A 22-year-old G4P2 at 35 weeks gestation presents to the hospital after she noticed that "her water broke." Her prenatal course is unremarkable, but her obstetric history includes postpartum hemorrhage after her third pregnancy, attributed to a retained placenta. The patient undergoes augmentation of labor with oxytocin and within four hours delivers a male infant with Apgar scores of 8 and 9 at 1 and 5 minutes, respectively. Three minutes later, the placenta passes the vagina, but a smooth mass attached to the placenta continues to follow. Her temperature is 98.6°F (37°C), blood pressure is 110/70 mmHg, pulse is 90/min, and respirations are 20/min. What is the most likely complication in the absence of intervention?
Q42
A 24-year-old woman presents to the labor and delivery floor in active labor at 40 weeks gestation. She has a prolonged course but ultimately vaginally delivers an 11 pound boy. On postpartum day 2, she is noted to have uterine tenderness and decreased bowel sounds. She states she has been urinating more frequently as well. Her temperature is 102°F (38.9°C), blood pressure is 118/78 mmHg, pulse is 111/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam is notable for a non-distended abdomen and a tender uterus. Pulmonary exam reveals minor bibasilar crackles. Initial laboratory studies and a urinalysis are pending. Which of the following is the most likely diagnosis?
Q43
A 27-year-old G2P2002 is recovering in the hospital on postpartum day 3 after a low transverse C-section. During morning rounds, she reports a “pus-like” discharge and shaking chills overnight. She also endorses increased uterine cramping compared to the day before, but her postpartum course has otherwise been uneventful with a well-healing incision and normal vaginal bleeding. The patient’s prenatal care was complicated by HIV with a recent viral load of 400 copies/mL, type I diabetes well controlled on insulin, and a history of herpes simplex virus encephalitis in her first child. She did not have any genital lesions during the most recent pregnancy. Four days ago, she presented to the obstetric triage unit after spontaneous rupture of membranes and onset of labor. She made slow cervical change and reached full dilation after 16 hours, but there was limited fetal descent. Cephalopelvic disproportion was felt to be the reason for arrest of descent, so prophylactic ampillicin was administered and C-section was performed. A vaginal hand was required to dislodge the fetus’s head from the pelvis, and a healthy baby boy was delivered. On postpartum day 3, her temperature is 101.5°F (38.6°C), blood pressure is 119/82 mmHg, pulse is 100/min, and respirations are 14/min. Her incision looks clean and dry, there is mild suprapubic tenderness, and a foul yellow discharge tinged with blood is seen on her pad. Which of the following is the most significant risk factor for this patient’s presentation?
Postpartum hemorrhage US Medical PG Practice Questions and MCQs
Question 41: A 22-year-old G4P2 at 35 weeks gestation presents to the hospital after she noticed that "her water broke." Her prenatal course is unremarkable, but her obstetric history includes postpartum hemorrhage after her third pregnancy, attributed to a retained placenta. The patient undergoes augmentation of labor with oxytocin and within four hours delivers a male infant with Apgar scores of 8 and 9 at 1 and 5 minutes, respectively. Three minutes later, the placenta passes the vagina, but a smooth mass attached to the placenta continues to follow. Her temperature is 98.6°F (37°C), blood pressure is 110/70 mmHg, pulse is 90/min, and respirations are 20/min. What is the most likely complication in the absence of intervention?
A. Hypertension
B. Hemorrhagic shock (Correct Answer)
C. Tachypnea
D. Heart failure
E. Hyperthermia
Explanation: ***Hemorrhagic shock***
- The presenting symptoms suggest **uterine inversion**, a rare but serious obstetrical emergency where the uterus turns inside out, which is usually accompanied by a **sudden gush of blood** or **postpartum hemorrhage**.
- Without immediate intervention to correct the uterine inversion and manage bleeding, the rapid and significant blood loss will lead to **hemorrhagic shock**, characterized by inadequate tissue perfusion and oxygen delivery.
*Hypertension*
- **Uterine inversion** and associated significant blood loss would typically lead to **hypotension** and shock, not hypertension.
- Hypertension in the postpartum period is usually linked to conditions like **preeclampsia** or **essential hypertension**, which are not indicated here.
*Tachypnea*
- While tachypnea can be a symptom of **hemorrhagic shock** due to metabolic acidosis and compensatory mechanisms, it is a *symptom* of the underlying problem, not the most likely primary complication itself.
- The immediate life-threatening complication from uterine inversion is **massive blood loss**, leading to shock.
*Heart failure*
- **Acute heart failure** due to uterine inversion or postpartum hemorrhage is unlikely unless the patient has pre-existing cardiac conditions or develops severe, prolonged shock leading to multi-organ dysfunction.
- The immediate concern is the **circulatory collapse** from blood loss, not primary cardiac failure.
*Hyperthermia*
- **Hyperthermia** (fever) is typically associated with **infection**, such as endometritis or chorioamnionitis, and not a direct consequence of uterine inversion or immediate postpartum hemorrhage.
- The patient's temperature is normal, indicating no infection at presentation.
Question 42: A 24-year-old woman presents to the labor and delivery floor in active labor at 40 weeks gestation. She has a prolonged course but ultimately vaginally delivers an 11 pound boy. On postpartum day 2, she is noted to have uterine tenderness and decreased bowel sounds. She states she has been urinating more frequently as well. Her temperature is 102°F (38.9°C), blood pressure is 118/78 mmHg, pulse is 111/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam is notable for a non-distended abdomen and a tender uterus. Pulmonary exam reveals minor bibasilar crackles. Initial laboratory studies and a urinalysis are pending. Which of the following is the most likely diagnosis?
A. Atelectasis
B. Chorioamnionitis
C. Deep vein thrombosis
D. Urinary tract infection
E. Endometritis (Correct Answer)
Explanation: ***Endometritis***
- The patient's presentation with **fever**, **uterine tenderness**, and a history of **prolonged labor** and **vaginal delivery** of a large infant are all strong risk factors for postpartum endometritis.
- **Decreased bowel sounds** and minor bibasilar crackles are common non-specific findings in the postpartum period, which can be seen in the context of sepsis, but **uterine tenderness** is the key finding.
*Atelectasis*
- While **bibasilar crackles** and fever can be consistent with atelectasis, it typically presents within the first 24 hours postpartum and primarily with **respiratory symptoms**.
- **Uterine tenderness** and decreased bowel sounds are not characteristic findings of atelectasis.
*Chorioamnionitis*
- This is an **intra-amniotic infection**, typically diagnosed **during labor** with maternal fever, fetal tachycardia, and uterine tenderness.
- The patient is 2 days postpartum, making acute chorioamnionitis unlikely, though prior undiagnosed chorioamnionitis during labor could increase the risk of postpartum endometritis.
*Deep vein thrombosis*
- Symptoms usually include **unilateral leg pain**, swelling, and warmth, not **uterine tenderness** or systemic signs of infection.
- While postpartum women are at increased risk for DVT, the specific constellation of symptoms points away from this diagnosis.
*Urinary tract infection*
- Although the patient reports **increased urination frequency** and a UTI can cause fever, **uterine tenderness** is not a primary symptom of UTI.
- A UTI would also typically present with dysuria, urgency, and suprapubic pain, which are not explicitly mentioned.
Question 43: A 27-year-old G2P2002 is recovering in the hospital on postpartum day 3 after a low transverse C-section. During morning rounds, she reports a “pus-like” discharge and shaking chills overnight. She also endorses increased uterine cramping compared to the day before, but her postpartum course has otherwise been uneventful with a well-healing incision and normal vaginal bleeding. The patient’s prenatal care was complicated by HIV with a recent viral load of 400 copies/mL, type I diabetes well controlled on insulin, and a history of herpes simplex virus encephalitis in her first child. She did not have any genital lesions during the most recent pregnancy. Four days ago, she presented to the obstetric triage unit after spontaneous rupture of membranes and onset of labor. She made slow cervical change and reached full dilation after 16 hours, but there was limited fetal descent. Cephalopelvic disproportion was felt to be the reason for arrest of descent, so prophylactic ampillicin was administered and C-section was performed. A vaginal hand was required to dislodge the fetus’s head from the pelvis, and a healthy baby boy was delivered. On postpartum day 3, her temperature is 101.5°F (38.6°C), blood pressure is 119/82 mmHg, pulse is 100/min, and respirations are 14/min. Her incision looks clean and dry, there is mild suprapubic tenderness, and a foul yellow discharge tinged with blood is seen on her pad. Which of the following is the most significant risk factor for this patient’s presentation?
A. HIV positive status
B. Maternal diabetes
C. C-section after onset of labor (Correct Answer)
D. Prolonged rupture of membranes
E. History of herpes simplex virus in previous pregnancy
Explanation: ### **C-section after onset of labor**
* **Intrapartum C-sections**, especially after a prolonged period of labor and ruptured membranes as seen in this patient, significantly increase the risk of **postpartum endometritis** due to increased exposure to vaginal flora and manipulation.
* The clinical picture of fever, chills, uterine tenderness, and foul-smelling lochia is highly consistent with **endometritis**, and the mode of delivery after established labor is the most significant predisposing factor in this case.
### *HIV positive status*
* While HIV can compromise the immune system, the patient's viral load of 400 copies/mL suggests **moderately controlled HIV**, and opportunistic infections of this nature are less common with such a viral load.
* Moreover, **endometritis** is primarily an ascending polymicrobial infection, where the mechanical aspects of delivery often play a more direct role than systemic immunosuppression in its pathogenesis.
### *Maternal diabetes*
* **Diabetes** does increase the risk of infection in general, including postpartum infections, due to impaired immune function and altered microvasculature.
* However, in the context of the detailed obstetric history, the **C-section performed after a prolonged labor** is a more direct and significant risk factor for endometritis than diabetes alone.
### *Prolonged rupture of membranes*
* **Prolonged rupture of membranes (PROM)**, especially combined with prolonged labor, is indeed a risk factor for **chorioamnionitis** and subsequent **endometritis**.
* In this case, the patient had ruptured membranes for four days prior to presentation, but the specific mention of "C-section after onset of labor" encompasses the additional risk conferred by **vaginal examinations** during labor and surgical trauma.
### *History of herpes simplex virus in previous pregnancy*
* A history of **herpes simplex virus (HSV)** in a previous pregnancy is relevant for neonatal infection prevention in subsequent pregnancies if active lesions are present at the time of delivery.
* However, the patient had no genital lesions during this pregnancy, and **HSV is not a direct risk factor for postpartum endometritis**.
