LE4- POST PARTUM

Question 1

FOR NOS. 1 & 2:

A 40 y/o, G1P1 (1-0-0-1) presents with profuse vaginal bleeding. Thirty minutes prior to admission, she delivered spontaneously at home to a live term fetus weighing 4,500 grams. On examination, a soft and boggy uterus was noted and the rest of the pelvic examination was unremarkable.

What is the most likely cause of postpartum bleeding?

A. Lower uterine tear
B. Genital tract laceration
C. Retained secundines
D. Uterine atony
What is the most appropriate management?

A. Uterotonics
B. Manual uterine compression
C. Hysterectomy
D. Uterine compression sutures

Answer 1

D. Uterine atony – The most common cause of postpartum hemorrhage, particularly with a soft and boggy uterus.
A. Uterotonics – The first-line management for uterine atony.

Question 2

FOR NOS. 3 & 4:

A 30 y/o, G3P3, presents with a fleshy mass protruding out of the introitus following vaginal delivery. Vital signs revealed a BP of 70/50, PR of 120/min. On examination, there was no palpable mass on the lower abdomen.

What is the most likely diagnosis?

A. Pelvic organ prolapse
B. Uterine inversion
C. Prolapsed submucous myoma
D. Vulvar hematoma
What is the most appropriate treatment?

A. Vaginal hysterectomy
B. Manual reposition of the uterus
C. Evacuation of vulvar hematoma
D. Repair of the laceration

Answer 2

B. Uterine inversion – Characterized by a fleshy mass protruding through the introitus and absence of a palpable fundus.
B. Manual reposition of the uterus – The immediate treatment for uterine inversion.

Question 3

FOR NOS. 5 & 6:

A 25 y/o, G5P5, delivered spontaneously at home assisted by a traditional birth attendant. Ten days after delivery, the patient was rushed to the hospital because of profuse vaginal bleeding. Vital signs revealed a BP of 80/50, PR of 120/min, and a T of 37°C. On examination, the cervix was open with meaty tissues at the os and the uterus was slightly enlarged. There was no adnexal mass nor tenderness noted.

What is the most likely diagnosis?

A. Cervical laceration
B. Retained products of conception
C. Uterine subinvolution
D. Postpartum metritis
What is the most appropriate management?

A. IV Oxytocin drip
B. Repair of cervical laceration
C. Curettage of retained secundines
D. Antimicrobial therapy

Answer 3

B. Retained products of conception – “Meaty tissues” at the cervical os are indicative of retained placental tissue.
C. Curettage of retained secundines – Removal of the retained tissue is necessary to stop the bleeding.

Question 4

FOR NOS. 7 & 8:

A primigravid at 39 weeks delivered by low forceps extraction of the fetus. On the first postpartum day, the patient complained of excruciating vulvar pain. On examination, there was a violaceous gray 4x6 cm mass on the posterolateral aspect of the vulva on the right which was tense and tender on palpation. The median episiotomy was intact and the rest of the pelvic exam was unremarkable.

What is the most likely diagnosis?

A. Hemangioma of the vulva
B. Bartholin’s gland abscess
C. Fibroma of the vulva
D. Vulvar hematoma
What is the most appropriate management?

A. Wide excision of the mass
B. I & D of the abscess
C. Antimicrobial therapy
D. Evacuation of the hematoma and drainage

Answer 4

D. Vulvar hematoma – A tense, violaceous, tender mass in the vulvar region is classic for a hematoma.
D. Evacuation of the hematoma and drainage – Definitive management of vulvar hematomas to relieve pain and stop bleeding.

Question 5

FOR NOS. 9 & 10:

A 35 y/o grand multigravid delivered vaginally in a Lying-In-Clinic after 8 hours of labor. Thirty minutes postpartum, the patient started to bleed and the uterus was soft and boggy. Uterotonics were given and bimanual compression of the uterus was done but to no avail. The patient requested to be transferred to a medical center.

What is a temporary measure to manage the bleeding?

A. Compression uterine suture
B. Balloon intrauterine tamponade
C. Selective arterial embolization
D. Selective devascularization
What is the definitive management?

A. Selective devascularization
B. Bimanual compression of the uterus
C. Hysterectomy
D. Compression of aorta

Answer 5

B. Balloon intrauterine tamponade – A temporary measure to control hemorrhage when uterotonics and compression fail.
C. Hysterectomy – Definitive management for uncontrolled postpartum hemorrhage not responsive to conservative measures.

Question 6

A 32 y/o G3P3 presents with profuse vaginal bleeding immediately after a spontaneous vaginal delivery. On palpation, the uterus feels soft and boggy, and vital signs reveal BP 90/60 and PR 120/min.

Questions:

What is the most likely classification of this postpartum hemorrhage (PPH)?
A. Early PPH
B. Late PPH
C. Subacute PPH
D. Chronic PPH

What is the most likely cause of this PPH?
A. Retained placental tissue
B. Uterine atony
C. Cervical laceration
D. Coagulopathy

Answer 6

A. Early PPH
Rationale: Early PPH occurs within 24 hours of delivery. The patient’s presentation of immediate postpartum bleeding fits this classification.

B. Uterine atony
Rationale: Uterine atony is the most common cause of early PPH, indicated by a soft and boggy uterus and failure to contract effectively.

Question 7

A 28 y/o G2P2 presents with vaginal bleeding 10 days after an uncomplicated vaginal delivery. The bleeding is profuse, and the uterus is mildly enlarged on examination.

Questions:

What is the most likely classification of this postpartum hemorrhage (PPH)?
A. Early PPH
B. Late PPH
C. Subacute PPH
D. Chronic PPH

What is the most likely cause of this PPH?
A. Trauma from delivery
B. Retained placental tissue
C. Coagulopathy
D. Uterine atony

Answer 7

B. Late PPH
Rationale: Late PPH occurs between 24 hours and 6 weeks postpartum. The 10-day timeframe categorizes this as late PPH.

B. Retained placental tissue
Rationale: Retained placenta is a common cause of late PPH, characterized by persistent bleeding and an enlarged uterus.

Question 8

A 35 y/o G4P4 delivers vaginally and begins bleeding profusely 20 minutes after delivery. Examination reveals a well-contracted uterus, but active bleeding is noted from a cervical tear.

Questions:

Which of the 4 T’s is the most likely cause of this postpartum hemorrhage?
A. Tone
B. Tissue
C. Trauma
D. Thrombin

What is the most appropriate management for this condition?
A. Uterotonics
B. Balloon tamponade
C. Surgical repair of the tear
D. Administration of clotting factors

Answer 8

C. Trauma
Rationale: Genital tract lacerations, such as cervical tears, are a common cause of PPH when the uterus is well-contracted.

C. Surgical repair of the tear
Rationale: Repair of the cervical tear is necessary to stop the bleeding and manage the hemorrhage effectively.

Question 9

A 30 y/o G1P1 delivered vaginally 6 hours ago and presents with continued vaginal bleeding despite uterine massage and oxytocin administration. Examination reveals a soft and boggy uterus.

Questions:

What is the most likely cause of this postpartum hemorrhage?
A. Retained placenta
B. Uterine atony
C. Coagulopathy
D. Vaginal laceration

What is the next step in management?
A. Manual uterine massage and second-line uterotonics
B. Uterine artery embolization
C. Hysterectomy
D. Repair of genital tract lacerations

Answer 9

B. Uterine atony
Rationale: Uterine atony is characterized by a soft and boggy uterus and is the most common cause of PPH.

A. Manual uterine massage and second-line uterotonics
Rationale: First-line management of uterine atony includes uterine massage and uterotonics like oxytocin. If bleeding persists, second-line uterotonics like carboprost or misoprostol are used.

Question 10

A 29 y/o G2P2 presents 1 hour postpartum with severe vaginal bleeding and abnormal coagulation studies, including prolonged PT and PTT. Examination reveals a well-contracted uterus and no genital tract injuries.

Questions:

Which of the 4 T’s is the most likely cause of this postpartum hemorrhage?
A. Tone
B. Tissue
C. Trauma
D. Thrombin

What is the most appropriate management?
A. Uterine compression sutures
B. Administration of fresh frozen plasma
C. Repair of genital tract lacerations
D. Manual removal of retained placenta

Answer 10

D. Thrombin
Rationale: Coagulopathy (Thrombin) is suggested by prolonged PT and PTT, absence of uterine atony, and no evidence of genital tract trauma.

B. Administration of fresh frozen plasma
Rationale: Fresh frozen plasma replaces clotting factors and is the primary treatment for coagulopathy-induced PPH.

Question 11

A 30 y/o G5P5 presents with profuse vaginal bleeding immediately after delivering a term baby. Examination reveals a soft and boggy uterus. The patient has a history of uterine atony in a prior delivery.

Questions:

What is the most likely cause of this postpartum hemorrhage (PPH)?
A. Retained placental tissues
B. Uterine atony
C. Trauma to the genital tract
D. Coagulation defect

Which of the following is a significant risk factor for this condition?
A. Primigravida
B. Prolonged labor
C. Polyhydramnios
D. Both B and C

Answer 11

B. Uterine atony
Rationale: Uterine atony is the most common cause of immediate PPH, accounting for 90% of cases. A soft and boggy uterus strongly indicates inadequate uterine contraction leading to continued bleeding.

D. Both B and C
Rationale: Risk factors for uterine atony include prolonged labor and overdistension of the uterus, as seen in cases of polyhydramnios.

Question 12

A 27 y/o G2P2 presents with excessive vaginal bleeding immediately after manual extraction of the placenta. Examination reveals a firm uterus, but active bleeding is noted.

Questions:

What is the most likely cause of this postpartum hemorrhage (PPH)?
A. Uterine atony
B. Retained placental tissue
C. Trauma to the genital tract
D. Coagulation defect

What is the most appropriate initial management?
A. Uterotonics
B. Repair of the laceration
C. Manual removal of retained products
D. Transfusion of clotting factors

Answer 12

C. Trauma to the genital tract
Rationale: A firm uterus and persistent bleeding suggest trauma, such as lacerations or uterine rupture, rather than uterine atony or retained placental tissue.

B. Repair of the laceration
Rationale: Identifying and repairing the laceration is essential to control bleeding from trauma to the genital tract.

Question 13

A 35 y/o G3P3 develops severe postpartum bleeding following a prolonged labor complicated by oxytocin augmentation. Examination reveals a soft uterus with the fundus above the umbilicus.

Questions:

Which of the following is the most likely cause of this PPH?
A. Uterine inversion
B. Uterine atony
C. Retained placental tissue
D. Coagulation defect

Which risk factors in this patient predispose her to this condition?
A. Oxytocin augmentation
B. Prolonged labor
C. History of uterine atony
D. All of the above

Answer 13

B. Uterine atony
Rationale: A soft uterus and fundal height above the umbilicus indicate uterine atony, the most common cause of PPH.

D. All of the above
Rationale: Prolonged labor, oxytocin augmentation, and a history of uterine atony are significant risk factors for uterine atony.

Question 14

A 29 y/o G1P1 presents with heavy vaginal bleeding and a protruding mass following a spontaneous vaginal delivery. Examination reveals the uterus is not palpable abdominally.

Questions:

What is the most likely cause of this postpartum hemorrhage (PPH)?
A. Retained placenta
B. Uterine atony
C. Uterine inversion
D. Genital tract laceration

What is the most appropriate management for this condition?
A. Manual reposition of the uterus
B. Uterotonics
C. Repair of the laceration
D. Curettage under ultrasound guidance

Answer 14

C. Uterine inversion
Rationale: A protruding mass and absent uterine fundus on abdominal examination strongly indicate uterine inversion.

A. Manual reposition of the uterus
Rationale: Manual repositioning of the uterus is the immediate treatment for uterine inversion to restore normal anatomy and stop bleeding.

Question 15

A 40 y/o G4P4 presents with severe postpartum bleeding despite uterotonics. Laboratory studies reveal prolonged PT and PTT. The patient has a history of preeclampsia treated with magnesium sulfate.

Questions:

What is the most likely cause of this postpartum hemorrhage (PPH)?
A. Uterine atony
B. Retained placenta
C. Trauma to the genital tract
D. Coagulation defect

What is the most appropriate management for this patient?
A. Uterine massage
B. Fresh frozen plasma transfusion
C. Repair of genital tract trauma
D. Manual removal of placenta

Answer 15

D. Coagulation defect
Rationale: Prolonged PT and PTT suggest a coagulopathy, a rare but significant cause of PPH. Risk factors include preeclampsia and magnesium sulfate use.

B. Fresh frozen plasma transfusion
Rationale: Fresh frozen plasma replaces clotting factors and corrects the underlying coagulopathy causing bleeding.

Question 16

A 28 y/o primigravida delivers a healthy term infant. Ten minutes later, the placenta is delivered with bleeding concealed until delivery. The placenta appears shiny on the fetal side upon inspection.

Questions:

What is the most likely mechanism of placental extrusion?
A. Duncan mechanism
B. Schultze mechanism
C. Partial placental separation
D. Retained placenta

What is the key feature of this mechanism?
A. Blood escapes immediately into the vagina during placental separation.
B. Blood is concealed until the placenta is delivered.
C. Separation starts at the periphery of the placenta.
D. Prolonged placental separation.

Answer 16

B. Schultze mechanism
Rationale: The Schultze mechanism involves concealed bleeding, as blood collects behind the placenta until delivery. The shiny fetal side appears first during inspection.

B. Blood is concealed until the placenta is delivered.
Rationale: In the Schultze mechanism, separation starts in the center of the placenta, and bleeding remains concealed behind the placenta until it is fully delivered.

Question 17

A 32 y/o G3P3 delivers a term infant. Thirty minutes later, the placenta remains undelivered despite uterine massage and gentle cord traction. Examination reveals no signs of placental separation.

Questions:

How is this prolonged third stage of labor defined?
A. Placenta not delivered within 10 minutes of delivery
B. Placenta not delivered within 15 minutes of delivery
C. Placenta not delivered within 20 minutes of delivery
D. Placenta not delivered within 30 minutes of delivery

What is the most appropriate management at this point?
A. Administer oxytocin and continue observation
B. Perform manual extraction of the placenta
C. Administer antibiotics and schedule surgical removal
D. Immediate hysterectomy

Answer 17

D. Placenta not delivered within 30 minutes of delivery
Rationale: A prolonged third stage of labor is defined as the placenta remaining undelivered for 30 minutes or more.

B. Perform manual extraction of the placenta
Rationale: If the placenta remains undelivered for 30 minutes, manual extraction is indicated to prevent hemorrhage and other complications.

Question 18

A 29 y/o G2P2 develops heavy vaginal bleeding during the third stage of labor before the placenta is delivered. Examination reveals no evidence of placental separation.

Questions:

What is the most likely cause of this bleeding?
A. Uterine atony
B. Premature attempt to deliver the placenta
C. Retained placental fragments
D. Coagulopathy

What is the most appropriate management for this patient?
A. Continue waiting for natural placental separation
B. Perform manual extraction of the placenta and administer oxytocin
C. Immediate uterine curettage
D. Initiate blood transfusion immediately

Answer 18

B. Premature attempt to deliver the placenta
Rationale: Bleeding during the third stage of labor typically occurs due to attempts to hasten placental delivery before complete separation.

B. Perform manual extraction of the placenta and administer oxytocin
Rationale: Manual extraction ensures complete placental removal, and oxytocin stimulates uterine contraction to control bleeding.

Question 19

A 26 y/o G1P1 delivers a term infant. The placenta is delivered 5 minutes later, and blood escapes immediately into the vagina during placental separation. The maternal side of the placenta is visible on inspection.

Questions:

What is the most likely mechanism of placental extrusion?
A. Duncan mechanism
B. Schultze mechanism
C. Partial placental separation
D. Retained placenta

What is the distinguishing feature of this mechanism?
A. Blood collects behind the placenta until delivery.
B. Blood escapes immediately as separation begins.
C. Separation starts at the center of the placenta.
D. Prolonged placental separation.

Answer 19

A. Duncan mechanism
Rationale: The Duncan mechanism involves immediate blood escape during placental separation, with the maternal side appearing first on inspection.

B. Blood escapes immediately as separation begins.
Rationale: In the Duncan mechanism, placental separation starts at the edges, allowing blood to escape into the vagina immediately.

Question 20

A 26 y/o G1P1 delivers a term infant via spontaneous vaginal delivery. To prevent postpartum hemorrhage, oxytocin is administered immediately after delivery of the baby.

Questions:

What is the correct timing for administering oxytocin in the active management of the third stage of labor?
A. Immediately after placental delivery
B. Within 1 minute after delivery of the baby
C. 5 minutes after placental delivery
D. After assessing for signs of uterine atony

What is the preferred dose and route of oxytocin administration?
A. Oxytocin 10 units IV
B. Oxytocin 5 units IM
C. Oxytocin 10 units IM
D. Ergometrine 1.2 mg IM

Answer 20

B. Within 1 minute after delivery of the baby
Rationale: Administering oxytocin within 1 minute after delivery of the baby is crucial for its effectiveness in reducing the risk of uterine atony and postpartum hemorrhage.

C. Oxytocin 10 units IM
Rationale: The preferred dose and route for routine active management is oxytocin 10 units IM, which takes effect within 2–3 minutes.

Question 21

A 30 y/o G2P2 is undergoing the third stage of labor. The midwife applies controlled traction to the umbilical cord while supporting the uterus with the other hand.

Questions:

What is the purpose of applying counter traction during cord traction?
A. To prevent uterine inversion
B. To facilitate faster placental delivery
C. To avoid retained placental fragments
D. To prevent postpartum hemorrhage

What is a critical error to avoid during controlled cord traction?
A. Applying counter traction above the symphysis pubis
B. Applying traction without counter traction
C. Pulling the cord after placental separation
D. Using oxytocin after placental delivery

Answer 21

A. To prevent uterine inversion
Rationale: Counter traction stabilizes the uterus and prevents inversion, a serious complication during controlled cord traction.

B. Applying traction without counter traction
Rationale: Pulling the cord without counter traction increases the risk of uterine inversion, which can cause significant morbidity.

Question 22

A 32 y/o G3P3 has just delivered the placenta. The healthcare provider performs uterine massage every 15 minutes during the first 2 hours postpartum.

Questions:

What is the primary purpose of uterine massage during the active management of the third stage of labor?
A. To enhance placental separation
B. To stimulate uterine contraction and firmness
C. To prevent uterine inversion
D. To prevent placental retention

How frequently should uterine massage be performed during the first 2 hours postpartum?
A. Every 10 minutes
B. Every 15 minutes
C. Every 30 minutes
D. Only if the uterus is soft

Answer 22

B. To stimulate uterine contraction and firmness
Rationale: Uterine massage promotes contraction and ensures the uterus remains firm, reducing the risk of postpartum hemorrhage.

B. Every 15 minutes
Rationale: Regular uterine massage every 15 minutes in the first 2 hours postpartum helps monitor uterine tone and prevent atony.

Question 23

A 35 y/o G4P4 with a history of postpartum hemorrhage undergoes active management of the third stage of labor. Controlled traction of the umbilical cord is applied, and the uterus is massaged until it becomes firm.

Questions:

Which of the following is a key component of active management of the third stage of labor?
A. Immediate uterine curettage
B. Immediate cord traction without counter traction
C. Administration of uterotonics within 1 minute of delivery
D. Delayed uterine massage until postpartum hemorrhage occurs

What is the primary goal of active management of the third stage of labor?
A. Decrease the risk of retained placenta
B. Reduce the duration of labor
C. Prevent uterine rupture
D. Reduce the incidence of uterine atony and postpartum hemorrhage

Answer 23

C. Administration of uterotonics within 1 minute of delivery
Rationale: Timely administration of uterotonics, such as oxytocin, is a cornerstone of active management to prevent uterine atony.

D. Reduce the incidence of uterine atony and postpartum hemorrhage
Rationale: The main purpose of active management is to reduce uterine atony and its associated risk of postpartum hemorrhage.

Question 24

A 34 y/o G3P3 delivered a term infant 15 minutes ago and presents with heavy vaginal bleeding. Examination reveals a soft and boggy uterus on palpation.

Questions:

What is the most likely cause of this postpartum hemorrhage (PPH)?
A. Retained placental fragments
B. Trauma to the genital tract
C. Uterine atony
D. Coagulopathy

What is the first-line management for this condition?
A. Manual removal of the placenta
B. Hysterectomy
C. Uterine massage and uterotonics
D. Balloon tamponade

Answer 24

C. Uterine atony
Rationale: Uterine atony is the most common cause of postpartum hemorrhage and is characterized by a soft and boggy uterus due to insufficient uterine contraction.

C. Uterine massage and uterotonics
Rationale: Initial management includes uterine massage to stimulate contraction and administration of uterotonics, such as oxytocin, to enhance uterine tone and reduce bleeding.

Question 25

A 29 y/o G2P2 presents with persistent vaginal bleeding despite uterine massage and oxytocin administration. Examination reveals a soft uterus and retained placental fragments on ultrasound.

Questions:

What is the next step in management for this patient?
A. Continue uterine massage
B. Manual removal of the placenta
C. Administer additional uterotonics only
D. Perform a hysterectomy

What complication should be avoided when performing cord traction to remove the placenta?
A. Coagulopathy
B. Retained placenta
C. Uterine inversion
D. Genital tract trauma

Answer 25

B. Manual removal of the placenta
Rationale: If retained placental fragments are identified and bleeding persists, manual removal of the placenta is necessary to prevent ongoing hemorrhage.

C. Uterine inversion
Rationale: Excessive cord traction without counter traction, especially in an atonic uterus, can lead to uterine inversion, a potentially life-threatening complication.

Question 26

A 37 y/o G4P4 delivered a term infant after prolonged labor and presents with uterine atony and active postpartum hemorrhage. Uterine massage and uterotonics have not controlled the bleeding.

Questions:

What is the next step in the management of this patient?
A. Perform uterine artery embolization
B. Apply intrauterine balloon tamponade
C. Continue uterine massage for another 30 minutes
D. Perform immediate hysterectomy

Why is uterine massage crucial in the management of uterine atony?
A. To facilitate placental separation
B. To prevent uterine rupture
C. To stimulate uterine contraction
D. To reduce coagulopathy

Answer 26

B. Apply intrauterine balloon tamponade
Rationale: In cases where uterotonics and massage are ineffective, intrauterine balloon tamponade can provide mechanical compression to control hemorrhage while planning definitive treatment.

C. To stimulate uterine contraction
Rationale: Uterine massage helps stimulate contraction, which is critical for arresting bleeding in cases of uterine atony.

Question 27

A 31 y/o G2P2 develops postpartum hemorrhage due to uterine atony following a spontaneous vaginal delivery. Controlled cord traction is performed, but excessive traction causes a sudden increase in bleeding.

Questions:

What is the most likely complication of excessive traction on the umbilical cord during an atonic uterus?
A. Retained placenta
B. Uterine rupture
C. Uterine inversion
D. Genital tract laceration

How can this complication be prevented during active management of the third stage of labor?
A. Apply steady, continuous traction without counter traction
B. Perform uterine curettage before cord traction
C. Use counter traction on the uterus during cord traction
D. Delay oxytocin administration until the placenta delivers

Answer 27

C. Uterine inversion
Rationale: Excessive traction on the cord, especially with an atonic uterus, can lead to uterine inversion, a life-threatening complication.

C. Use counter traction on the uterus during cord traction
Rationale: Counter traction stabilizes the uterus and prevents inversion during controlled cord traction.

Question 28

A 36 y/o G3P2 woman with a history of one previous cesarean section and one vaginal delivery presents with sudden-onset severe abdominal pain during labor. Fetal heart monitoring shows late decelerations, and the patient becomes hypotensive. On examination, there is loss of fetal station and irregular uterine contour.

Questions:

What is the most likely diagnosis?
A. Placental abruption
B. Uterine rupture
C. Uterine atony
D. Amniotic fluid embolism

What is the definitive management for this patient?
A. Immediate cesarean delivery
B. Blood transfusion only
C. Hysterectomy without laparotomy
D. Medical management with uterotonics

Answer 28

B. Uterine rupture
Rationale: Sudden severe abdominal pain, fetal distress (late decelerations), hypotension, loss of fetal station, and irregular uterine contour strongly indicate uterine rupture, particularly in a patient with a prior cesarean section.

A. Immediate cesarean delivery
Rationale: The definitive treatment for uterine rupture is immediate abdominal delivery to save the fetus and prevent further complications.

Question 29

A 30 y/o G4P3 woman with a history of two previous cesarean sections undergoes labor induction with high-dose oxytocin. She suddenly develops vaginal bleeding, abdominal pain, and fetal bradycardia.

Questions:

What is the most significant risk factor for this patient’s condition?
A. Labor induction with oxytocin
B. Multiparity
C. Previous cesarean sections
D. Advanced maternal age

What is the initial step in managing this condition?
A. Administer additional oxytocin
B. Perform immediate laparotomy
C. Perform instrumental delivery
D. Start conservative management

Answer 29

C. Previous cesarean sections
Rationale: The most significant risk factor for uterine rupture is a prior uterine surgery, such as a cesarean section. Induction with high-dose oxytocin further increases the risk.

B. Perform immediate laparotomy
Rationale: Laparotomy is required to evaluate the extent of rupture and to deliver the fetus rapidly, minimizing maternal and fetal morbidity.

Question 30

A 28 y/o G2P1 woman at 39 weeks gestation presents with a history of prior myomectomy. She is in active labor when she reports sharp abdominal pain and signs of hemodynamic instability. Vaginal examination reveals no presenting part of the fetus.

Questions:

What is the most likely cause of her symptoms?
A. Dehiscence of a uterine scar
B. Uterine rupture
C. Uterine atony
D. Placenta accreta

What is the most appropriate definitive management?
A. Conservative monitoring with IV fluids
B. Immediate hysterorrhaphy
C. Emergent cesarean delivery
D. Medical management with prostaglandins

Answer 30

B. Uterine rupture
Rationale: A history of uterine surgery (e.g., myomectomy), sharp abdominal pain, hemodynamic instability, and loss of fetal station suggest uterine rupture.

C. Emergent cesarean delivery
Rationale: Immediate cesarean delivery is required to save the fetus and stabilize the mother. Hysterorrhaphy or hysterectomy may follow based on the extent of rupture.

Question 31

A 33 y/o G5P4 woman is undergoing an internal podalic version for breech delivery when she develops severe vaginal bleeding and hypotension. Fetal heart tracing shows severe bradycardia.

Questions:

What obstetric maneuver likely precipitated this complication?
A. Excessive fundal pressure
B. Internal podalic version
C. Vacuum-assisted delivery
D. High-dose oxytocin administration

What is the most appropriate next step in management?
A. Manual removal of the placenta
B. Continue the current delivery attempt
C. Immediate laparotomy with possible hysterectomy
D. Administer uterotonics and observe

Answer 31

B. Internal podalic version
Rationale: Internal podalic version is a known risk factor for uterine rupture due to excessive manipulation of the uterus.

C. Immediate laparotomy with possible hysterectomy
Rationale: Immediate laparotomy is required to manage the uterine rupture, deliver the fetus, and address bleeding. Hysterectomy may be necessary if uterine repair is not feasible.

Question 32

A 35 y/o G3P2 presents for elective cesarean delivery due to a history of prior uterine rupture. During the procedure, the surgeon notes a dehiscent uterine scar with intact membranes.

Questions:

What best describes a uterine scar dehiscence?
A. Complete separation of the uterine wall with bleeding into the abdominal cavity
B. Partial separation of the uterine scar with intact membranes and minimal bleeding
C. Complete rupture of the uterus with the fetus extruding into the abdominal cavity
D. Perforation of the uterus due to surgical injury

How should this condition be managed?
A. Hysterectomy
B. Surgical repair of the scar (hysterorrhaphy)
C. Conservative management
D. Immediate delivery via forceps

Answer 32

B. Partial separation of the uterine scar with intact membranes and minimal bleeding
Rationale: Uterine scar dehiscence involves partial separation of the uterine scar with the membranes and peritoneum remaining intact, and bleeding is minimal.

B. Surgical repair of the scar (hysterorrhaphy)
Rationale: In cases of scar dehiscence, repair of the defect (hysterorrhaphy) is typically performed after delivery.

Question 33

A 35 y/o G3P2 woman with a history of one prior cesarean section presents with severe abdominal pain during active labor. On examination, fetal parts are palpable abdominally, and the patient is hemodynamically unstable. Vaginal examination reveals a loss of fetal station.

Questions:

What is the most likely diagnosis?
A. Uterine rupture (complete)
B. Uterine rupture (incomplete)
C. Uterine dehiscence
D. Placenta previa

What feature confirms this diagnosis?
A. Intact visceral peritoneum
B. Fetal membranes intact, with intrauterine fetus
C. Fetal parts extruded into the peritoneal cavity
D. Minimal bleeding

Answer 33

A. Uterine rupture (complete)
Rationale: Complete uterine rupture is characterized by disruption of all uterine layers, extruding fetal parts into the abdominal cavity. Severe pain, hemodynamic instability, and loss of station support this diagnosis.

C. Fetal parts extruded into the peritoneal cavity
Rationale: In complete uterine rupture, the communication between the uterine and peritoneal cavities allows fetal parts to move into the abdominal cavity.

Question 34

A 28 y/o G2P1 woman undergoes a trial of labor after cesarean section (TOLAC). She complains of sudden pain and mild vaginal bleeding. Fetal monitoring shows mild bradycardia. Examination reveals an intact uterine contour with no extruded fetal parts, and fetal membranes remain intact.

Questions:

What is the most likely diagnosis?
A. Uterine rupture (complete)
B. Uterine rupture (incomplete)
C. Uterine dehiscence
D. Placental abruption

What is the key feature distinguishing this condition from complete rupture?
A. Intact visceral peritoneum
B. Ruptured bag of waters
C. Massive bleeding
D. Palpable fetal parts intra-abdominally

Answer 34

C. Uterine dehiscence
Rationale: Uterine dehiscence involves partial separation of a previous uterine scar with intact membranes and minimal or no bleeding.

A. Intact visceral peritoneum
Rationale: In uterine dehiscence, the peritoneum and fetal membranes remain intact, which differentiates it from complete uterine rupture.

Question 35

A 32 y/o G4P3 woman with a history of two cesarean sections experiences vaginal bleeding and abdominal tenderness during labor induction with prostaglandins. Ultrasound reveals a partial disruption of the uterine wall, but the fetus remains intrauterine.

Questions:

What is the most likely diagnosis?
A. Uterine rupture (complete)
B. Uterine rupture (incomplete)
C. Uterine dehiscence
D. Placenta previa

What is the immediate management for this condition?
A. Continue labor induction with close monitoring
B. Immediate cesarean delivery
C. Uterine massage and observation
D. Hysterectomy

Answer 35

B. Uterine rupture (incomplete)
Rationale: Incomplete uterine rupture involves partial disruption of the uterine wall without extruding fetal parts into the peritoneal cavity. The fetus remains intrauterine.

B. Immediate cesarean delivery
Rationale: Even with incomplete uterine rupture, prompt delivery via cesarean section is necessary to prevent further rupture and ensure maternal and fetal safety.

Question 36

A 40 y/o G5P4 woman with grand multiparity presents with abdominal pain and moderate bleeding after excessive fundal pressure during delivery. Examination shows fetal bradycardia and segmental uterine scar separation on imaging.

Questions:

What is the most likely diagnosis?
A. Uterine rupture (complete)
B. Uterine rupture (incomplete)
C. Uterine dehiscence
D. Cervical laceration

What is the characteristic feature of this condition?
A. All layers disrupted with massive bleeding
B. Partial disruption of uterine layers with variable bleeding
C. Intact membranes and minimal bleeding
D. Ruptured membranes and loss of fetal station

Answer 36

B. Uterine rupture (incomplete)
Rationale: Incomplete uterine rupture involves partial disruption of uterine layers, with fetal parts remaining intrauterine and bleeding variable. Grand multiparity and excessive fundal pressure are significant risk factors.

B. Partial disruption of uterine layers with variable bleeding
Rationale: Incomplete rupture involves partial wall disruption, distinguishing it from complete rupture (all layers disrupted) and dehiscence (intact membranes).

Question 37

A 29 y/o G2P2 woman delivers a healthy term infant, but the placenta has not been delivered after 1 hour despite uterine massage and administration of oxytocin. The uterus feels firm on palpation, and there are no signs of placental separation.

Questions:

What is the most likely diagnosis?
A. Uterine atony
B. Retained placenta
C. Uterine rupture
D. Placenta previa

What is the definitive management of this condition?
A. Perform manual removal of the placenta under general anesthesia
B. Continue observation for another hour
C. Perform hysterectomy immediately
D. Administer additional doses of oxytocin

Answer 37

B. Retained placenta
Rationale: Retained placenta is defined as failure to deliver the placenta within 1 hour after delivery. The firm uterus suggests uterine tone is adequate, ruling out uterine atony.

A. Perform manual removal of the placenta under general anesthesia
Rationale: Manual removal under general anesthesia is the definitive treatment, ensuring the uterus is relaxed and preventing excessive trauma or uterine inversion.

Question 38

A 35 y/o G3P3 delivers a term baby. The placenta does not separate despite efforts to stimulate uterine contraction. During manual extraction, no cleavage plane is found between the placenta and the uterine wall.

Questions:

What is the most likely underlying condition?
A. Placenta previa
B. Placenta accreta
C. Retained placental fragments
D. Uterine atony

What is the next step in management?
A. Continue manual extraction forcefully
B. Stop the procedure and prepare for hysterectomy
C. Administer additional oxytocin and observe
D. Apply intrauterine balloon tamponade

Answer 38

B. Placenta accreta
Rationale: The absence of a cleavage plane between the placenta and the uterine wall indicates placenta accreta, where the placenta is abnormally adherent to the myometrium.

B. Stop the procedure and prepare for hysterectomy
Rationale: Forceful removal in placenta accreta can lead to catastrophic hemorrhage. Hysterectomy is often required to control bleeding and prevent further complications.

Question 39

A 28 y/o G2P1 delivers a term infant. The placenta is partially detached, but manual removal is required to complete delivery. The physician stabilizes the uterus with one hand on the abdomen while using the other hand to sweep the uterine cavity.

Questions:

What is the purpose of placing one hand on the abdomen during manual removal of the placenta?
A. To palpate for uterine rupture
B. To counter traction and prevent uterine inversion
C. To assess uterine contraction during removal
D. To facilitate uterine tone monitoring

Which of the following is a key step in manual removal of the placenta?
A. Insert fingers and pull the placenta forcefully
B. Sweep fingers laterally to detach the placenta along the cleavage plane
C. Apply fundal pressure to assist in delivery of the placenta
D. Begin curettage immediately if the placenta does not deliver

Answer 39

B. To counter traction and prevent uterine inversion
Rationale: The abdominal hand stabilizes the uterus to prevent uterine inversion during traction applied to the placenta.

B. Sweep fingers laterally to detach the placenta along the cleavage plane
Rationale: Gentle sweeping of fingers along the cleavage plane ensures safe detachment without causing trauma or uterine damage.

Question 40

A 33 y/o G4P3 with a history of prior uterine surgery delivers a term baby. The placenta fails to separate, and the patient develops vaginal bleeding. Manual removal reveals focal adherence of the placenta to the myometrium.

Questions:

What is the most likely diagnosis?
A. Placenta accreta
B. Placenta previa
C. Retained placenta with atony
D. Uterine inversion

What is a significant risk factor for this condition?
A. Prolonged labor
B. Prior uterine surgery (e.g., cesarean section, myomectomy)
C. Advanced maternal age
D. Use of oxytocin during labor

Answer 40

A. Placenta accreta
Rationale: Focal adherence of the placenta to the myometrium suggests placenta accreta, a condition often associated with prior uterine surgery.

B. Prior uterine surgery (e.g., cesarean section, myomectomy)
Rationale: Prior uterine surgeries are the most significant risk factor for placenta accreta due to scarring and abnormal placental implantation.

Question 41

A 30 y/o G1P1 develops postpartum hemorrhage due to retained placenta. Manual removal is performed successfully, but the patient continues to bleed despite a firm uterus.

Questions:

What is the most likely cause of ongoing bleeding in this case?
A. Uterine atony
B. Retained placental fragments
C. Genital tract trauma
D. Coagulopathy

What is the appropriate next step in management?
A. Perform uterine massage
B. Perform uterine curettage under ultrasound guidance
C. Administer blood transfusion immediately
D. Begin high-dose oxytocin infusion

Answer 41

C. Genital tract trauma
Rationale: Persistent bleeding despite a firm uterus suggests trauma to the genital tract rather than uterine atony or retained fragments.

B. Perform uterine curettage under ultrasound guidance
Rationale: Curettage under ultrasound guidance ensures removal of any retained placental fragments, a common cause of ongoing postpartum hemorrhage.

Question 42

A 36 y/o G3P2 woman with a history of two prior cesarean deliveries presents at 34 weeks gestation with painless vaginal bleeding. Ultrasound reveals a placenta implanted over the lower uterine segment and invading the myometrium.

Questions:

What is the most likely diagnosis?
A. Placenta previa
B. Placenta accreta
C. Placenta increta
D. Placenta percreta

What is the most significant risk factor for this condition?
A. Advanced maternal age
B. Prior uterine curettage
C. Prior cesarean deliveries
D. Placenta previa

Answer 42

C. Placenta increta
Rationale: Placenta increta is characterized by placental villi invading into the myometrium, as seen on imaging in this case.

C. Prior cesarean deliveries
Rationale: Prior cesarean deliveries are the most significant risk factor for abnormal placental adherence due to scarring of the uterine wall.

Question 43

A 30 y/o G2P1 with a history of uterine curettage presents with persistent vaginal bleeding after delivery of the infant. Manual removal of the placenta is attempted but reveals firm adherence of the placenta to the uterine wall without a cleavage plane.

Questions:

What is the most likely type of abnormal placental adherence in this case?
A. Placenta accreta
B. Placenta increta
C. Placenta percreta
D. Retained placenta

What is the next best step in management?
A. Forceful manual extraction of the placenta
B. Uterine balloon tamponade
C. Prepare for surgical intervention (e.g., hysterectomy)
D. Administer high-dose oxytocin

Answer 43

A. Placenta accreta
Rationale: Placenta accreta involves abnormal adherence of the placental villi to the myometrium due to defective decidua basalis formation, preventing separation.

C. Prepare for surgical intervention (e.g., hysterectomy)
Rationale: Forceful removal in cases of placenta accreta can cause life-threatening hemorrhage. Surgical management, often including hysterectomy, is typically required.

Question 44

A 40 y/o G5P4 presents at 32 weeks gestation with recurrent vaginal bleeding. Ultrasound and MRI confirm placental villi penetrating the myometrium and reaching the bladder wall.

Questions:

What is the most likely diagnosis?
A. Placenta accreta
B. Placenta increta
C. Placenta percreta
D. Placenta previa

What is the primary concern with this condition during delivery?
A. Uterine atony
B. Severe hemorrhage requiring transfusion
C. Retained placenta fragments
D. Preterm labor

Answer 44

C. Placenta percreta
Rationale: Placenta percreta involves placental villi penetrating through the myometrium to the serosa and potentially invading adjacent organs, such as the bladder.

B. Severe hemorrhage requiring transfusion
Rationale: Placenta percreta is associated with significant hemorrhage during delivery due to deep invasion of the placenta into uterine and extrauterine structures. Blood transfusion and surgical expertise must be prepared.

Question 45

A 33 y/o G4P3 with a history of placenta previa is undergoing cesarean delivery. Upon opening the uterine cavity, the surgeon observes that the placenta is adherent to the uterine wall without a plane of separation, and significant bleeding begins.

Questions:

What is the most appropriate classification of this condition?
A. Placenta previa with accreta
B. Placenta increta
C. Placenta percreta
D. Retained placenta

What is the definitive treatment for this case?
A. Perform uterine massage and administer oxytocin
B. Uterine curettage
C. Hysterectomy with surgical removal of the placenta
D. Forceful manual extraction of the placenta

Answer 45

A. Placenta previa with accreta
Rationale: Placenta previa and placenta accreta often coexist, particularly in cases of previous cesarean sections. Here, placental adherence without separation defines placenta accreta.

C. Hysterectomy with surgical removal of the placenta
Rationale: In cases of placenta accreta with significant bleeding, hysterectomy is often required to manage hemorrhage and ensure maternal safety.

Question 46

A 28 y/o G3P2 undergoes planned cesarean delivery at 35 weeks for suspected placenta accreta based on imaging. Blood loss during delivery is significant despite careful management.

Questions:

What imaging feature is most diagnostic of placenta accreta?
A. Placental thickness >4 cm
B. Absence of the hypoechoic retroplacental zone on ultrasound
C. Placental separation plane on Doppler ultrasound
D. Placental calcifications

What key perioperative preparation is essential in managing suspected placenta accreta?
A. Administration of high-dose oxytocin preoperatively
B. Placement of uterine balloon tamponade
C. Preoperative cross-matching and blood transfusion readiness
D. Delaying delivery to 39 weeks to allow placental maturity

Answer 46

B. Absence of the hypoechoic retroplacental zone on ultrasound
Rationale: The absence of the hypoechoic retroplacental zone is a key sonographic feature of placenta accreta, indicating abnormal adherence to the myometrium.

C. Preoperative cross-matching and blood transfusion readiness
Rationale: Placenta accreta is associated with massive hemorrhage during delivery, requiring adequate preparation with blood products and a skilled surgical team.

Question 47

A 30 y/o G1P1 delivers a term infant via forceps-assisted vaginal delivery. The patient develops significant vaginal bleeding after delivery. Examination reveals a 3 cm cervical tear with active bleeding.

Questions:

What is the most appropriate management for this cervical tear?
A. Observe and monitor bleeding
B. Suture the cervical tear
C. Administer uterotonics only
D. Perform immediate hysterectomy

What is the primary indication for suturing cervical tears?
A. Prevent cervical incompetence
B. Control active bleeding
C. Avoid rectal involvement
D. Restore normal cervical contour

Answer 47

B. Suture the cervical tear
Rationale: Suturing is required to stop active bleeding from a cervical tear, especially when the tear exceeds 2 cm.

B. Control active bleeding
Rationale: The primary reason for suturing cervical tears is to control active bleeding and prevent further maternal blood loss.

Question 48

A 25 y/o G2P2 woman experiences vaginal bleeding after spontaneous vaginal delivery. Examination reveals a first-degree perineal laceration.

Questions:

What structures are involved in a first-degree perineal laceration?
A. Perineal skin and vaginal mucosa
B. Perineal muscles and fascia
C. Anal sphincter and rectal mucosa
D. Vaginal wall and anal sphincter

What is the recommended management for first-degree perineal lacerations?
A. Immediate suturing
B. Leave unsutured to heal by secondary intention
C. Perform an episiotomy
D. Administer prophylactic antibiotics

Answer 48

A. Perineal skin and vaginal mucosa
Rationale: First-degree lacerations involve only the perineal skin and vaginal mucosa without affecting deeper structures.

B. Leave unsutured to heal by secondary intention
Rationale: First-degree lacerations can be left unsutured, as healing by secondary intention reduces postpartum pain and dyspareunia.

Question 49

A 28 y/o G3P2 delivers a baby vaginally, and examination reveals a perineal tear extending through the skin, perineal body, and anal sphincter. The rectal mucosa remains intact.

Questions:

How is this perineal laceration classified?
A. Second-degree laceration
B. Third-degree laceration
C. Fourth-degree laceration
D. First-degree laceration

What is the appropriate management for this type of laceration?
A. Leave unsutured to heal by secondary intention
B. Immediate surgical repair with layered closure
C. Perform episiotomy to reduce tension
D. Prescribe antibiotics only

Answer 49

B. Third-degree laceration
Rationale: Third-degree lacerations extend through the perineal body and anal sphincter but do not involve the rectal mucosa.

B. Immediate surgical repair with layered closure
Rationale: Surgical repair is essential for third-degree lacerations to restore the integrity of the perineum and anal sphincter.

Question 50

A 35 y/o G4P3 delivers a baby vaginally after internal podalic version. Examination reveals a perineal laceration involving the rectal mucosa and anal epithelium.

Questions:

What degree of perineal laceration does this represent?
A. Second-degree laceration
B. Third-degree laceration
C. Fourth-degree laceration
D. First-degree laceration

What is the primary goal in repairing this laceration?
A. Prevent infection
B. Restore rectal and anal function
C. Reduce postpartum pain
D. Ensure cosmetic outcomes

Answer 50

C. Fourth-degree laceration
Rationale: Fourth-degree lacerations involve the rectal mucosa and anal epithelium in addition to the perineal body and anal sphincter.

B. Restore rectal and anal function
Rationale: The repair of fourth-degree lacerations aims to restore the structural and functional integrity of the rectal and anal areas.

Question 51

A 29 y/o G1P1 experiences a breech delivery, and examination reveals a deep anterior perineal tear involving the labia and urethral area.

Questions:

How is this type of trauma classified by location?
A. Posterior perineal trauma
B. Anterior perineal trauma
C. Combined perineal trauma
D. First-degree laceration

What is the key consideration during repair of this type of trauma?
A. Avoid damaging the anal sphincter
B. Restore urethral integrity and function
C. Ensure cosmetic closure of the labia
D. Reduce postpartum pain and swelling

Answer 51

B. Anterior perineal trauma
Rationale: Anterior perineal trauma involves the labia, urethra, and anterior vaginal wall, distinct from posterior trauma.

B. Restore urethral integrity and function
Rationale: Repairing anterior perineal trauma requires careful attention to urethral integrity to prevent urinary complications.

Question 52

A 29 y/o G2P2 develops severe vaginal bleeding and profound hypotension immediately after delivery of the placenta. Examination reveals a fleshy mass protruding through the cervix and an empty hypogastric area on abdominal palpation.

Questions:

What is the most likely diagnosis?
A. Uterine atony
B. Uterine inversion (complete)
C. Cervical laceration
D. Retained placenta

What is the primary management for this condition?
A. Immediate uterine curettage
B. Administer uterotonics before repositioning
C. Manual repositioning of the uterus
D. Apply traction to the umbilical cord

Answer 52

B. Uterine inversion (complete)
Rationale: Complete uterine inversion is characterized by a fleshy mass protruding through the external os and an empty hypogastric area due to the fundus turning inside out.

C. Manual repositioning of the uterus
Rationale: The definitive management of uterine inversion is manual repositioning of the inverted fundus back into its normal anatomical position.

Question 53

A 35 y/o G4P3 presents with vaginal bleeding after delivery. On examination, the uterine fundus is not palpable abdominally, but there is a depression in the hypogastric area. The fundus is felt through the cervix but has not protruded into the vagina.

Questions:

How is this uterine inversion classified?
A. Complete inversion
B. Partial inversion
C. Total inversion
D. Uterine rupture

What abdominal finding is expected in this condition?
A. Empty hypogastric area
B. Palpable uterine fundus above the umbilicus
C. Greater depression in the hypogastric area
D. No abnormal findings

Answer 53

B. Partial inversion
Rationale: Partial inversion occurs when the uterine fundus protrudes into the uterine cavity but does not cross the cervix.

C. Greater depression in the hypogastric area
Rationale: In partial inversion, the hypogastric area shows a depression due to inward displacement of the uterine fundus.

Question 54

A 32 y/o G2P2 experiences significant blood loss after delivery due to fundal inversion caused by excessive cord traction. She is stabilized with IV fluids. The physician attempts to reposition the uterus manually.

Questions:

What step is critical during manual repositioning of the uterus?
A. Apply downward pressure on the fundus
B. Administer uterotonics before repositioning
C. Use one hand to palpate the depression and another to push the fundus upward
D. Perform curettage to remove placental fragments first

Why is uterotonics administered after successful repositioning?
A. To enhance uterine relaxation during the procedure
B. To prevent uterine atony and maintain uterine tone
C. To manage hypovolemic shock
D. To assist in expelling retained placenta

Answer 54

C. Use one hand to palpate the depression and another to push the fundus upward
Rationale: Manual repositioning involves palpating the depression with the abdominal hand and using the vaginal hand to gently push the inverted fundus back into position.

B. To prevent uterine atony and maintain uterine tone
Rationale: Uterotonics are administered after repositioning to ensure the uterus contracts and remains in place, reducing the risk of re-inversion or atony.

Question 55

A 28 y/o G3P3 develops uterine inversion during delivery. Despite manual repositioning, the uterus fails to stay in place, and bleeding persists. The patient is hemodynamically unstable.

Questions:

What is the next step in management?
A. Hysterectomy
B. Surgical repositioning of the uterus
C. Administer high-dose oxytocin and observe
D. Apply uterine artery embolization

What supportive measures are critical for this patient?
A. Blood transfusion and IV fluids
B. Immediate antibiotics to prevent infection
C. Insertion of intrauterine balloon tamponade
D. Prolonged observation for spontaneous recovery

Answer 55

B. Surgical repositioning of the uterus
Rationale: If manual repositioning is unsuccessful, surgical correction is required to restore the uterus to its normal position and control bleeding.

A. Blood transfusion and IV fluids
Rationale: Supportive management with fluid resuscitation and blood transfusion is essential to manage hypovolemic shock and stabilize the patient.

Question 56

A 25 y/o G1P1 with a fundal placenta develops uterine inversion after delivery. Examination shows the fundus protruding through the cervix, and significant bleeding is noted.

Questions:

What risk factor is most associated with this complication?
A. Low-lying placenta
B. Fundal placental implantation
C. Excessive uterine contraction
D. Multiparity

What is the mechanism leading to this condition?
A. Premature traction on the umbilical cord before placental separation
B. Delayed uterine contraction
C. Rupture of the uterine wall
D. Placental abruption

Answer 56

B. Fundal placental implantation
Rationale: Fundal placental implantation increases the risk of uterine inversion because of the force applied during delivery.

A. Premature traction on the umbilical cord before placental separation
Rationale: Premature traction can pull the uterus inside out, particularly in the presence of a fundal placenta or uterine atony.

Question 57

A 28 y/o G2P2 delivers a term infant via spontaneous vaginal delivery. To prevent postpartum hemorrhage, oxytocin is administered immediately after delivery.

Questions:

What is the preferred dose and route for oxytocin in the active management of the third stage of labor?
A. Oxytocin 5 units IV
B. Oxytocin 10 units IM
C. Oxytocin 20 units IV infusion
D. Ergometrine 1.2 mg IM

What is the purpose of administering oxytocin immediately after delivery?
A. To stimulate uterine relaxation
B. To prevent uterine atony and reduce PPH risk
C. To promote placental separation
D. To facilitate fetal expulsion

Answer 57

B. Oxytocin 10 units IM
Rationale: The recommended dose of oxytocin for active management of the third stage of labor is 10 units IM, which is effective in 2–3 minutes.

B. To prevent uterine atony and reduce PPH risk
Rationale: Oxytocin promotes uterine contractions, thereby reducing the risk of uterine atony and subsequent postpartum hemorrhage.

Question 58

A 32 y/o G1P1 is undergoing active management of the third stage of labor. Controlled cord traction is performed to deliver the placenta.

Questions:

What is the role of counter traction during controlled cord traction (CCT)?
A. To assist in faster placental delivery
B. To stabilize the uterus and prevent uterine inversion
C. To promote uterine contraction
D. To increase blood flow to the uterus

What should be avoided during controlled cord traction?
A. Gentle traction on the umbilical cord
B. Application of counter traction above the symphysis pubis
C. Pulling on the cord before placental separation
D. Massage of the uterine fundus after placental delivery

Answer 58

B. To stabilize the uterus and prevent uterine inversion
Rationale: Counter traction stabilizes the uterus and reduces the risk of uterine inversion during controlled cord traction.

C. Pulling on the cord before placental separation
Rationale: Premature traction on the umbilical cord before placental separation can lead to uterine inversion or retained placenta.

Question 59

A 35 y/o G3P2 delivers a term baby, and the placenta is successfully delivered. The provider performs uterine massage every 15 minutes for the first 2 hours postpartum.

Questions:

What is the purpose of uterine massage in active management of the third stage of labor?
A. To promote placental separation
B. To prevent uterine atony and maintain uterine tone
C. To reduce postpartum pain
D. To assess for retained placental fragments

How frequently should uterine massage be performed during the immediate postpartum period?
A. Every 10 minutes for the first 4 hours
B. Every 30 minutes for the first 2 hours
C. Every 15 minutes for the first 2 hours
D. Only if uterine atony is suspected

Answer 59

B. To prevent uterine atony and maintain uterine tone
Rationale: Uterine massage stimulates contractions and ensures the uterus remains firm, reducing the risk of postpartum hemorrhage.

C. Every 15 minutes for the first 2 hours
Rationale: Regular uterine massage every 15 minutes during the first 2 hours postpartum helps monitor and maintain uterine tone.

Question 60

A 40 y/o G5P4 develops heavy vaginal bleeding immediately after delivery. The placenta has not yet been delivered, and the uterus feels soft and boggy on palpation.

Questions:

What is the first step in managing this patient?
A. Manual removal of the placenta
B. Immediate uterine massage and oxytocin administration
C. Controlled cord traction without counter traction
D. Perform uterine curettage

Why is uterine massage a critical component of active management of the third stage of labor?
A. It reduces placental adherence
B. It promotes uterine relaxation during delivery
C. It stimulates uterine contraction and reduces bleeding
D. It prevents uterine rupture

Answer 60

B. Immediate uterine massage and oxytocin administration
Rationale: Uterine massage and oxytocin are the first-line interventions for uterine atony, the most common cause of immediate postpartum hemorrhage.

C. It stimulates uterine contraction and reduces bleeding
Rationale: Uterine massage promotes contraction, which reduces bleeding by compressing the placental blood vessels.

Question 61

A 25 y/o G2P1 is undergoing active management of the third stage of labor. The provider administers oxytocin and performs controlled cord traction. The uterus is stabilized with the abdominal hand.

Questions:

Why is fundal pressure avoided during active management?
A. It delays placental separation
B. It reduces uterine contractions
C. It increases the risk of uterine inversion
D. It interferes with counter traction

When should uterotonics be administered during active management of labor?
A. Immediately after placental delivery
B. After the umbilical cord is clamped
C. Within 1 minute of delivery of the baby
D. Only if uterine atony is suspected

Answer 61

C. It increases the risk of uterine inversion
Rationale: Fundal pressure can lead to uterine inversion, particularly if the placenta has not fully separated.

C. Within 1 minute of delivery of the baby
Rationale: Early administration of uterotonics is the cornerstone of active management to promote uterine contraction and prevent postpartum hemorrhage.

Question 62

A 30 y/o G2P2 woman develops postpartum hemorrhage due to uterine atony. IV fluids with 20 units of oxytocin are initiated. Bleeding persists, and the physician decides to administer additional pharmacological agents.

Questions:

What is the maximum dose of oxytocin IV infusion that can be administered for PPH management?
A. 1 L of IV fluid
B. 3 L of IV fluid
C. 5 L of IV fluid
D. 4 L of IV fluid

Which uterotonic is contraindicated in a patient with a history of severe asthma?
A. Oxytocin
B. Ergometrine
C. Carboprost (15-methylprostaglandin)
D. Misoprostol

Answer 62

B. 3 L of IV fluid
Rationale: The maximum dose of oxytocin IV infusion is 3 L of fluid containing 20 units of oxytocin. Administering more can lead to water intoxication and other complications.

C. Carboprost (15-methylprostaglandin)
Rationale: Carboprost is contraindicated in patients with asthma as it can cause bronchoconstriction due to its prostaglandin F2-α mechanism of action.

Question 63

A 28 y/o G3P2 develops postpartum hemorrhage. Oxytocin fails to control the bleeding, so the physician administers ergometrine 0.2 mg IM. The patient has a history of preeclampsia.

Questions:

Why is ergometrine contraindicated in this patient?
A. It increases the risk of bronchoconstriction
B. It can cause severe hypertension
C. It worsens uterine atony
D. It is ineffective in preeclampsia

What alternative medication can be safely administered in this scenario?
A. Carboprost
B. Ergometrine IV
C. Misoprostol rectally
D. Carbetocin

Answer 63

B. It can cause severe hypertension
Rationale: Ergometrine is contraindicated in preeclampsia as it causes vasoconstriction, potentially leading to severe hypertension or stroke.

C. Misoprostol rectally
Rationale: Misoprostol is safe for use in patients with preeclampsia and effectively promotes uterine contraction through prostaglandin action.

Question 64

A 35 y/o G4P3 presents with uterine atony and refractory bleeding despite oxytocin administration. The physician administers carboprost IM. After 6 doses, bleeding persists.

Questions:

What is the maximum dose of carboprost for managing PPH?
A. 1 mg
B. 2 mg
C. 3 mg
D. 4 mg

If carboprost fails to control bleeding, what additional pharmacological option can be considered?
A. Ergometrine IV
B. Carbetocin IM
C. Uterine curettage
D. Methylergonovine

Answer 64

B. 2 mg
Rationale: Carboprost is administered at 0.25 mg every 15 minutes, with a maximum total dose of 2 mg (8 doses).

B. Carbetocin IM
Rationale: Carbetocin is a synthetic oxytocin analogue that provides prolonged uterine contraction and is a valid alternative for refractory bleeding.

Question 65

A 40 y/o G5P4 woman with asthma develops postpartum hemorrhage due to uterine atony. The physician administers misoprostol rectally.

Questions:

What is the standard dose of rectal misoprostol for PPH management?
A. 200–400 µg
B. 600 µg
C. 800–1000 µg
D. 1200 µg

What is the mechanism of action of misoprostol?
A. Direct stimulation of myometrial contraction through prostaglandin E1 action
B. Vasoconstriction of uterine arteries
C. Bronchodilation and uterine relaxation
D. Inhibition of platelet aggregation

Answer 65

C. 800–1000 µg
Rationale: The standard dose of misoprostol for PPH is 800–1000 µg, typically administered rectally for optimal absorption.

A. Direct stimulation of myometrial contraction through prostaglandin E1 action
Rationale: Misoprostol is a prostaglandin E1 analogue that directly stimulates myometrial contraction to reduce uterine bleeding.

Question 66

A 29 y/o G2P2 develops postpartum hemorrhage after delivery. Despite oxytocin administration, bleeding persists. The physician administers carbetocin 100 µg IM.

Questions:

What is the advantage of carbetocin over oxytocin in PPH management?
A. Longer duration of action
B. Fewer side effects
C. Rapid onset of action
D. Higher efficacy

What is the contraindication to carbetocin use?
A. Asthma
B. Preeclampsia
C. Severe cardiac disease
D. Retained placenta

Answer 66

A. Longer duration of action
Rationale: Carbetocin is a synthetic long-acting oxytocin analogue, providing sustained uterine contraction for up to 24 hours compared to oxytocin’s shorter duration.

C. Severe cardiac disease
Rationale: Carbetocin, like oxytocin, is contraindicated in patients with severe cardiac disease due to its cardiovascular effects.

Question 67

A 30 y/o G2P2 develops postpartum hemorrhage after delivery. Uterine atony is noted, and bleeding persists despite uterotonics. The physician performs bimanual uterine compression.

Questions:

What is the primary mechanism of action of bimanual uterine compression?
A. Stimulating uterine contraction by manual massage
B. Compressing uterine sinuses to reduce blood flow
C. Angulating the uterine veins to prevent reflux
D. Enhancing oxytocin absorption in the uterus

Which arteries contribute most to the uterine blood supply and are targeted during compression?
A. Uterine and ovarian arteries
B. Iliac and femoral arteries
C. Uterine and renal arteries
D. Ovarian and internal pudendal arteries

Answer 67

B. Compressing uterine sinuses to reduce blood flow
Rationale: Bimanual uterine compression reduces blood flow by compressing the open uterine sinuses and angulating the uterine arteries, effectively controlling bleeding.

A. Uterine and ovarian arteries
Rationale: The uterine artery supplies 90% of the uterine blood flow, with the ovarian artery contributing 10%. Compression reduces flow from these arteries, controlling hemorrhage.

Question 68

A 35 y/o G4P3 with ongoing postpartum hemorrhage is treated with bimanual uterine compression. Bleeding slows significantly but does not completely stop.

Questions:

What is the appropriate next step if bimanual compression does not fully control the bleeding?
A. Perform uterine curettage
B. Apply abdominal aortic compression
C. Perform hysterectomy immediately
D. Administer high-dose misoprostol

How does aortic compression help control postpartum hemorrhage?
A. Angulates the uterine veins to limit reflux
B. Temporarily reduces blood flow to the uterus by compressing the abdominal aorta
C. Directly stimulates uterine contraction by pressure
D. Blocks sympathetic innervation to the uterus

Answer 68

B. Apply abdominal aortic compression
Rationale: If bimanual compression is not fully effective, abdominal aortic compression is a temporary measure to reduce uterine blood flow until definitive treatment is available.

B. Temporarily reduces blood flow to the uterus by compressing the abdominal aorta
Rationale: Aortic compression reduces blood flow to the uterus by occluding the aorta, which limits hemorrhage while further interventions are prepared.

Question 69

A 28 y/o G3P2 develops severe postpartum hemorrhage. The physician applies abdominal aortic compression. Femoral pulses are still palpable despite sustained pressure.

Questions:

What does the presence of a palpable femoral pulse indicate?
A. Compression is effective and adequate
B. Insufficient pressure on the abdominal aorta
C. Increased risk of uterine rupture
D. Hemodynamic stabilization of the patient

What should be done if the femoral pulse remains palpable during aortic compression?
A. Continue observation and monitoring
B. Apply more downward pressure until the femoral pulse is no longer palpable
C. Switch to uterine artery embolization
D. Administer high-dose oxytocin immediately

Answer 69

B. Insufficient pressure on the abdominal aorta
Rationale: Palpable femoral pulses indicate that aortic compression is not effectively reducing blood flow to the uterus.

B. Apply more downward pressure until the femoral pulse is no longer palpable
Rationale: Effective aortic compression requires sufficient pressure to obliterate the femoral pulse, ensuring blood flow to the uterus is minimized.

Question 70

A 40 y/o G5P4 with uterine atony and refractory postpartum hemorrhage is treated with a combination of bimanual uterine compression and aortic compression while preparing for surgical intervention.

Questions:

What is the primary purpose of combining bimanual uterine and aortic compression?
A. To facilitate oxytocin absorption
B. To reduce both uterine blood flow and venous pooling
C. To directly enhance uterine contractions
D. To prevent uterine inversion during bleeding

How long should aortic compression be maintained during postpartum hemorrhage management?
A. Until the patient stabilizes or definitive interventions are performed
B. No longer than 10 minutes to prevent ischemic complications
C. Until bimanual compression is stopped
D. For at least 30 minutes regardless of bleeding control

Answer 70

B. To reduce both uterine blood flow and venous pooling
Rationale: Bimanual compression reduces venous pooling in uterine sinuses, while aortic compression reduces arterial blood supply, synergistically controlling bleeding.

A. Until the patient stabilizes or definitive interventions are performed
Rationale: Aortic compression is a temporary measure to control bleeding and stabilize the patient until surgical or other definitive management is available.

Question 71

A 25 y/o G1P1 with ongoing postpartum hemorrhage is stabilized with IV fluids and bimanual uterine compression. Aortic compression is initiated, and the bleeding subsides.

Questions:

What is the main limitation of aortic compression as a long-term treatment for postpartum hemorrhage?
A. It cannot control bleeding from uterine veins
B. It is only effective for arterial bleeding
C. It is a temporary measure and does not address the underlying cause
D. It requires general anesthesia

What additional intervention should be prepared after stabilization with aortic compression?
A. Uterine artery embolization
B. Uterine massage and observation
C. High-dose steroids
D. Transfusion of blood components only

Answer 71

C. It is a temporary measure and does not address the underlying cause
Rationale: Aortic compression provides temporary control of bleeding and buys time for definitive interventions to address the cause of hemorrhage.

A. Uterine artery embolization
Rationale: After stabilization, definitive interventions like uterine artery embolization or surgical procedures should be performed to achieve long-term bleeding control.

Question 72

A 29 y/o G2P2 develops postpartum hemorrhage due to uterine atony. Uterotonics fail to control the bleeding. The physician decides to use balloon tamponade.

Questions:

What is the primary purpose of uterine tamponade in managing postpartum hemorrhage?
A. Definitively repair uterine rupture
B. Temporarily arrest bleeding by applying pressure to uterine sinuses
C. Prevent uterine inversion
D. Stimulate uterine contraction

What is the advantage of using balloon tamponade over uterine packing?
A. Lower risk of infection and concealed bleeding
B. Faster procedure requiring minimal equipment
C. More effective at stimulating uterine contraction
D. Reduced risk of uterine perforation

Answer 72

B. Temporarily arrest bleeding by applying pressure to uterine sinuses
Rationale: Uterine tamponade works by exerting direct pressure on the open uterine sinuses, thereby controlling bleeding.

A. Lower risk of infection and concealed bleeding
Rationale: Balloon tamponade is preferred due to its lower risk of infection and concealed hemorrhage compared to traditional uterine packing.

Question 73

A 32 y/o G3P3 with ongoing postpartum hemorrhage undergoes balloon tamponade using a Foley catheter fitted with a condom. The condom is inflated with 500 mL of normal saline.

Questions:

How long should the balloon tamponade typically remain in place?
A. 6–12 hours
B. 12–24 hours
C. 24–48 hours
D. Until the uterus is completely contracted

What is the appropriate next step after bleeding is controlled with the tamponade?
A. Immediate deflation of the balloon
B. Gradual deflation over 24–48 hours
C. Immediate removal of the tamponade
D. Surgical intervention

Answer 73

C. 24–48 hours
Rationale: The balloon is typically left in place for 24–48 hours to allow hemostasis before being gradually deflated.

B. Gradual deflation over 24–48 hours
Rationale: Gradual deflation ensures that bleeding does not resume and allows the uterus to contract fully.

Question 74

A 35 y/o G4P3 with uterine atony is treated with uterine balloon tamponade. After insertion, bleeding continues.

Questions:

What should be done if bleeding persists despite balloon tamponade?
A. Increase the volume in the balloon
B. Perform uterine artery embolization or surgical intervention
C. Administer additional uterotonics
D. Remove the balloon and observe

What definitive procedure might be required if tamponade and uterotonics fail to control the bleeding?
A. Repeat balloon tamponade
B. Perform hysterectomy
C. Insert a second tamponade device
D. Administer high-dose misoprostol

Answer 74

B. Perform uterine artery embolization or surgical intervention
Rationale: Persistent bleeding despite tamponade indicates a need for more invasive procedures, such as uterine artery embolization or surgery.

B. Perform hysterectomy
Rationale: Hysterectomy is the definitive treatment for life-threatening hemorrhage that does not respond to conservative measures.

Question 75

A 40 y/o G5P4 presents with postpartum hemorrhage. The physician performs uterine balloon tamponade using a sterile catheter. Bleeding stops after inflation.

Questions:

What material is commonly used to inflate the condom in a balloon tamponade device?
A. Air
B. Normal saline
C. Ringer’s lactate
D. Dextrose 5%

Why is a balloon tamponade preferred over uterine packing?
A. Balloon tamponade requires anesthesia for insertion
B. Balloon tamponade conforms to the uterine contour, distributing pressure evenly
C. Uterine packing is quicker but less effective
D. Balloon tamponade is only effective in traumatic PPH

Answer 75

B. Normal saline
Rationale: The condom or balloon is inflated with 250–500 mL of normal saline to achieve hemostasis.

B. Balloon tamponade conforms to the uterine contour, distributing pressure evenly
Rationale: Balloon tamponade is effective because it conforms to the uterine shape, providing even pressure and minimizing the risk of concealed bleeding or infection.

Question 76

A 28 y/o G1P1 develops severe postpartum hemorrhage. Balloon tamponade is performed, and the bleeding stops. The physician monitors the patient closely.

Questions:

How can the effectiveness of balloon tamponade be assessed?
A. By the cessation of uterine contractions
B. By observing reduced vaginal bleeding
C. By palpating the balloon through the abdomen
D. By confirming with Doppler ultrasound

What complication is least likely with balloon tamponade compared to uterine packing?
A. Uterine overdistention
B. Infection
C. Concealed hemorrhage
D. Uterine inversion

Answer 76

B. By observing reduced vaginal bleeding
Rationale: The effectiveness of balloon tamponade is indicated by a significant reduction or cessation of vaginal bleeding.

C. Concealed hemorrhage
Rationale: Unlike uterine packing, balloon tamponade has a lower risk of concealed hemorrhage because the device conforms to the uterine contour and does not obstruct the outflow of blood.

Question 77

A 28 y/o G2P2 presents with postpartum hemorrhage due to uterine atony. Uterotonics fail to control the bleeding. The surgeon decides to apply B-Lynch sutures.

Questions:

What is the primary mechanism of action of the B-Lynch suture?
A. Enhances uterine contraction by stimulating oxytocin release
B. Provides vertical compression of the uterine walls to arrest bleeding
C. Compresses the ascending uterine arteries to stop bleeding
D. Creates a vascular shunt to bypass uterine sinuses

What is the main limitation of the B-Lynch suture?
A. Ineffective for placenta previa
B. Higher risk of bowel entrapment during uterine involution
C. Requires extensive surgical expertise
D. Longer operating time compared to hysterectomy

Answer 77

B. Provides vertical compression of the uterine walls to arrest bleeding
Rationale: The B-Lynch suture exerts vertical compression on the anterior and posterior uterine walls, effectively controlling bleeding by tamponading the vascular sinuses.

B. Higher risk of bowel entrapment during uterine involution
Rationale: The B-Lynch technique involves vertical sutures that pose a higher risk of trapping bowel loops during uterine involution.

Question 78

A 32 y/o G3P2 with refractory postpartum hemorrhage undergoes uterine compression suturing. The surgeon applies multiple longitudinal and transverse sutures (Pereira technique).

Questions:

What is the advantage of Pereira sutures over B-Lynch sutures?
A. Easier application without laparotomy
B. Better compression and reduced risk of bowel entrapment
C. Shorter operative time and reduced infection risk
D. Does not require exteriorization of the uterus

What structures are directly compressed by Pereira sutures to control bleeding?
A. Uterine fundus and lower uterine segment
B. Uterine arteries and vascular sinuses
C. Placental site and cervix
D. Internal iliac arteries and veins

Answer 78

B. Better compression and reduced risk of bowel entrapment
Rationale: Pereira sutures provide enhanced uterine compression with both longitudinal and transverse sutures, reducing the risk of bowel or omental entrapment.

B. Uterine arteries and vascular sinuses
Rationale: Pereira sutures collapse the ascending uterine branches and compress the vascular sinuses to control bleeding effectively.

Question 79

A 35 y/o G4P3 with uterine atony is treated surgically after medical management fails. The surgeon applies B-Lynch sutures. Postoperatively, the patient develops bowel obstruction symptoms.

Questions:

What is the most likely cause of this complication?
A. Inadequate uterine compression
B. Uterine rupture due to suture placement
C. Bowel loop entrapment during uterine involution
D. Infection at the suture site

How could this complication have been avoided?
A. Use of longitudinal sutures exclusively
B. Application of Pereira sutures instead of B-Lynch sutures
C. Avoiding hysterotomy during the procedure
D. Administering antibiotics preoperatively

Answer 79

C. Bowel loop entrapment during uterine involution
Rationale: B-Lynch sutures are associated with a higher risk of bowel entrapment, especially during uterine involution, due to the vertical compression technique.

B. Application of Pereira sutures instead of B-Lynch sutures
Rationale: Pereira sutures have a lower risk of bowel entrapment because of their comprehensive placement and better uterine wall coverage.

Question 80

A 30 y/o G3P2 with placenta accreta develops massive postpartum hemorrhage during delivery. The surgeon applies Pereira compression sutures, and bleeding stops.

Questions:

What is the main indication for uterine compression sutures in postpartum hemorrhage?
A. Placenta previa with no bleeding
B. Uterine atony refractory to medical management
C. Complete uterine rupture
D. Coagulopathy-induced bleeding

Why are uterine compression sutures preferred over hysterectomy in selected cases?
A. Shorter operative time and reduced skill requirement
B. Preserves uterine anatomy and fertility
C. Eliminates the need for postoperative care
D. Avoids laparotomy in most cases

Answer 80

B. Uterine atony refractory to medical management
Rationale: Uterine compression sutures are indicated in cases of uterine atony and other causes of PPH when medical management fails to control bleeding.

B. Preserves uterine anatomy and fertility
Rationale: Compression sutures conserve the uterus, making them a preferred option in women who wish to preserve fertility.

Question 81

A 28 y/o G2P1 undergoes uterine compression suturing for postpartum hemorrhage. The surgeon explains that the patient will be monitored for infection and bowel complications postoperatively.

Questions:

What postoperative complication is more likely with the B-Lynch technique compared to Pereira sutures?
A. Uterine rupture
B. Bowel entrapment and strangulation
C. Vaginal bleeding recurrence
D. Thrombosis

What factor contributes to the lower risk of infection with Pereira sutures?
A. Simpler technique requiring fewer sutures
B. Better suture placement and reduced tissue trauma
C. Exclusive use of absorbable sutures
D. Avoidance of uterine exteriorization

Answer 81

B. Bowel entrapment and strangulation
Rationale: B-Lynch sutures, being vertical, carry a higher risk of bowel or omental entrapment during uterine involution compared to Pereira sutures.

B. Better suture placement and reduced tissue trauma
Rationale: Pereira sutures involve longitudinal and transverse placement, ensuring better coverage and reduced trauma, which lowers the risk of infection.

Question 82

A 30 y/o G2P2 presents with postpartum hemorrhage after a cesarean section. Uterotonics and uterine compression fail to control the bleeding. She is hemodynamically stable, and the physician decides to perform arterial embolization.

Questions:

What is the primary mechanism of arterial embolization in controlling postpartum hemorrhage?
A. Direct stimulation of uterine contraction
B. Surgical ligation of the uterine artery
C. Temporary occlusion of bleeding vessels using embolic agents
D. Reduction of blood flow by compressing the abdominal aorta

Why is arterial embolization preferred over hysterectomy in this scenario?
A. It is faster than hysterectomy
B. It eliminates the risk of infection
C. It preserves fertility while controlling bleeding
D. It does not require imaging equipment

Answer 82

C. Temporary occlusion of bleeding vessels using embolic agents
Rationale: Arterial embolization involves placing embolic materials in the target vessels to temporarily occlude blood flow and control hemorrhage.

C. It preserves fertility while controlling bleeding
Rationale: Arterial embolization is a minimally invasive procedure that preserves the uterus, making it ideal for patients who wish to maintain fertility.

Question 83

A 28 y/o G3P3 with refractory postpartum hemorrhage undergoes arterial embolization. The procedure successfully controls the bleeding. Postoperatively, she develops mild fever and localized pain at the catheter insertion site.

Questions:

What is the most likely complication in this patient?
A. Buttock ischemia
B. Uterine necrosis
C. Localized hematoma and infection
D. Vascular perforation

How can the risk of complications from arterial embolization be minimized?
A. Use general anesthesia during the procedure
B. Limit the duration of embolization to 15 minutes
C. Ensure proper aseptic technique and skilled operator intervention
D. Avoid the use of gel foam pledgets

Answer 83

C. Localized hematoma and infection
Rationale: Localized fever, pain, and swelling at the catheter site are common complications due to hematoma or mild infection post-procedure.

C. Ensure proper aseptic technique and skilled operator intervention
Rationale: Proper aseptic technique and expertise during catheter insertion reduce the risk of infection and procedural complications.

Question 84

A 35 y/o G4P3 develops severe postpartum hemorrhage. Arterial embolization is performed successfully. The patient is informed about potential serious complications of the procedure.

Questions:

Which of the following is a serious complication of arterial embolization?
A. Buttock ischemia
B. Prolonged fever
C. Uterine atony
D. Pelvic hematoma

What is the mechanism of buttock ischemia in arterial embolization?
A. Dislodgement of embolic agents into systemic circulation
B. Accidental embolization of branches supplying the gluteal region
C. Prolonged procedure time leading to vascular spasm
D. Excessive blood loss during the procedure

Answer 84

A. Buttock ischemia
Rationale: Buttock ischemia is a rare but serious complication due to accidental embolization of gluteal artery branches.

B. Accidental embolization of branches supplying the gluteal region
Rationale: Misplacement of embolic material can block blood flow to the gluteal arteries, leading to ischemia in the buttock region.

Question 85

A 40 y/o G5P4 with cervical hemorrhage post-conization undergoes arterial embolization. During the procedure, the interventional radiologist identifies the bleeding vessels.

Questions:

Which imaging modality is used to guide arterial embolization?
A. Ultrasound
B. Fluoroscopy
C. Magnetic resonance imaging (MRI)
D. Computed tomography (CT)

What is the average duration of the actual embolization process?
A. 15–30 minutes
B. 45–60 minutes
C. 90–120 minutes
D. 2–3 hours

Answer 85

B. Fluoroscopy
Rationale: Arterial embolization is performed under fluoroscopic guidance, allowing real-time visualization of the target vessels.

B. 45–60 minutes
Rationale: The actual embolization process takes approximately 45–60 minutes, though the total procedure time may extend to 1–3 hours.

Question 86

A 29 y/o G2P1 undergoes arterial embolization for postpartum hemorrhage. The bleeding is controlled, but the patient is concerned about long-term effects.

Questions:

What is a significant long-term benefit of arterial embolization compared to hysterectomy?
A. It avoids the need for anesthesia
B. It does not require catheter insertion
C. It preserves reproductive function
D. It eliminates the risk of infection

What is a potential long-term complication of arterial embolization?
A. Persistent uterine contraction
B. Uterine necrosis
C. Secondary hemorrhage
D. Recurrent pelvic infections

Answer 86

C. It preserves reproductive function
Rationale: Arterial embolization is fertility-preserving, making it an excellent alternative to hysterectomy for women desiring future pregnancies.

B. Uterine necrosis
Rationale: Uterine necrosis is a rare but serious long-term complication caused by excessive or improper embolization, leading to ischemia of uterine tissue.

Question 87

A 32 y/o G2P2 presents with persistent postpartum hemorrhage. She is hemodynamically stable, and the decision is made to perform internal iliac artery ligation.

Questions:

What is the primary purpose of internal iliac artery ligation in managing postpartum hemorrhage?
A. Completely occluding uterine blood flow
B. Reducing arterial pulse pressure by 85% to promote clot formation
C. Stimulating uterine contractions to control bleeding
D. Preventing ovarian blood supply

What is the most significant technical challenge associated with internal iliac artery ligation?
A. Isolation of the ureter during the procedure
B. Difficulty in locating the ovarian arteries
C. High failure rate compared to hysterectomy
D. Increased risk of uterine rupture

Answer 87

B. Reducing arterial pulse pressure by 85% to promote clot formation
Rationale: Internal iliac artery ligation reduces the pressure in the pelvic vasculature, allowing clot formation and hemostasis.

A. Isolation of the ureter during the procedure
Rationale: The ureter lies close to the internal iliac artery and must be carefully isolated to prevent injury during ligation.

Question 88

A 28 y/o G3P3 with postpartum hemorrhage undergoes bilateral uterine artery ligation. The bleeding is successfully controlled.

Questions:

What percentage of the uterine blood supply is controlled by uterine artery ligation?
A. 50%
B. 75%
C. 90%
D. 100%

Where are sutures placed during bilateral uterine artery ligation (BUAL)?
A. 1–2 cm lateral to the ascending uterine artery
B. 2–3 cm medial to the ascending uterine artery
C. At the base of the internal iliac artery
D. Along the infundibulopelvic ligament

Answer 88

C. 90%
Rationale: The uterine arteries provide 90% of the uterine blood supply, making their ligation highly effective for hemorrhage control.

B. 2–3 cm medial to the ascending uterine artery
Rationale: Sutures are placed medial to the ascending uterine artery to avoid damaging the artery directly and to effectively reduce blood flow.

Question 89

A 34 y/o G4P3 with uterine atony undergoes both uterine artery and ovarian artery ligation after persistent bleeding.

Questions:

What percentage of the uterine blood supply is addressed by ovarian artery ligation?
A. 5%
B. 10%
C. 25%
D. 50%

At what anatomical location is the ovarian artery ligated?
A. At its origin from the abdominal aorta
B. High on the uterine fundus, just below the utero-ovarian ligament
C. At the level of the internal iliac artery
D. Within the infundibulopelvic ligament

Answer 89

B. 10%
Rationale: The ovarian arteries contribute approximately 10% of the uterine blood supply and are targeted when uterine artery ligation is insufficient.

B. High on the uterine fundus, just below the utero-ovarian ligament
Rationale: Ovarian artery ligation is performed at the anastomosis of the ovarian and uterine arteries, close to the utero-ovarian ligament.

Question 90

A 40 y/o G5P4 presents with intractable postpartum hemorrhage. Uterine compression sutures and arterial ligation fail to control the bleeding. The decision is made to perform a hysterectomy.

Questions:

What is the primary indication for hysterectomy in postpartum hemorrhage?
A. Persistent uterine atony with hemodynamic stability
B. Intractable hemorrhage unresponsive to conservative measures
C. Presence of a broad ligament hematoma
D. Failed uterine balloon tamponade

What is the main disadvantage of performing a hysterectomy in postpartum hemorrhage?
A. Higher risk of infection compared to arterial ligation
B. Loss of reproductive potential
C. Increased failure rate compared to selective devascularization
D. Requires expertise in interventional radiology

Answer 90

B. Intractable hemorrhage unresponsive to conservative measures
Rationale: Hysterectomy is a last-resort intervention for postpartum hemorrhage when all conservative and surgical measures fail.

B. Loss of reproductive potential
Rationale: The main disadvantage of hysterectomy is that it permanently eliminates fertility, which may not be acceptable to all patients.

Question 91

A 29 y/o G1P1 with severe postpartum hemorrhage undergoes transvaginal uterine artery ligation. The procedure is successful, and the patient stabilizes.

Questions:

What is a notable advantage of transvaginal uterine artery ligation?
A. Reduced operative time compared to laparotomy
B. Controls ovarian blood supply directly
C. Avoids the need for general anesthesia
D. Does not require suturing

What is the reported success rate of bilateral uterine artery ligation (BUAL) in controlling postpartum hemorrhage?
A. 50%
B. 75%
C. 96%
D. 100%

Answer 91

A. Reduced operative time compared to laparotomy
Rationale: Transvaginal uterine artery ligation avoids the need for laparotomy, reducing operative time and morbidity.

C. 96%
Rationale: Bilateral uterine artery ligation has a reported success rate of over 96% in controlling postpartum hemorrhage.

Question 92

A 28 y/o G2P2 delivered vaginally 10 days ago presents with vaginal bleeding. She reports soaking through two sanitary pads per hour. On examination, her uterus is enlarged and tender.

Questions:

What is the most likely cause of her late postpartum hemorrhage (PPH)?
A. Uterine rupture
B. Uterine subinvolution
C. Coagulation disorder
D. Uterine atony

What is the first-line management for this condition?
A. Immediate blood transfusion
B. Antibiotics and uterotonics
C. Balloon tamponade
D. Surgical curettage

Answer 92

B. Uterine subinvolution
Rationale: Late PPH is often caused by uterine subinvolution due to infection, retained placental fragments, or poor healing of the placental site.

B. Antibiotics and uterotonics
Rationale: Uterotonics promote uterine contraction, and antibiotics treat any underlying infection contributing to subinvolution.

Question 93

A 35 y/o G3P3 develops significant vaginal bleeding 8 hours postpartum. She is anxious, with a pulse rate of 110/min, blood pressure of 100/70 mmHg, and urine output of 25 mL/hr. Estimated blood loss is 1,000 mL.

Questions:

What percentage of blood volume loss does this patient have?
A. <15%
B. 15–25%
C. 30–40%
D. >40%

What is the appropriate initial management for this patient?
A. Close monitoring only
B. Volume replacement with crystalloids
C. Immediate blood transfusion
D. Emergency hysterectomy

Answer 93

B. 15–25%
Rationale: Blood loss of 750–1,500 mL corresponds to 15–25% of total blood volume, indicated by a pulse rate >100/min and urine output of 20–30 mL/hr.

B. Volume replacement with crystalloids
Rationale: For 15–25% blood loss, fluid resuscitation with crystalloids is the first step before considering blood transfusion if bleeding persists.

Question 94

A 30 y/o G2P1 with postpartum hemorrhage becomes hypotensive with a pulse rate of 130/min and urine output of 10 mL/hr. Estimated blood loss is 1,800 mL.

Questions:

What classification of blood volume loss does this patient fall under?
A. <15%
B. 15–25%
C. 30–40%
D. >40%

What is the most appropriate management at this stage?
A. Close monitoring and uterotonics
B. Volume replacement with crystalloids
C. Immediate blood transfusion
D. Uterine artery embolization

Answer 94

C. 30–40%
Rationale: Blood loss of 1,500–2,000 mL corresponds to 30–40% blood volume loss, presenting with hypotension, tachycardia >120/min, and oliguria.

C. Immediate blood transfusion
Rationale: For 30–40% blood loss, blood transfusion is required to restore circulatory volume and oxygen-carrying capacity.

Question 95

A 25 y/o G1P1 presents with postpartum hemorrhage estimated at >2,000 mL. She is lethargic, with a pulse rate of 145/min, BP of 80/50 mmHg, and no urine output in the past hour.

Questions:

What is the classification of blood volume loss in this patient?
A. 15–25%
B. 30–40%
C. >40%
D. 50%

What is the immediate management for this patient?
A. Volume replacement with crystalloids and close monitoring
B. Blood transfusion and surgical intervention
C. Uterotonics and uterine massage
D. Antibiotics and uterine packing

Answer 95

C. >40%
Rationale: Blood loss >2,000 mL corresponds to >40% blood volume loss, presenting with severe hypotension, marked tachycardia, anuria, and lethargy.

B. Blood transfusion and surgical intervention
Rationale: Immediate blood transfusion is needed for hemodynamic instability, and surgical intervention may be required if conservative measures fail.

Question 96

A 38 y/o G4P4 presents 7 days postpartum with heavy vaginal bleeding and an enlarged, tender uterus. Her vitals are stable. Ultrasound reveals retained placental fragments.

Questions:

What is the underlying cause of this patient’s late postpartum hemorrhage?
A. Uterine atony
B. Retained placental fragments
C. Uterine rupture
D. Coagulation disorder

What is the most appropriate next step in management?
A. Antibiotics only
B. Immediate surgical curettage
C. Balloon tamponade
D. Uterotonics and uterine massage

Answer 96

B. Retained placental fragments
Rationale: Retained placental fragments are a common cause of late PPH and are associated with an enlarged, tender uterus and persistent bleeding.

B. Immediate surgical curettage
Rationale: Curettage removes retained placental tissue, which is the source of bleeding. Antibiotics may also be administered to prevent or treat infection.