Obstetric Hemorrhage (Moulton)

Question 1

In the initial evaluation of antepartum hemorrhage, you want to type and crossmatch for ___ units of blood.

Answer 1

4

Question 2

One unit (250-300cc) of PRBC will raise the __1__ by 3% and __2__ by 1 g/dL.

Answer 2

1) Hct

2) Hgb

Question 3

In the initial evaluation of antepartum hemorrhage, you want to avoid digital exam until ____ has been ruled out by US.

Answer 3

Placenta previa

Question 4

In the initial evaluation of antepartum hemorrhage, a sterile speculum exam is used to look for?

A digital exam is used to assess?

Answer 4

1) Genital lacerations or cervical lesions (cancer, polyps)

2) Cervical dilation

Question 5

Abortions, ectopics, cervical/vaginal etiology (cancer, trauma, polyps), subchorionic hemorrhage/retroplacental clot, and cervical insufficiency can all present with vaginal bleeding at what time?

Answer 5

Before 20 weeks

Question 6

Placental Abruption, Placenta Previa, Uterine rupture, and Vasa previa can all present with vaginal bleeding from the what part of the genital tract?

They result in vaginal bleeding when?

Answer 6

1) Upper genital tract

2) After 20 weeks

Question 7

Cervical polyps, infections, trauma, cancer, vulvar varicosities, and blood dyscrasia an all present with vaginal bleeding from the what part of the genital tract?

They result in vaginal bleeding when?

Answer 7

1) Lower genital tract

2) After 20 weeks

Question 8

What is the most common type of abnormal placentation and accounts for about 20% of all cases of antepartum hemorrhages?

Answer 8

Placenta previa

Question 9

Placenta previa is defined as the implantation of the placenta over the?

It presents classically as?

Answer 9

1) Cervical os

2) Painless vaginal bleeding

Question 10

Maternal age greater than what age is a risk factor for placenta previa?

Multiparity or nulliparity is a risk factor?

Use of what substances are risk factors?

What previous procedure increases risk?

Answer 10

1) 35 y/o
2) Multiparity
3) Cocaine and smoking
4) Cesarean section

Question 11

In the classifications of placenta previa, __1__ is characterized by the edge of the placenta extending to the edge of the cervical os and it does not cover the os.

__2__ is characterized by only slight occlusion of the cervical os by the placenta.

__3__ is characterized by cervical os being fully covered by the placenta and is the most serious type as it is associated with greater blood loss.

Answer 11

1) Marginal
2) Partial
3) Complete

Question 12

With placenta previa the mean gestational age bleeding that occurs is at ___ weeks.

Answer 12

30 weeks

Question 13

90% of placenta previa will resolve by 32-35 weeks by a phenomenon known as ____.

Answer 13

Placental migration

Question 14

__1__ is characterized by abnormal firm attachment to the superficial lining of the myometrium.

__2__ is characterized by invasion into myometrium.

__3__ is characterized by invasion through the myometrium into the uterine serosa.

Which are the most and least common?

Answer 14

1) Placenta accreta (Most common)
2) Placenta increta
2) Placenta percreta (Least common)

Question 15

Previous cesarean section and placenta previa increases the incidence of?

Answer 15

Placenta accreta

Question 16

What is defined as premature separation of the normally implanted placenta?

Answer 16

Placental abruption

Question 17

Placental abruption is the most common cause of __1__ trimester bleeding.

It classically presents as __2__ bleeding.

Answer 17

1) Third

2) Painful

Question 18

What is the most common risk factor for placental abruption?

Use of what substance is a risk factor?

What preceding event is a risk factor?

Polyhydramnios or oligohydramnios is a risk factor?

Multiparity or nulliparity is a risk factor?

Answer 18

1) Maternal HTN
2) Cocaine use
3) Physical trauma (MVA and physical abuse)
4) Polyhydramnios
5) Multiparity

Question 19

If a 36 year old pregnant patient presents with painless vaginal bleeding what is the diagnosis?

If a patient presents with painful vaginal bleeding, uterine tenderness, uterine hyperactivity, and fetal death what is the diagnosis?

Answer 19

1) Placenta previa

2) Placental abruption

Question 20

Placental abruption is the most common cause of __1__ in pregnancy.

It results from the release of __2__ from the disrupted placenta and subplacental decidua causing a consumptive coagulopathy.

Answer 20

1) DIC

2) Thromboplastin

Question 21

Placental abruption can result in couvelaire uterus which is characterized by extravasation of blood into the uterus causing ____ of the serosa.

Answer 21

Red and purple discoloration

Question 22

What implies complete separation of the uterine musculature through all of its layers?

Answer 22

Uterine rupture

Question 23

What is the most common risk factor for uterine rupture?

Answer 23

Prior uterine incision such as from C-section or myomectomy

Question 24

Uterine rupture is associated with sudden onset of ___ along with +/- vaginal bleeding.

Answer 24

Intense abdominal pain

Question 25

What must be done for future pregnancies due to previous uterine rupture?

Answer 25

Deliver via C-section

Question 26

What is a rare but important cause of third trimester bleeding? It is often secondary to velamentous insertion of?

Answer 26

1) Rupture of fetal vessel | 2) Umbilical cord

Question 27

Velamentous insertion of umbilical cord is characterized by the cord inserting at a distance away from the placenta and it’s vessels must traverse between the chorion and amnion without the protective __1__. If unprotected vessels pass over the cervical os it is termed a __2__.

Answer 27

1) Wharton’s jelly | 2) Vasa previa

Question 28

Postpartum Hemorrhages can be classified as primary which occurs within __1__. Or classified as secondary with occurs within __2__.

Answer 28

1) First 24 hours | 2) 24 hours to 12 weeks

Question 29

Primary postpartum hemorrhage is secondary to ____ 80% of the time.

Answer 29

Uterine atony

Question 30

Postpartum Hemorrhage is the leading cause of?

Answer 30

Maternal death

Question 31

Subinvolution of the uterus, sloughing of the eschar or retained products are the etiologies of?

Answer 31

Secondary postpartum hemorrhages

Question 32

The excessive blood loss seen with uterine atony most commonly results when the uterus ____ after delivery of placenta.

Answer 32

Fails to contract

Question 33

What is done in the management of uterine atony?

Answer 33

Bimanual massage of the uterus

Question 34

What is commonly given prophylactically after delivery of the infant or placenta in the management of uterine atony?

Answer 34

Oxytocin (Pitocin)

Question 35

Methylergonovine (Methergine) can be given in the management of uterine atony but is contraindicated in __1__ patients. 15- Methyl prostaglandin F2a (Hemabate) can be given in the management of uterine atony but is contraindicated in __2__ patients. Dinoprostone (Prostin E2) can be given in the management of uterine atony but is contraindicated in __3__ patients.

Answer 35

1) HTN 2) Asthmatics 3) Hypotensive

Question 36

In the diagnosis of uterine atony, palpation will reveal a ___ uterus.

Answer 36

Boggy

Question 37

In the management of uterine atony, a 4 inch gauze layer back and forth from one cornu to the other using a sponge stick is known as?

Answer 37

Uterine packing

Question 38

If patient has stable vitals and persistent bleeding they may be a candidate for use of what interventional radiology in the management of uterine atony?

Answer 38

Arterial embolization

Question 39

Surgery in the management of uterine atony is the last resort and if patient desires future fertility the surgeon may try to? If they are unstable then they must proceed with?

Answer 39

1) Ligate uterine arteries | 2) Total abdominal hysterectomy

Question 40

What is the second most common cause of postpartum hemorrhage?

Answer 40

Trauma during delivery

Question 41

About 50% of patients with secondary postpartum hemorrhages have __1__. Bleeding is secondary to inability of uterus to maintain a __2__ and involute normally around the placental tissue mass.

Answer 41

1) Retained placental fragments | 2) Contraction

Question 42

Previous c-section, leiomyomas, prior D&C, and accessory (succenturiate) placenta lobe are all risk factors for?

Answer 42

Retained placenta

Question 43

What is characterized by the top of the fundus descending into the vagina and sometimes through the cervix? If this occurs before placenta is delivered DO NOT remove placenta until?

Answer 43

1) Uterine inversion | 2) Inversion is corrected

Question 44

What cause of postpartum hemorrhage is thought to be caused by infusion of amniotic fluid into maternal circulation and is characterized by respiratory distress, cyanosis, and cardiovascular collapse?

Answer 44

Amniotic fluid embolism

Question 45

What inherited coagulopathy with prolonged bleeding times can cause postpartum hemorrhage? It is due to what deficiency?

Answer 45

1) von Willebrand's disease | 2) Factor VIII

Question 46

What coagulation disorder is a cause of postpartum hemorrhage and is characterized by platelets functioning abnormally and have a shorter life span?

Answer 46

Idiopathic thrombocytopenia

Question 47

Circulating antiplatelet antibodies of the ____ type can occasionally cross placenta resulting in fetal and neonatal thrombocytopenia.

Answer 47

IgG

Question 48

Fresh frozen plasma and Cryoprecipitate can increase ____ by 10 mg/dl. Cryoprecipitate can be used to treat?

Answer 48

1) Fibrinogen | 2) von Willebrand's disease

Question 49

__1__ is characterized by women developing a febrile morbidity following delivery. Most of the fevers are due to __2__.

Answer 49

1) Puerperal sepsis | 2) Endometritis

Question 50

In the etiology of puerperal sepsis, after deliver the pH of the vagina becomes more ____.

Answer 50

Alkaline

Question 51

____ organisms cause about 70% of puerperal infections. Most are cocci such as?

Answer 51

1) Anaerobic | 2) Peptostreptococcus, Peptococcus, and Streptococcus

Question 52

What aerobic infection is the most common cause of puerperal sepsis?

Answer 52

E. coli

Question 53

Postpartum fever and increasing uterine tenderness on postpartum day 2 to 3 are the key clinical findings for?

Answer 53

Puerperal sepsis

Question 54

What broad-spectrum antibiotic regimens are effective first line drugs for the management of puerperal sepsis? The major pathogen that is resistant to this combination is? This pathogen is usually sensitive to?

Answer 54

1) Ampicillin and Gentamicin 2) Bacteroides fragilis 3) Clindamycin

Question 55

Fever and abdominal pain within 1 week after delivery or surgery along with patient appearing clinically ill (fever, abdominal pain, localized to the side of the affected vein) is diagnostic of which septic pelvic thrombophlebitis?

Answer 55

Ovarian vein thrombophlebitis

Question 56

Unlocalized fever in the first few days after delivery that is non responsive to antibiotics and the patient does not appear clinically ill is diagnostic of which septic pelvic thrombophlebitis?

Answer 56

Deep Septic Pelvic Vein Thrombophlebitis

Question 57

Because anticoagulation is thought to prevent further thrombosis, what should be given to treat septic pelvic thrombophlebitis?

Answer 57

Unfractionated Heparin or low molecular weight heparin

Question 58

Which septic pelvic thrombophlebitis may be seen radiographically?

Answer 58

Ovarian vein thrombophlebitis