - This timeframe is **too broad** and does not align with the standard diagnostic criteria for PPCM. - While some women may experience ongoing cardiac dysfunction or relapse, the initial diagnosis of PPCM is restricted to within 5 months postpartum. - Extended cardiac issues beyond 5 months may represent persistent PPCM or dilated cardiomyopathy rather than new-onset PPCM. *Within 6 weeks after delivery.* - While many cases of PPCM manifest within **6 weeks postpartum** (the traditional puerperium), this definition is **too restrictive**. - Symptoms can appear up to **5 months after delivery**, and using only 6 weeks would miss a significant proportion of cases. - This period captures the most acute presentations but doesn't encompass the entire recognized diagnostic window. *Within 7 days after delivery.* - The onset within **7 days after delivery** represents only the **immediate postpartum period** and is an overly narrow definition. - PPCM can develop much later in the postpartum period (up to 5 months), making this timeframe inadequate for diagnosis. - Using this restrictive criterion would result in many missed diagnoses.
Question 9: A 24-year-old woman who had a home delivery 2 weeks ago now presents with a complete perineal tear. What is the next line of management?
- A. Repair after 3 weeks
- B. Repair after 6 months
- C. Repair after 3 months (Correct Answer)
- D. Repair immediately
Explanation: ***Repair after 3 months*** - Delayed repair, typically after **3 to 6 months**, allows for resolution of **inflammation**, re-epithelialization of the wound edges, and softening of the scar tissue. - This timing optimizes conditions for successful surgical reconstruction by minimizing the risk of **infection** and promoting better tissue healing. *Repair after 3 weeks* - Repairing a complete perineal tear at this stage is too early as the tissue is still highly **inflamed** and prone to **infection** and **dehiscence**. - The wound bed would not have sufficiently healed or softened, making surgical repair more challenging and increasing the likelihood of poor outcomes. *Repair after 6 months* - Waiting for 6 months to repair a complete perineal tear is generally considered too long, as the tissues may become excessively **fibrotic** and less amenable to successful reconstruction. - While sometimes necessary in complex cases, waiting this long can lead to prolonged discomfort and functional issues for the patient. *Repair immediately* - Immediate repair of a complete perineal tear that was missed or inadequately repaired at the time of delivery is typically not recommended several weeks postpartum due to significant **edema**, **inflammation**, and potential for **infection**. - Immediate repair is usually performed **at the time of delivery** if the tear is recognized, not two weeks later.
Question 10: A 34-year-old lady with 4 children, after her 5th normal vaginal delivery, experiences excessive bleeding after the placenta is removed. What is the cause for this?
- A. Uterine atony (Correct Answer)
- B. Genital tract trauma
- C. Retained placental tissue
- D. Coagulation disorders
Explanation: ***Uterine atony*** - The most common cause of **postpartum hemorrhage (PPH)**, accounting for 70-80% of cases - **Multiparity** (Grand multipara with 5 deliveries) is a major risk factor, as repeated pregnancies lead to **overdistension and decreased uterine muscle tone** - Uterine atony is the failure of the myometrium to contract adequately after placental delivery, preventing compression of spiral arteries - Part of the **"4 Ts" mnemonic** for PPH causes: **Tone** (atony), Trauma, Tissue, Thrombin *Genital tract trauma* - Second most common cause of PPH (approximately 20% of cases) - Includes cervical lacerations, vaginal tears, or perineal trauma - However, the question specifically mentions **"normal vaginal delivery"** and bleeding **"after placenta removal"**, making trauma less likely - Trauma-related bleeding typically occurs **during or immediately after delivery**, not specifically post-placental *Retained placental tissue* - Accounts for approximately 10% of PPH cases - The question states the placenta **"is removed"**, suggesting complete placental delivery - If placental fragments were retained, bleeding would persist due to inability of the uterus to contract fully - Less likely given the clinical scenario described *Coagulation disorders* - Least common cause of primary PPH (1-2% of cases) - Includes conditions like **DIC, thrombocytopenia, or inherited coagulopathies** - No clinical history suggesting coagulopathy (e.g., no bleeding during pregnancy, no family history) - Would typically present with **oozing from multiple sites**, not just uterine bleeding
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