Secondary Postpartum Hemorrhage — MCQs
Active management of 3rd stage of labour involves all EXCEPT:
A 28-year-old postpartum woman presents with uterine atony and heavy bleeding. Which medication should be avoided due to a history of hypertension?
Which drug is contraindicated before delivery of the baby (during first and second stages of labor)?
A multigravida woman in labor room, after delivery and placenta removal, uncontrolled bleeding was seen. What is the most common cause of PPH in this woman?
A 28-year-old woman, G2 P1, with severe PPH unresponsive to oxytocin presents with hypotension and tachycardia. She has a soft uterus and ongoing bleeding. What is the next best step in management?
Which of the following statements is false regarding postpartum hemorrhage and pelvic hematomas?
A multiparous woman delivered by a village dai (midwife) presents on the 22nd postnatal day with bleeding per vaginum with clots. On examination, the uterus is 14-16 weeks, the internal os is open, and there is bleeding through the os. The likely cause of this bleeding is
Most common cause of secondary PPH is :
What is the primary use of prophylactic methergin?
Most probable cause of heavy bleeding in a P2L2 during tenth day post partum is:
Secondary Postpartum Hemorrhage Indian Medical PG Practice Questions and MCQs
Question 1: Active management of 3rd stage of labour involves all EXCEPT:
- A. IV oxytocin
- B. Delayed cord clamping
- C. Controlled cord traction
- D. Uterine massage (Correct Answer)
Explanation: ***Uterine massage*** - **Uterine massage** is performed *after* the delivery of the placenta to promote sustained uterine contraction and prevent **postpartum hemorrhage**. - While it's a crucial step in preventing excessive bleeding, it is not considered part of the *active management of the third stage of labor* as defined by WHO guidelines, which focuses on interventions *during* placental separation and expulsion. - Uterine massage is part of **routine postpartum care** rather than AMTSL itself. *IV oxytocin* - Administering **prophylactic uterotonic** (oxytocin 10 IU IM/IV) *immediately* after birth of the baby (within 1 minute) is a **core component** of active management. - Oxytocin stimulates uterine contractions to aid placental separation and significantly **reduces postpartum hemorrhage** risk. *Delayed cord clamping* - **Delayed cord clamping** (clamping the umbilical cord between 1-3 minutes after birth) is recommended by **current WHO guidelines** as part of active management. - This practice provides neonatal benefits (improved iron stores, better hemoglobin levels) while not increasing maternal hemorrhage risk. - This replaced the older practice of early cord clamping in modern AMTSL protocols. *Controlled cord traction* - **Controlled cord traction** with **counter-traction on the uterus** (Brandt-Andrews maneuver) is performed to facilitate placental delivery once signs of placental separation appear. - This maneuver **reduces the duration of third stage**, blood loss, and risk of retained placenta.
Question 2: A 28-year-old postpartum woman presents with uterine atony and heavy bleeding. Which medication should be avoided due to a history of hypertension?
- A. Carboprost
- B. Misoprostol
- C. Oxytocin
- D. Methylergonovine (Correct Answer)
Explanation: ***Methylergonovine*** - **Methylergonovine** is contraindicated in patients with **hypertension** due to its potent vasoconstrictive effect, which can lead to a hypertensive crisis, stroke, or myocardial infarction. - This medication should be avoided in a postpartum woman with a history of hypertension to prevent severe cardiovascular complications while treating uterine atony. *Carboprost* - **Carboprost** is a prostaglandin F2-alpha analog that can cause **bronchoconstriction** and is contraindicated in patients with asthma. - While it can cause transient hypertension, it is generally considered safer than methylergonovine in patients with a history of hypertension. *Misoprostol* - **Misoprostol** is a synthetic prostaglandin E1 analog that can be safely used in patients with hypertension. - Its primary side effects include **diarrhea**, shivering, and fever, rather than significant cardiovascular effects. *Oxytocin* - **Oxytocin** is the first-line uterotonic agent for preventing and treating postpartum hemorrhage and is safe to use in patients with hypertension. - While large doses can cause **hypotension** and **tachycardia**, it does not typically exacerbate pre-existing hypertension.
Question 3: Which drug is contraindicated before delivery of the baby (during first and second stages of labor)?
- A. Mifepristone
- B. Oxytocin
- C. Misoprostol
- D. Ergometrine (Correct Answer)
Explanation: ***Ergometrine*** - **Ergometrine** is a potent uterotonic agent that causes **tetanic (sustained) uterine contractions**. - It is **absolutely contraindicated before delivery of the baby** (during first and second stages of labor) because: - Sustained contractions lead to **fetal hypoxia** and **fetal distress** by reducing placental blood flow - Risk of **uterine rupture** due to excessive uterine tone - **Obstructed labor** and **cervical lacerations** from forcing delivery against sustained contraction - Ergometrine is **only used after delivery of the baby** in the third stage for active management and prevention of postpartum hemorrhage. *Mifepristone* - **Mifepristone** is an antiprogesterone used for medical abortion in early pregnancy or cervical ripening before labor induction. - It is not relevant during active labor as it acts by blocking progesterone receptors, not by causing immediate uterine contractions. *Oxytocin* - **Oxytocin** is the drug of choice for induction and augmentation of labor. - It causes **rhythmic, intermittent contractions** that allow for adequate placental perfusion between contractions. - Safe to use during first and second stages when properly monitored. *Misoprostol* - **Misoprostol** is a prostaglandin E1 analog used for cervical ripening and labor induction. - Can be used before and during labor for induction, though requires careful monitoring. - Unlike ergometrine, it does not cause sustained tetanic contractions when used in appropriate doses.
Question 4: A multigravida woman in labor room, after delivery and placenta removal, uncontrolled bleeding was seen. What is the most common cause of PPH in this woman?
- A. Clotting factor deficiency
- B. Atony (Correct Answer)
- C. Traumatic PPH
- D. Retained tissues
Explanation: ***Atonic*** - **Uterine atony** is the most common cause of **postpartum hemorrhage (PPH)**, accounting for approximately 70-80% of cases. The uterus fails to contract adequately after placental delivery, leading to continuous bleeding from the placental bed. - Risk factors for uterine atony include multiparity, prolonged labor, rapid labor, polyhydramnios, and multiple gestations, which can lead to overdistension and fatigue of the uterine muscle. *Clotting factor deficiency* - While **coagulopathies** (clotting factor deficiencies) can cause PPH, they are a less common primary cause than uterine atony. - This cause would be suspected if there is a history of bleeding disorders, liver disease, or if PPH persists despite a well-contracted uterus. *Traumatic PPH* - **Traumatic PPH** results from lacerations of the cervix, vagina, or perineum, or from uterine rupture. These are less common than uterine atony. - This cause is typically suspected when the uterus feels firm but bleeding continues, or when visible trauma is present. *Retained tissues* - **Retained placental tissue** can prevent the uterus from contracting effectively, leading to PPH. However, it is less common than atony. - This cause is usually identified by the presence of placental fragments or membranes in the uterine cavity upon examination.
Question 5: A 28-year-old woman, G2 P1, with severe PPH unresponsive to oxytocin presents with hypotension and tachycardia. She has a soft uterus and ongoing bleeding. What is the next best step in management?
- A. IM carboprost (Correct Answer)
- B. Immediate hysterectomy
- C. Expectant management
- D. IV tranexamic acid
Explanation: ***IM carboprost*** - The **soft uterus** with ongoing bleeding despite oxytocin indicates **uterine atony** as the cause of PPH - Carboprost (PGF2α) is the **standard second-line uterotonic agent** after oxytocin failure - Effectively stimulates strong **uterine contractions** to control hemorrhage from the placental bed - Given intramuscularly at **0.25 mg every 15-90 minutes** (maximum 8 doses) - Contraindicated in active cardiac, pulmonary, or hepatic disease *Immediate hysterectomy* - Peripartum hysterectomy is a **last-resort surgical intervention** for refractory PPH - Should only be performed after failure of medical management (all uterotonics) and conservative surgical options (uterine tamponade, uterine artery ligation, B-Lynch suture) - **Too aggressive** as the immediate next step when second-line uterotonics haven't been tried *Expectant management* - **Completely inappropriate** for severe PPH with hemodynamic instability (hypotension, tachycardia) - Ongoing bleeding from uterine atony requires **immediate aggressive intervention** - Delays increase risk of hypovolemic shock, DIC, maternal morbidity, and mortality *IV tranexamic acid* - **Antifibrinolytic agent** that inhibits plasminogen activation, promoting clot stability - WHO recommends administration **within 3 hours** of PPH onset as an adjunct therapy - While useful in PPH management, it does **not address uterine atony** (the primary cause indicated by soft uterus) - Should be given **in addition to uterotonics**, not as a substitute for definitive management of atony
Question 6: Which of the following statements is false regarding postpartum hemorrhage and pelvic hematomas?
- A. The vulva is the most common site for pelvic hematoma. (Correct Answer)
- B. Hematomas less than 5 cm can often be managed conservatively.
- C. Uterine atony is the most common cause of postpartum hemorrhage.
- D. The most common artery to form a vulvar hematoma is the pudendal artery.
Explanation: ***The vulva is the most common site for pelvic hematoma.*** - While vulvar hematomas are common, the **vagina is actually the most common site** for puerperal hematomas. - **Retroperitoneal hematomas** are the least common but most dangerous type, often associated with a higher mortality rate due to delayed diagnosis. *Hematomas less than 5 cm can often be managed conservatively.* - **Small, stable hematomas** (typically less than 2-5 cm) that are not expanding can often be managed with observation, pain control, and ice packs. - Close monitoring for continued bleeding, signs of infection, or hemodynamic instability is crucial even with conservative management. *Uterine atony is the most common cause of postpartum hemorrhage.* - **Uterine atony** (failure of the uterus to contract after birth) accounts for approximately 70-80% of all cases of postpartum hemorrhage. - This condition leads to excessive bleeding from the placental site due to the inability of uterine muscle fibers to compress blood vessels effectively. *The most common artery to form a vulvar hematoma is the pudendal artery.* - Vulvar hematomas primarily arise from injury to branches of the **pudendal artery**, particularly during lacerations or episiotomies. - Trauma to the **perineum** during childbirth can cause these arteries or their venous counterparts to bleed into the surrounding loose connective tissue.
Question 7: A multiparous woman delivered by a village dai (midwife) presents on the 22nd postnatal day with bleeding per vaginum with clots. On examination, the uterus is 14-16 weeks, the internal os is open, and there is bleeding through the os. The likely cause of this bleeding is
- A. Perineal tears
- B. Retained bits of placenta and membranes (Correct Answer)
- C. Excessive postnatal physical work
- D. Uterine atony
Explanation: ***Retained bits of placenta and membranes*** - Postnatal bleeding with clots on day 22, an enlarged uterus (14-16 weeks size), and an open internal os are **classic features of retained products of conception**. - Retained placental fragments prevent proper **uterine involution** and interfere with myometrial contraction, leading to **secondary postpartum hemorrhage** (PPH occurring after 24 hours up to 12 weeks postpartum). - The open internal os with bleeding through it strongly suggests intrauterine retained tissue. *Perineal tears* - Perineal tears cause **immediate postpartum bleeding**, typically bright red and continuous, identified and repaired at the time of delivery. - They would **not explain** an enlarged uterus, subinvolution, or delayed bleeding with clots on **day 22 postpartum**. *Excessive postnatal physical work* - While physical overexertion may delay recovery or cause fatigue, it does **not directly cause vaginal bleeding with clots** and an enlarged uterus. - This clinical presentation requires an **obstetric pathology** such as retained products. *Uterine atony* - Uterine atony is the most common cause of **primary PPH** (within 24 hours of delivery), presenting with a soft, boggy uterus and profuse bleeding. - However, on day 22 with an **open os and retained tissue**, the primary issue is retained products rather than atony alone.
Question 8: Most common cause of secondary PPH is :
- A. Retained placenta (Correct Answer)
- B. Cervical tear
- C. Uterine atony
- D. Vaginal laceration
Explanation: ***Retained placenta*** - Retained placental tissue prevents the uterus from contracting effectively, leading to continued bleeding after delivery. - While it's a common cause of primary PPH as well, it often presents as a secondary PPH when small fragments remain and later detach or become infected. *Uterine atony* - This is the **most common cause of primary PPH**, occurring within 24 hours of delivery due to the uterus failing to contract. - It is less likely to be the primary cause of secondary PPH unless there's a delayed presentation. *Vaginal laceration* - Lacerations of the vagina usually present as **primary PPH**, with bright red blood despite a well-contracted uterus. - While bleeding can persist, it's not the most common cause of delayed, secondary PPH. *Cervical tear* - Cervical tears also typically cause **primary PPH**, characterized by continuous bleeding immediately after delivery. - Similar to vaginal lacerations, while continuous bleeding can occur, it's not the most common etiology for secondary PPH.
Question 9: 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 10: Most probable cause of heavy bleeding in a P2L2 during tenth day post partum is:
- A. Infected episiotomy wound
- B. Resumption of menstruation
- C. Retained bits of cotyledons and membranes (Correct Answer)
- D. Subinvolution of placental site
Explanation: ***Retained bits of cotyledons and membranes*** - **Retained placental fragments** prevent the uterus from contracting effectively, leading to uterine atony and heavy bleeding. - This typically presents as secondary postpartum hemorrhage, which occurs **24 hours to 6 weeks postpartum**, consistent with bleeding on the tenth day. *Infected episiotomy wound* - An infected episiotomy wound would primarily cause **local pain**, **swelling**, **redness**, and **purulent discharge**, not heavy uterine bleeding. - While infection can exacerbate pain and discomfort, it does not directly lead to **prolonged or excessive uterine hemorrhage**. *Resumption of menstruation* - Menstruation typically resumes much later postpartum, especially in breastfeeding individuals, often **months after delivery**. - Bleeding on the tenth day is likely related to the **postpartum state** and not a return to normal menstrual cycles. *Subinvolution of placental site* - Subinvolution refers to the failure of the uterus to return to its normal size and state, which can cause **prolonged lochia** and bleeding. - While a possible cause of later postpartum bleeding, **retained placental tissue** is a more direct and common cause for significant hemorrhage on the tenth day.
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