Postpartum Haemorrhage MCQs

In PPH with a contracted uterus, the most likely cause is genital tract trauma. The most appropriate management is examination of the genital tract under anesthesia to identify and repair any tears. Emergency laparotomy is not the first step. Fundal massage is for uterine atony. Intrauterine bowel tamponade and vaginal packing are not appropriate for bleeding from genital tract trauma.

In the management of PPH, the correct steps would involve the use of Crystalloids as the preferred initial fluid resuscitation over starch and uncross-matched group-specific blood can be given until fully cross-matched blood becomes available. (RCOG Green-top Guideline No. 52, 2017, updated 2023)

A rapidly enlarging vaginal hematoma requires active management. The best management is to explore the hematoma to evacuate the clot and ligate the bleeding vessels. Blood transfusion is considered if the patient becomes hemodynamically unstable. KUO (Keep Under Observation) is inappropriate for a rapidly enlarging hematoma. Vaginal packing is not as effective as exploration for active bleeding from a hematoma. Vaginal examination is part of the assessment but not the definitive management.

With a contracted uterus and continued bleeding after a forceps delivery of a large baby, the most likely cause is genital tract trauma. The next step is to look for genital tract trauma. Oxytocin is for uterine atony, which is not the case here. A condom catheter is used for uterine tamponade, which is a later step. Inspecting the placenta is part of routine care but does not address ongoing bleeding with a contracted uterus. Re-assessing after 15 minutes is too long with active bleeding.

The patient has PPH with persistent bleeding despite uterotonics (oxytocin and ergometrine). The next step is to consider uterine exploration to exclude retained placental tissue or uterine rupture. Blood transfusion and uterine packing are important but *after* excluding retained tissue. Repeating ergometrine is not effective if it has already failed. Close observation is insufficient with ongoing bleeding.

Postpartum hemorrhage (PPH) in the first 24 hours (primary PPH) is most commonly caused by uterine atony. From 24 hours to 6 weeks it is called secondary PPH. Bicornuate uterus and coagulation disorders can increase risk, but are not the *most* common cause. Retained products are a more common cause of *secondary* PPH, but less common in the first 24-72 hours. Second-degree perineal tear causes *bleeding*, but is not classified as PPH.

A second-degree perineal tear extends into the perineal body. It does *not* involve the anal mucosa or anal sphincter. An episiotomy may *increase* the risk of a second-degree tear, not avoid it. Forceps delivery can *increase* the risk of perineal tears.

The patient presents with non-offensive, blood-stained vaginal discharge 7 days postpartum, with a slightly enlarged uterus. This is likely due to subinvolution of the uterus, which is a common cause of secondary PPH. The most appropriate management is to reassure the mother. High vaginal swab, IV antibiotics, and IV fluids are not indicated without signs of infection or hemodynamic instability. A transvaginal ultrasound may be used to rule out retained products but is not the first-line management.

The patient has PPH from uterine atony that is not responding to oxytocics. The next step is to use a uterine balloon tamponade. B-Lynch suture, uterine artery ligation, and hysterectomy are all surgical options, with hysterectomy being the last resort for uncontrolled PPH. Uterine packing may be considered in some settings, but a balloon is often preferred.

Fever, severe abdominal pain, and offensive vaginal discharge one week after Cesarean section suggest a postpartum infection, likely endometritis. The initial management should be IV antibiotics to treat the infection. Abdominal and pelvic ultrasound is important for diagnosis, but antibiotics should not be delayed. Exploratory laparotomy is only for severe cases. A high vaginal swab can be done, but antibiotics are the priority. Withholding breastfeeding is not part of the initial management.

Severe perineal pain and signs of hypovolemia after a forceps delivery strongly suggest a perineal hematoma. A perineal tear would present with ongoing bleeding, not primarily pain. Uterine inversion is very rare and presents with a visible mass. Urinary retention causes lower abdominal discomfort. Uterine rupture presents with severe abdominal pain.

Causes of uterine atony (failure of the uterus to contract after delivery) include: Placental accreta (abnormal placental adherence), Polyhydramnios (excess amniotic fluid), and Prolonged latent phase of labor. Maternal anemia can contribute but is not a *direct* cause. Low body mass index (BMI) is not a significant risk factor for uterine atony.

With continuous bleeding despite a contracted uterus, the most likely cause is genital tract trauma (cervical, vaginal, or perineal tears). The next step is to examine for genital tract trauma. Bimanual compression is for uterine atony, which is not the case here. Exploration of the uterus is indicated if trauma is ruled out. Misoprostol is for uterine atony. Balloon tamponade is for uterine atony or uncontrolled PPH *after* other causes are excluded.

A symptomatic episiotomy hematoma requires evacuation and resuturing to control the bleeding and relieve pain. Simple analgesia will not resolve the problem. Laparotomy is not indicated. Applying an ice bag is a temporizing measure, but evacuation is definitive. Reassurance is insufficient for a large, symptomatic hematoma.

The patient has PPH despite uterotonics, a contracted uterus, and no retained products. This suggests a cause other than uterine atony. The most appropriate next step is a balloon tamponade. B-Lynch suture and uterine artery ligation are surgical options but should follow balloon tamponade. Postpartum hysterectomy is the last resort. Selective embolization is a specialized technique that may be used later, if available, but tamponade is faster and more readily available.

Drugs used to manage PPH include intra-myometrial carboprost and IV ergometrine. Tranexamic acid is also a key medication for PPH. Factor VII is used in specific situations of severe PPH. Rectal prostaglandin E2 (PGE2, misoprostol) is a uterotonic, but oxytocin is first-line. Oral tamoxifen is used for breast cancer, not PPH.

Risk factors for postpartum hemorrhage (PPH) include advanced maternal age, chorioamnionitis (infection), anemia, and multiparity. Obstetric cholestasis is a liver condition in pregnancy and does not directly cause PPH.

Severe perineal pain following delivery, especially with resuscitation efforts, suggests a possible perineal hematoma. The next step is to look for a hematoma at the episiotomy site or within the perineum. Tranexamic acid and fundal pressure do not directly address a hematoma. Examining for a hamartoma is not the primary concern. Pethidine is for pain relief, but the source of the pain must be identified first.

The patient has severe PPH due to uterine atony that is unresponsive to initial uterotonics (ergometrine, oxytocin, misoprostol). The next step is uterine balloon tamponade. Tranexamic acid should have already been given, but it does not address the mechanical problem of atony. Examination under anesthesia is a part of the management but not the immediate next step. Hysterectomy is a last resort. Uterine artery ligation is a surgical option, but balloon tamponade should be tried first. (RCOG Green-top Guideline No. 52, 2017, updated 2023)

The patient has severe PPH from uterine atony that is not responding to medical management. The next step is to use mechanical methods to control bleeding. Balloon tamponade is typically performed before surgical procedures. B-Lynch suture, uterine artery ligation, and hysterectomy are all surgical options, with hysterectomy being the last resort for uncontrolled PPH. A vaginal pack will not address the uterine atony. (RCOG Green-top Guideline No. 52, 2017, updated 2023)

The patient has an episiotomy hematoma. The most appropriate management is exploration of the hematoma to evacuate the clot and ligate any bleeding vessels. Analgesia alone will not resolve the hematoma. Tranexamic acid may reduce further bleeding but does not address the existing hematoma. Allowing spontaneous resolution is not appropriate for a large hematoma. Tight vaginal packing is not indicated for an episiotomy hematoma.

Postpartum hemorrhage (PPH) is defined as blood loss of 500 ml or more after vaginal birth or 1000 ml or more after Cesarean birth. Major PPH is often defined as >1000ml. Life-threatening hemorrhage can occur with a 30-40% blood loss. If clinical signs are reassuring, bleeding may still be significant and should not be dismissed as minor. Oxytocin is superior to misoprostol for *preventing* PPH. Crystalloids are the initial fluid of choice in resuscitation. (RCOG Green-top Guideline No. 52, 2017, updated 2023)

The patient is pale with tachycardia, and the uterus is high and deviated, suggesting possible retained products of conception or a pelvic hematoma/collection. The most appropriate next step is a pelvic ultrasound (USS) to investigate the cause. Reopening the abdomen is too invasive at this stage. A blood transfusion may be needed, but the cause of the ongoing issue needs to be determined first. IV antibiotics are not indicated without signs of infection. A repeat FBC is useful but does not address the acute problem.

The patient has primary postpartum hemorrhage (PPH) with a soft uterus and bleeding despite oxytocin, suggesting uterine atony. The most appropriate next step is to administer IV ergometrine, a second-line uterotonic. Checking clotting profile, examining the cervix, and inserting a vaginal pack are later steps if initial measures fail. IV tranexamic acid should be given, but ergometrine is the priority here. (RCOG Green-top Guideline No. 52, 2017, updated 2023)