Postpartum hemorrhage Practice Questions

Question 1

A 38-year-old woman, gravida 2, para 1, at 35 weeks' gestation comes to the emergency department because of an episode of vaginal bleeding that morning. The bleeding has subsided. She has had no prenatal care. Her previous child was delivered with a caesarean section because of a breech presentation. Her temperature is 37.1°C (98.8°F), pulse is 88/min, respirations are 14/min, and blood pressure is 125/85 mm Hg. The abdomen is nontender and the size of the uterus is consistent with a 35-week gestation. No contractions are felt. The fetal heart rate is 145/min. Her hemoglobin concentration is 12 g/dL, leukocyte count is 13,000/mm3, and platelet count is 350,000/mm3. Transvaginal ultrasound shows that the placenta covers the internal os. Which of the following is the most appropriate next step in management?

Accepted Answer

Schedule elective cesarean delivery

Answer

Observation only

Answer

Perform bimanual pelvic examination

Answer

Perform emergency cesarean delivery

Answer

Administer oxytocin to induce labor

Question 2

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?

Accepted Answer

Chorionic villi attaching to the myometrium

Answer

Chorionic villi invading into the myometrium

Answer

Placental implantation over internal cervical os

Answer

Chorionic villi attaching to the decidua basalis

Answer

Chorionic villi invading into the serosa

Question 3

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?

Accepted Answer

Lack of uterine muscle contraction

Answer

Adherent placenta to myometrium

Answer

Uterine inversion

Answer

Infection of the endometrial lining of the uterus

Answer

Uterine rupture

Question 4

A 32-year-old woman, gravida 2, para 1, at 38 weeks' gestation comes to the emergency department because of vaginal bleeding for the past hour. The patient reports that she felt contractions prior to the onset of the bleeding, but the contractions stopped after the bleeding started. She also has severe abdominal pain. Her first child was delivered by lower segment transverse cesarean section because of a nonreassuring fetal heart rate. Her pulse is 110/min, respirations are 17/min, and blood pressure is 90/60 mm Hg. Examination shows diffuse abdominal tenderness with no rebound or guarding; no contractions are felt. The fetal heart rate shows recurrent variable decelerations. Which of the following is the most likely diagnosis?

Accepted Answer

Uterine rupture

Answer

Uterine inertia

Answer

Amniotic fluid embolism

Answer

Vasa previa

Answer

Abruptio placentae

Question 5

A 29-year-old G1P0 female at 32 weeks gestation presents to the emergency department with vaginal bleeding. She has had minimal prenatal care to-date with only an initial visit with an obstetrician after a positive home pregnancy test. She describes minimal spotting that she noticed earlier today that has progressed to larger amounts of blood; she estimates 30 mL of blood loss. She denies any cramping, pain, or contractions, and she reports feeling continued movements of the baby. Ultrasound and fetal heart rate monitoring confirm the presence of a healthy fetus without any evidence of current or impending complications. The consulted obstetrician orders blood testing for Rh-status of both the mother as well as the father, who brought the patient to the hospital. Which of the following represents the best management strategy for this situation?

Accepted Answer

If mother is Rh-negative and father is Rh-positive then administer RhoGAM

Answer

After 28 weeks gestation, administration of RhoGAM will have no benefit

Answer

If mother is Rh-positive and father is Rh-negative then administer RhoGAM

Answer

If mother is Rh-negative and father is Rh-negative then administer RhoGAM

Answer

If mother is Rh-negative and father is Rh-positive, RhoGAM administration is not needed

Question 6

A 27-year-old woman, gravida 2, para 1, at 38 weeks' gestation comes to the emergency department in active labor. She received all of her prenatal care for this pregnancy. Pregnancy and delivery of her first child were uncomplicated. The patient's blood type is Rh-negative. Four hours after arrival, a healthy 3650-g (8-lb) female newborn is delivered. Delivery of the fetus is followed by placental retention and heavy vaginal bleeding. One hour later, the placenta is manually removed and the bleeding ceases. The mother's temperature is 36.7°C (98.1°F), pulse is 90/min, and blood pressure is 110/60 mm Hg. Examination shows blood on the vulva, the introitus, and on the medial aspect of each thigh. The neonate's blood type is Rh-positive. A single dose of anti-D immune globulin is administered. Which of the following is the most appropriate next step in management?

Accepted Answer

Perform rosette test

Answer

Perform Kleihauer-Betke test

Answer

Administer additional dose of anti-D immune globulin

Answer

Perform flow cytometry

Answer

Perform Coombs test

Question 7

A 25-year-old G2P1001 at 32 weeks gestation presents to the hospital with painless vaginal bleeding. The patient states that she was taking care of laundry at home when she experienced a sudden sensation of her water breaking and saw that her groin was covered in blood. Her prenatal history is unremarkable according to the clinic records, but she has not seen an obstetrician for the past 14 weeks. Her previous delivery was by urgent cesarean section for placenta previa. Her temperature is 95°F (35°C), blood pressure is 125/75 mmHg, pulse is 79/min, respirations are 18/min, and oxygen saturation is 98% on room air. Cervical exam shows gross blood in the vaginal os. The fetal head is not palpable. Fetal heart rate monitoring demonstrates decelerations and bradycardia. Labs are pending. IV fluids are started. What is the best next step in management?

Accepted Answer

Cesarean section

Answer

Betamethasone

Answer

Red blood cell transfusion

Answer

Vaginal delivery

Answer

Lumbar epidural block

Question 8

Two days after being admitted to the hospital because of severe peripartum vaginal bleeding during a home birth, a 40-year-old woman, gravida 3, para 3, has a 30-second generalized convulsive seizure followed by unconsciousness. Prior to the event she complained of acute onset of sweating and uncontrollable shivering. She was hemodynamically unstable and required several liters of intravenous fluids and 5 units of packed red blood cells in the intensive care unit. The patient's two prior pregnancies, at ages 33 and 35, were uncomplicated. She is otherwise healthy. Prior to admission, her only medication was a daily prenatal vitamin. Temperature is 37.5°C (99.5°F), pulse is 120/min, respirations are 18/min, blood pressure is 101/61 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 96%. Examination shows very little milk expression from the breasts bilaterally. Finger-stick glucose level is 36 mg/dL. Which of the following is the most likely underlying cause of this patient's condition?

Accepted Answer

Pituitary ischemia

Answer

Lactotrophic adenoma

Answer

Hypothalamic infarction

Answer

Adrenal hemorrhage

Answer

Hypoactive thyroid

Question 9

A 31-year-old G6P6 woman with a history of fibroids gives birth to twins via vaginal delivery. Her pregnancy was uneventful, and she reported having good prenatal care. Both placentas are delivered immediately after the birth. The patient continues to bleed significantly over the next 20 minutes. Her temperature is 97.0°F (36.1°C), blood pressure is 124/84 mmHg, pulse is 95/min, respirations are 16/min, and oxygen saturation is 98% on room air. Continued vaginal bleeding is noted. Which of the following is the most appropriate initial step in management?

Accepted Answer

Bimanual massage

Answer

Oxytocin

Answer

Blood product transfusion

Answer

Uterine artery embolization

Answer

Hysterectomy

Question 10

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?

Accepted Answer

Hysteroscopy with potential adhesiolysis

Answer

Measurement of serum FSH and LH concentrations

Answer

Measurement of antisperm antibody concentration

Answer

Dilation and curettage

Answer

Estrogen/progestin withdrawal test

Postpartum hemorrhage

Study Resources

Lessons

Questions

Flashcards

Lessons

Definition and classification

Risk factors for postpartum hemorrhage

Uterine atony management

Retained placenta management

Genital tract trauma repair

Coagulation disorders in obstetrics

Medical management of PPH

Surgical management of PPH

Balloon tamponade techniques

Uterine compression sutures

Postpartum hemorrhage protocols

Blood product replacement strategies

Prevention of postpartum hemorrhage

Practice Questions

Flashcards

About Postpartum hemorrhage for USMLE

Lessons in Postpartum hemorrhage

Master Postpartum hemorrhage