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?
AChorionic villi invading into the myometrium
BPlacental implantation over internal cervical os
CChorionic villi attaching to the decidua basalis
DChorionic villi invading into the serosa
EChorionic villi attaching to the myometrium
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?
AAdminister methylergonovine
BTransfuse blood
CPerform hysterectomy
DAdminister carboprost tromethamine
EPerform curettage
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?
AIntramuscular carboprost
BManual exploration of the uterus
CDiscontinuing oxytocin
DIntravenous methylergonovine
EUterine fundal massage
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