[SEM2 OB-GYNE] Hemorrhage in Pregnancy/ Abortion & Ectopic Pregnancy

Question 1

Which type of abortion is most likely associated with profuse vaginal bleeding?

Choices:
A. Inevitable abortion
B. Missed abortion
C. Threatened abortion
D. Incomplete abortion

Answer 1

D. Incomplete abortion

High-Yield Rationale:
Incomplete abortion presents with profuse vaginal bleeding due to partial expulsion of the products of conception while some remain in the uterus. This retained tissue causes the uterus to contract irregularly, leading to significant bleeding.

Why not the others:

A. Inevitable abortion – Cervix is open with products in utero but no expulsion yet; bleeding is usually moderate.

B. Missed abortion – No bleeding; fetus nonviable but retained.

C. Threatened abortion – Cervix is closed with only mild spotting, no passage of tissue.

Question 2

A 24-year-old patient, 18 weeks amenorrhea, presents with vaginal spotting. No fetal heart tones are appreciated by Doppler. The cervix is closed and the uterus is enlarged to 14-week size with no bleeding noted per vaginal canal. The working diagnosis is Missed Abortion. What is the first step in management?

Choices:
A. Dilatation and Curettage
B. Prostaglandin vaginal suppository
C. Oxytocin IV drip
D. Observation

Answer 2

B. Prostaglandin vaginal suppository

High-Yield Rationale:
At 18 weeks, the appropriate management for missed abortion is medical induction of uterine evacuation using prostaglandins. Surgical options like D&C are less preferred at this gestational age due to increased uterine size and risk of complications.

Why not the others:

A. Dilatation and Curettage – Preferred only for <12–14 weeks gestation.

C. Oxytocin IV drip – Less effective than prostaglandins for 2nd trimester evacuation.

D. Observation – Not advisable as retention increases risk of coagulopathy and infection.

Question 3

A 28-year-old, G2P1, 6 weeks gestation presents with vaginal spotting. Abdomen is soft and non-tender. Cervix is closed and uterus is enlarged to 6-week size. Impression is Threatened Abortion. Which differential diagnosis should be highly considered?

Choices:
A. Missed miscarriage
B. Ectopic pregnancy
C. Molar pregnancy
D. Inevitable abortion

Answer 3

B. Ectopic pregnancy

High-Yield Rationale:
In early pregnancy with spotting, ectopic pregnancy must always be ruled out even if the cervix is closed. It may present similarly to threatened abortion, but missing an ectopic can be life-threatening.

Why not the others:

A. Missed miscarriage – No bleeding expected; often asymptomatic.

C. Molar pregnancy – Usually presents with exaggerated symptoms like hyperemesis and larger uterine size.

D. Inevitable abortion – Cervix is open, which is not the case here.

Question 4

A 30-year-old, G5P3, with 12 weeks amenorrhea presents with intermittent vaginal spotting and hypogastric pain. On exam, cervix is closed, uterus is 12-week size, and fetal heart tones are present by Doppler. What is the most likely diagnosis?

Choices:
A. Threatened abortion
B. Hydatidiform mole
C. Inevitable miscarriage
D. Ectopic gestation

Answer 4

A. Threatened abortion

High-Yield Rationale:
Threatened abortion presents with a closed cervix, live intrauterine pregnancy (confirmed via FHT), and mild spotting or pain. No expulsion of products has occurred.

Why not the others:

B. Hydatidiform mole – FHT would not be present; usually no live fetus.

C. Inevitable miscarriage – Cervix is open and FHT usually absent.

D. Ectopic gestation – Uterus is not typically enlarged to gestational age and FHT wouldn’t be detected intrauterinely.

Question 5

A 19-year-old primigravid at 16 weeks’ gestation presents with watery vaginal discharge and lumbosacral pain. On exam, cervix is open, membranes are ruptured, and uterus is 16-week size. What is the most appropriate management?

Choices:
A. Oxytocin IV drip
B. Watchful waiting
C. Tocolysis
D. Curettage

Answer 5

A. Oxytocin IV drip

High-Yield Rationale:
Second-trimester inevitable abortion with ruptured membranes and open cervix should be managed with oxytocin-induced evacuation. The goal is to complete the abortion and prevent infection.

Why not the others:

B. Watchful waiting – Increases risk of infection (e.g., chorioamnionitis).

C. Tocolysis – Contraindicated when membranes have ruptured.

D. Curettage – Not the first-line in second trimester unless bleeding is heavy or incomplete abortion occurs.

Question 6

A 32-year-old, G4P0(0-0-3-0), at 28 weeks’ gestation had a cervical cerclage placed at 16 weeks. She is advised strict prenatal follow-up and must rush to the hospital at the onset of labor pains to prevent which complication?

Choices:
A. Intrauterine infection
B. Antepartum hemorrhage
C. Uterine rupture
D. Fetal demise

Answer 6

C. Uterine rupture

High-Yield Rationale:
Labor with an intact cerclage may cause mechanical resistance to cervical dilation, increasing the risk of uterine rupture. Patients must report immediately when labor begins so the cerclage can be removed.

Why not the others:

A. Intrauterine infection – A risk with prolonged rupture, not directly from labor with cerclage.

B. Antepartum hemorrhage – Not the direct risk in this context.

D. Fetal demise – A possible complication of uterine rupture, but not the primary concern triggering immediate hospital rush.

Question 7

A 28-year-old, 6 weeks pregnant, presents with vaginal spotting and a positive pregnancy test. Transvaginal ultrasound is non-diagnostic. Serum beta-hCG is <1,500 mIU/mL. When should the repeat assay be done to rule in/out uterine pregnancy, abortion, or ectopic pregnancy?

Choices:
A. 24 hours
B. 48 hours
C. 72 hours
D. 96 hours

Answer 7

B. 48 hours

High-Yield Rationale:
Serum beta-hCG should be repeated in 48 hours to assess for appropriate doubling. In viable intrauterine pregnancies, hCG rises by at least 66% every 48 hours. A plateau or suboptimal rise suggests ectopic or failed pregnancy.

Why not the others:

A. 24 hours – Too early for meaningful trend evaluation.

C. 72 hours – Acceptable in practice but 48 hours is standard.

D. 96 hours – Delay could risk missing ectopic pregnancy diagnosis.

Question 8

What is the cause of recurrent pregnancy loss in patients with Antiphospholipid Antibody Syndrome (APAS)?

Choices:
A. Increased prostacyclin release
B. Placental thrombosis and infarction
C. Increased platelet activation
D. Protein C activation

Answer 8

B. Placental thrombosis and infarction

High-Yield Rationale:
APAS is an autoimmune thrombophilic condition that causes fetal loss due to placental infarction from thrombosis, impairing perfusion.

Why not the others:

A. Increased prostacyclin release – Prostacyclin is vasodilatory and antithrombotic, not prothrombotic.

C. Increased platelet activation – May occur but not the primary mechanism for fetal loss.

D. Protein C activation – Protein C is anticoagulant; deficiency is more relevant to thrombosis, not activation.

Question 9

On her 6th hour post-partial salpingectomy for ruptured tubal gestation, a 25-year-old patient passed tissue per vagina. What is the most probable identity of the flesh-like tissue?

Choices:
A. Placental tissues
B. Organized blood clot
C. Products of conception
D. Decidual cast

Answer 9

D. Decidual cast

High-Yield Rationale:
After ectopic pregnancy surgery, decidual changes in the endometrium may slough off, presenting as a decidual cast. This is a non-fetal, endometrial structure expelled from the uterus.

Why not the others:

A. Placental tissues – Placenta did not form in the uterus in ectopic pregnancy.

B. Organized blood clot – Lacks structure and shape typical of a decidual cast.

C. Products of conception – Already removed surgically from the tube.

Question 10

A 37-year-old, G4P0(0-0-3-0), at 18 weeks gestation has had repeated 2nd-trimester miscarriages described as watery discharge followed by expulsion. On exam, cervix is 2 cm dilated, uneffaced, with prolapsing membranes. FHT is (+). What is the likely cause of her recurrent pregnancy loss?

Choices:
A. Septate uterus
B. Antiphospholipid Antibody Syndrome (APAS)
C. Incompetent cervix
D. Asherman syndrome

Answer 10

C. Incompetent cervix

High-Yield Rationale:
Incompetent cervix presents as painless cervical dilation in the 2nd trimester, often with membrane prolapse and no contractions. It’s a structural cause of recurrent 2nd-trimester losses.

Why not the others:

A. Septate uterus – Causes 1st-trimester losses due to poor implantation.

B. APAS – Thrombotic losses, typically with no cervical changes or membrane prolapse.

D. Asherman syndrome – Associated with intrauterine adhesions causing infertility or amenorrhea, not second-trimester losses.

Question 11

A 28-year-old, G6P5(5-0-0-5) at 30 weeks’ gestation presents to the ER with profuse, painless vaginal bleeding. BP is 80/50 mmHg, PR is 110/min. Fetal monitoring shows a non-reactive tracing. What is the most appropriate treatment?

Choices:
A. Double set-up examination
B. Cesarean delivery
C. Vaginal delivery
D. Expectant management

Answer 11

B. Cesarean delivery

High-Yield Rationale:
Profuse painless bleeding at 30 weeks with non-reactive fetal tracing is classic for Placenta Previa with fetal compromise. Emergency cesarean delivery is indicated for both maternal stabilization and fetal survival.

Why not the others:

A. Double set-up examination – Contraindicated in suspected placenta previa with active bleeding.

C. Vaginal delivery – Not appropriate with previa and fetal compromise.

D. Expectant management – Unsafe due to hemodynamic instability and fetal distress.

Question 12

A 40-year-old, G4P3(3-0-0-3), at 37 weeks with Total Placenta Previa undergoes cesarean delivery. After removing the placenta, profuse bleeding occurs at the implantation site. What is the cause of the hemorrhage?

Choices:
A. Poor contractile nature of the lower uterine segment
B. Inability of the active segment to constrict the torn vessels
C. Ineffective hemostasis in the upper uterine segment
D. Failure of the uterine body to contract

Answer 12

A. Poor contractile nature of the lower uterine segment

High-Yield Rationale:
The lower uterine segment lacks the contractile fibers necessary to constrict spiral arteries, leading to significant bleeding when placenta previa is present.

Why not the others:

B. Inability of the active segment to constrict – Irrelevant; bleeding originates from lower segment.

C. Ineffective hemostasis in upper segment – Not applicable in placenta previa.

D. Failure of uterine body to contract – Not the cause in lower segment hemorrhage.

Question 13

Artificial rupture of membranes is performed on a normotensive G2P1 in labor. Vaginal bleeding and fetal bradycardia occur immediately. What is the most likely diagnosis?

Choices:
A. Uterine rupture
B. Vasa previa
C. Placenta previa
D. Marginal sinus rupture

Answer 13

B. Vasa previa

High-Yield Rationale:
Sudden vaginal bleeding with fetal bradycardia after ROM suggests vasa previa rupture, where fetal vessels traverse the membranes and are torn, causing fetal hemorrhage.

Why not the others:

A. Uterine rupture – Usually in scarred uteri, with severe abdominal pain.

C. Placenta previa – Painless bleeding, not associated with bradycardia post-ROM.

D. Marginal sinus rupture – Minor bleeding, not typically associated with fetal distress.

Question 14

A 32-year-old, G8P5(5-1-1-6), at 39 weeks undergoes cesarean section for placenta previa. No cleavage plane is identified during placental extraction. What is the most appropriate management?

Choices:
A. Manual removal of the placenta
B. Leave the placenta in place and pack the uterus
C. Prompt removal of the uterus
D. Curettage of the uterine cavity

Answer 14

C. Prompt removal of the uterus

High-Yield Rationale:
No cleavage plane indicates placenta accreta spectrum, which is best managed with total abdominal hysterectomy to prevent life-threatening hemorrhage.

Why not the others:

A. Manual removal – Risk of massive hemorrhage.

B. Leave placenta and pack – Temporary measure, not definitive.

D. Curettage – Contraindicated and ineffective in accreta.

Question 15

A 45-year-old, G4P3(3-0-0-3) at 35 weeks with 3 prior cesarean deliveries. What complication should be highly suspected?

Choices:
A. Consumptive coagulopathy
B. Utero-placental apoplexy
C. Uterine atony
D. Placenta accreta

Answer 15

D. Placenta accreta

High-Yield Rationale:
Multiple prior cesarean deliveries increase the risk of placenta accreta, especially if placenta previa is also present. Scarring leads to abnormal placental adherence.

Why not the others:

A. Consumptive coagulopathy – May occur secondary to accreta, not primary concern.

B. Utero-placental apoplexy – Rare complication in severe abruption, not cesarean history.

C. Uterine atony – Common postpartum cause of hemorrhage, but not strongly tied to cesarean history alone.

Question 16

A 26-year-old, G2P1(1-0-0-1), at 33 weeks’ gestation presents with minimal vaginal bleeding. Admitting diagnosis is Placenta Previa. What is the most appropriate treatment?

Choices:
A. Cesarean delivery
B. Vaginal delivery
C. Double set-up examination
D. Expectant management

Answer 16

D. Expectant management

High-Yield Rationale:
In cases of minimal bleeding and stable patient at <36 weeks, the standard approach is expectant management to prolong pregnancy and reduce neonatal prematurity.

Why not the others:

A. Cesarean delivery – Reserved for active bleeding or ≥36–37 weeks.

B. Vaginal delivery – Contraindicated in placenta previa.

C. Double set-up examination – Not indicated in confirmed previa by imaging.

Question 17

What is the amount (in mL/min) of blood that flows through the intervillous space at term?

Choices:
A. 100 mL/min
B. 300 mL/min
C. 600 mL/min
D. 1,000 mL/min

Answer 17

C. 600 mL/min

High-Yield Rationale:
At term, the intervillous space receives about 600 mL/min of maternal blood, crucial for adequate fetal oxygenation and nutrient delivery.

Why not the others:

A. 100 mL/min – Too low, insufficient to meet fetal demands.

B. 300 mL/min – Still suboptimal.

D. 1,000 mL/min – Exceeds the physiologic uteroplacental flow at term.

Question 18

In severe forms of Abruptio Placenta, which therapy can prevent acute renal failure?

Choices:
A. Transfusion of packed RBC
B. Transfusion of fresh whole blood
C. Intravenous diuretics
D. Cryoprecipitate

Answer 18

B. Transfusion of fresh whole blood

High-Yield Rationale:
Fresh whole blood restores volume, oxygen-carrying capacity, and clotting factors, maintaining perfusion to vital organs like the kidneys and preventing ischemic acute tubular necrosis.

Why not the others:

A. Packed RBC – Restores oxygenation but lacks volume expanders and clotting factors.

C. IV diuretics – Contraindicated in hypovolemia.

D. Cryoprecipitate – Corrects coagulopathy but does not restore volume.

Question 19

After cesarean section for Abruptio Placenta, a patient develops profuse bleeding. Labs: Hb 7 mg/dL, Fibrinogen 120 mg/dL, Platelets 40,000/mL, FDPs 110 mg/mL. What is the most likely diagnosis?

Choices:
A. Uterine atony
B. Consumptive coagulopathy
C. Utero-placental apoplexy
D. Couvelaire uterus

Answer 19

B. Consumptive coagulopathy

High-Yield Rationale:
The lab findings (low Hb, low fibrinogen, thrombocytopenia, ↑FDPs) are diagnostic of DIC, which is a severe complication of Abruptio Placenta due to widespread activation of coagulation and fibrinolysis.

Why not the others:

A. Uterine atony – Uterus is boggy but not linked with coagulopathy.

C. Utero-placental apoplexy – Descriptive term for Couvelaire uterus, not a hematologic diagnosis.

D. Couvelaire uterus – Associated with abruptio but not defined by lab derangements.

Question 20

A 40-year-old, G2P2 presents with hypotension, chest and severe abdominal pain. One hour prior, she delivered spontaneously at home. History includes a prior cesarean delivery. Pelvic exam reveals a contracted uterus with a palpable lower uterine tear through which fingers pass into the peritoneal cavity. What is the diagnosis?

Choices:
A. Pulmonary embolism
B. Marginal sinus rupture
C. Abruptio placenta
D. Uterine rupture

Answer 20

D. Uterine rupture

High-Yield Rationale:
The classic triad of sudden abdominal pain, hypotension, and a palpable uterine wall defect in a post-cesarean patient is diagnostic of uterine rupture. Palpation of the defect is pathognomonic.

Why not the others:

A. Pulmonary embolism – Would present with chest pain and dyspnea, not abdominal tear.

B. Marginal sinus rupture – Minor bleeding, no uterine tear.

C. Abruptio placenta – Associated with painful bleeding but no uterine wall disruption.

Question 21

What is the most common cause of uterine rupture?

Choices:
A. Traumatic genital tract injury
B. Separation of a previous cesarean section scar
C. Internal podalic version
D. Labor induction

Answer 21

B. Separation of a previous cesarean section scar

High-Yield Rationale:
The most common cause of uterine rupture is the separation of a previous uterine scar, especially from a lower segment cesarean section. The scar weakens the uterine wall, especially during labor.

Why not the others:

A. Traumatic genital tract injury – Not the most common cause of rupture; more associated with vaginal/perineal injuries.

C. Internal podalic version – Rarely performed and not a major contributor to rupture risk.

D. Labor induction – Increases risk if there is a uterine scar, but not the primary cause.

Question 22

What is the most common predisposing factor for Abruptio Placenta?

Choices:
A. Hypertension
B. Uterine myoma
C. Prior abruption
D. Short umbilical cord

Answer 22

A. Hypertension

High-Yield Rationale:
Chronic or pregnancy-induced hypertension causes vasospasm and vascular fragility, making it the most common risk factor for abruptio placenta, especially in severe or poorly controlled cases.

Why not the others:

B. Uterine myoma – May distort placental attachment, but less common cause.

C. Prior abruption – Strong risk factor but not most common.

D. Short umbilical cord – Associated with mechanical causes but rare.

Question 23

A 28-year-old, G3P2(2-0-0-2), 32 weeks’ gestation with prior cesarean delivery presents with severe abdominal pain and persistent uterine hypertonus. She was kicked in the abdomen by her partner before admission. BP is 80/60, PR is 120/min, FHT is 100/min. What is the most likely diagnosis?

Choices:
A. Placenta previa
B. Abruptio placenta
C. Vasa previa
D. Placenta accreta

Answer 23

B. Abruptio placenta

High-Yield Rationale:
Trauma + uterine hypertonus + abdominal pain + fetal distress + hypotension is classic for abruptio placenta, where premature placental separation causes concealed or revealed hemorrhage and compromise.

Why not the others:

A. Placenta previa – Painless bleeding, no hypertonus or trauma-related origin.

C. Vasa previa – Causes painless bleeding after ROM, not trauma-induced.

D. Placenta accreta – Does not cause acute symptoms; diagnosed on delivery or imaging.

Question 24

Which of the following cases will most likely present as atony of the lower uterine segment?

Choices:
A. A patient with multifetal gestation at term who delivered both babies via vaginal route under general anesthesia
B. A young primigravid who delivered a macrosomic fetus by cesarean section and bled profusely after birth
C. A patient with twin gestation at term who delivered the second twin by internal podalic version followed by breech extraction
D. A multiparous patient who delivered a preterm fetus by cesarean section due to total placenta previa

Answer 24

D. A multiparous patient who delivered a preterm fetus by cesarean section due to total placenta previa

High-Yield Rationale:
Placenta previa involves implantation in the lower uterine segment, which lacks contractile capacity. After delivery, this area fails to contract properly, leading to uterine segment atony and PPH.

Why not the others:

A. Vaginal twin delivery under GA – May cause uterine atony (not lower segment-specific).

B. Primigravid macrosomic C/S – Uterine overdistension, but bleeding usually from uterine body atony.

C. Breech extraction of second twin – More risk for trauma or inversion, not lower segment atony.

Question 25

Which clinical finding supports a diagnosis of postpartum hemorrhage due to retained secundines? Choices: A. Soft and boggy uterus with open cervix B. Firm and well-contracted uterus with closed cervix C. Open cervix with meaty tissues at cervical os D. Open cervix with a 3 cm tear at 9:00 position

Answer 25

C. Open cervix with meaty tissues at cervical os High-Yield Rationale: Retained placental tissue (secundines) presents with continued bleeding despite a firm uterus. A key finding is meaty tissue at the os, indicating retained fragments obstructing full involution. Why not the others: A. Soft boggy uterus – Suggests uterine atony. B. Firm uterus, closed cervix – Normal postpartum finding. D. Cervical tear – Suggests genital tract trauma, not retained placenta.

Question 26

A 26-year-old primigravid delivered by low forceps under general anesthesia. On postpartum day 1, a 6x4 cm violaceous mass is noted on the posterolateral vulva. What is the most likely chief complaint? Choices: A. Severe dysuria B. Excruciating pain C. Profuse vaginal bleeding D. Vulvar mass

Answer 26

B. Excruciating pain High-Yield Rationale: This describes a vulvar hematoma, which is extremely painful due to pressure from the accumulating blood. The mass may or may not be visually noticeable to the patient, but the pain is prominent. Why not the others: A. Severe dysuria – Unlikely unless hematoma compresses the urethra. C. Profuse vaginal bleeding – Bleeding is concealed, not profuse externally. D. Vulvar mass – Descriptive, but not a chief complaint.

Question 27

A patient delivered a live term baby by vaginal breech extraction. After-coming head delivered by forceps. She presents with brisk vaginal bleeding, but the uterus is firm and well contracted. What is the most likely cause? Choices: A. Coagulopathy B. Uterine atony C. Retained placenta D. Genital tract trauma

Answer 27

D. Genital tract trauma High-Yield Rationale: A firm uterus with bleeding post-delivery points to trauma, especially after instrumental delivery like forceps or breech maneuvers, which can injure the cervix or vaginal wall. Why not the others: A. Coagulopathy – Would have oozing from multiple sites, not localized trauma. B. Uterine atony – Uterus would be soft, not firm. C. Retained placenta – Bleeding usually with a boggy uterus and retained fragments.

Question 28

A 40-year-old, G3P3(3-0-0-3), delivers a term baby at home with assistance from a hilot. VS: BP 80/50, PR 120 bpm, RR 22. No palpable uterine mass is noted. A fleshy mass protrudes from the introitus. What is the cause? Choices: A. Administration of uterotonics B. Strong traction on the umbilical cord C. Fundal implantation of the placenta D. Uterine massage through the abdomen

Answer 28

B. Strong traction on the umbilical cord High-Yield Rationale: Uterine inversion is suggested here: sudden hypotension, absence of uterine fundus, and a fleshy mass outside the vagina. It is commonly caused by excessive cord traction before placental separation. Why not the others: A. Uterotonics – Prevents inversion by helping uterine contraction. C. Fundal implantation – Increases inversion risk only if traction applied. D. Uterine massage – Therapeutic, not causative.

Question 29

Which of the following procedures will confirm the diagnosis of Placenta Accreta Spectrum (PAS)? Choices: A. Computed Tomography (CT) Scan B. Color Flow Doppler Ultrasound C. Magnetic Resonance Imaging (MRI) D. Transvaginal Ultrasound

Answer 29

B. Color Flow Doppler Ultrasound High-Yield Rationale: Color Doppler Ultrasound is the most practical and first-line modality for confirming PAS, showing abnormal vascularity and loss of the normal hypoechoic retroplacental zone. Why not the others: A. CT Scan – Not routinely used due to radiation and poor soft tissue detail. C. MRI – Helpful for surgical planning but not the primary diagnostic tool. D. Transvaginal US – Can aid in initial evaluation but lacks vascular assessment without Doppler.

Question 30

A 28-year-old, G1P1, presents postpartum with profuse bleeding and a soft, boggy uterus unresponsive to uterotonics. What is the next best step in management? Choices: A. Uterine compression sutures B. Intrauterine balloon tamponade C. Hypogastric artery ligation D. Hysterectomy

Answer 30

B. Intrauterine balloon tamponade High-Yield Rationale: In uterine atony unresponsive to medications, the next conservative step is intrauterine balloon tamponade, which helps compress the endometrial surface and control bleeding. Why not the others: A. Compression sutures – For surgical settings, not immediately done after meds. C. Hypogastric artery ligation – Last resort or adjunct to surgery. D. Hysterectomy – Definitive, but reserved if conservative measures fail.

Question 31

A 42-year-old, G10P9(9-0-0-8), at 38 weeks with total placenta previa undergoes emergency cesarean section for profuse vaginal bleeding. A cleavage plane cannot be developed between the placenta and uterus. What is the definitive management? Choices: A. Leave the placenta in place and pack the uterus B. Total abdominal hysterectomy with the placenta in situ C. Subtotal hysterectomy with methotrexate D. Manual removal of the placenta under general anesthesia

Answer 31

B. Total abdominal hysterectomy with the placenta in situ High-Yield Rationale: Failure to develop a cleavage plane suggests placenta accreta/increta/percreta. The safest definitive treatment is total hysterectomy with placenta left in situ to prevent life-threatening hemorrhage. Why not the others: A. Leave placenta + pack – Temporary measure, not definitive. C. Subtotal + methotrexate – Risky and less effective in PAS. D. Manual removal – Contraindicated; causes massive bleeding.

Question 32

A 28-year-old multiparous patient is bleeding profusely with an undelivered placenta. What is the most appropriate management? Choices: A. Immediate manual removal of the placenta B. Excessive traction on the umbilical cord C. Uterine massage through the abdomen D. Controlled traction on the umbilical cord

Answer 32

A. Immediate manual removal of the placenta High-Yield Rationale: Profuse bleeding with a retained placenta indicates retained placental tissue or abnormal adherence. Manual removal is warranted to stop hemorrhage and prevent DIC. Why not the others: B. Excessive traction – May cause uterine inversion. C. Uterine massage – May assist in uterine contraction but not definitive here. D. Controlled traction – Only applicable if there's no hemorrhage and signs of separation.

Question 33

A 35-year-old, G2P1(1-0-0-1), at 38 weeks with previous cesarean delivery is in latent labor and opted for VBAC. Two hours later, CTG shows fetal bradycardia. What is the most appropriate management? Choices: A. Give IV uterine relaxants and resume labor watch the next day B. Prepare for emergency repeat cesarean section C. Secure 2 units of fresh whole blood, typed and cross-matched D. Continue labor watch and call for a family conference

Answer 33

B. Prepare for emergency repeat cesarean section High-Yield Rationale: Fetal bradycardia in a VBAC patient raises concern for uterine rupture, a life-threatening complication requiring immediate cesarean section. Why not the others: A. Resume labor watch – Dangerous delay in setting of bradycardia. C. Secure blood – Supportive step but not definitive management. D. Family conference – Wastes critical time during fetal distress.

Question 34

A 30-year-old, G3P2(1-1-0-2), at 38 weeks’ gestation with known von Willebrand Disease presents in labor. After delivery, she experiences profuse vaginal bleeding. VS: BP 90/60, PR 80 bpm. Abdomen exam shows a firm and well-contracted uterus. What is the definitive management? Choices: A. Treat the coagulopathy before delivery for advance planning B. Proceed with AMTSL and alternative conservative procedures C. Treat the underlying disease and replace appropriate blood components D. Request for platelet count, PT, PTT, and fibrinogen level

Answer 34

C. Treat the underlying disease and replace appropriate blood components High-Yield Rationale: A firm uterus + bleeding in a coagulopathy (like von Willebrand disease) points to hematologic cause of PPH. Definitive treatment is replacement of vWF factor concentrates, cryoprecipitate, and clotting factors. Why not the others: A. Advance planning – Ideal but not the definitive management for this acute situation. B. AMTSL – Already done; uterus is firm, so not uterine atony. D. Requesting labs – Helpful, but does not treat the bleeding.

Question 35

Following delivery of the placenta, which drug is contraindicated in the management of uterine atony? Choices: A. Methylergometrine intramuscular B. Oxytocin in Ringer’s Lactate solution C. Oxytocin intravenous bolus D. Carbetocin slow intravenous

Answer 35

C. Oxytocin intravenous bolus High-Yield Rationale: Rapid IV bolus of oxytocin is contraindicated due to risk of severe hypotension and cardiac arrhythmias. All other routes/forms are safe for PPH prevention. Why not the others: A. Methylergometrine IM – Used unless hypertensive. B. Oxytocin in IVF – Standard AMTSL protocol. D. Carbetocin IV slow push – Safe long-acting alternative to oxytocin.

Question 36

Which statement is correct regarding the management of Uterine Inversion? Choices: A. Extraction of the placenta is done before the uterus is repositioned B. Uterotonics should be administered during reposition of the uterus C. Reposition of the uterus should be done under general anesthesia D. Tocolytics should be given after reposition to prevent recurrence

Answer 36

C. Reposition of the uterus should be done under general anesthesia High-Yield Rationale: Manual repositioning of an inverted uterus is best done under general anesthesia or heavy sedation to reduce pain and allow uterine relaxation for easier repositioning. Why not the others: A. Extracting placenta first – Contraindicated; increases bleeding and worsens inversion. B. Uterotonics – Given after reposition to maintain tone, not during. D. Tocolytics – Given before repositioning to relax the uterus, not after.

Question 37

On examination of a 19-year-old postpartum patient with profuse vaginal bleeding, the uterus is soft and boggy. What is the most appropriate management? Choices: A. Bimanual uterine compression B. Uterine compression sutures C. Selective devascularization D. Administration of uterotonics

Answer 37

D. Administration of uterotonics High-Yield Rationale: Uterine atony is the most common cause of PPH. First-line treatment is uterotonics (e.g., oxytocin) to stimulate contraction. Why not the others: A. Bimanual compression – Used if meds fail or while waiting for effect. B. Compression sutures – Surgical, for refractory cases. C. Devascularization – Advanced step if bleeding persists.

Question 38

A 48-year-old, G5P3(3-0-1-3), at 38 weeks has asymptomatic placenta previa. History includes prior CS and D&C. What is the correct statement regarding her definitive management? Choices: A. Secure informed consent for repeat cesarean section B. Request for Color Flow Doppler Ultrasound if available C. Manage the patient as if she has Placenta Previa Accreta D. Leave the placenta in place and treat with Methotrexate

Answer 38

C. Manage the patient as if she has Placenta Previa Accreta High-Yield Rationale: Prior CS + D&C + placenta previa → high risk for Placenta Accreta Spectrum (PAS). Even if asymptomatic, plan for surgery as if PAS is present (team readiness, blood products, consent for hysterectomy). Why not the others: A. Repeat CS consent – Necessary, but not enough if PAS is likely. B. Doppler US – Helpful for diagnosis but doesn’t replace full management planning. D. Methotrexate – Not used unless placenta is left in situ post-delivery (rare, risky).

Question 39

What is the etiopathogenesis of Uterine Atony? Choices: A. Oozing from puncture sites with unresponsive uterus to uterotonics B. Failure of the interlacing myometrial fibers to function as ligatures C. Injury in the friable cervix following placental detachment D. Decidual deficiency which prevents separation of the placenta

Answer 39

B. Failure of the interlacing myometrial fibers to function as ligatures High-Yield Rationale: Uterine atony occurs when myometrial fibers fail to contract, which normally compresses blood vessels and prevents hemorrhage. These muscle fibers act as "living ligatures." Why not the others: A. Oozing from puncture sites – Suggests coagulopathy, not atony. C. Cervical injury – Indicates genital tract trauma, not atony. D. Decidual deficiency – Related to placenta accreta, not uterine atony.

Question 40

Which procedure will help prevent uterine inversion? Choices: A. Undue traction on the umbilical cord B. Administration of tocolytic agents C. Induction of general anesthesia D. Controlled traction on the umbilical cord

Answer 40

D. Controlled traction on the umbilical cord High-Yield Rationale: Controlled cord traction during delivery of the placenta reduces the risk of uterine inversion, especially when the uterus is not fully contracted. Why not the others: A. Undue traction – Actually causes uterine inversion. B. Tocolytics – Relax the uterus, which increases inversion risk. C. General anesthesia – Relaxes uterine tone, not preventive.

Question 41

Which of the following statements is true regarding the medical management of Postpartum Hemorrhage (PPH)? Choices: A. Hemostatic agents are routinely administered in patients with PPH B. Oxytocin intravenous bolus is given following delivery of the placenta C. For prevention of bleeding, Carbetocin is preferred over oxytocin D. Oxytocin is routinely administered as the drug of choice to treat PPH

Answer 41

D. Oxytocin is routinely administered as the drug of choice to treat PPH High-Yield Rationale: Oxytocin is the first-line uterotonic agent used to treat PPH due to uterine atony, the most common cause. Why not the others: A. Hemostatic agents – Not routine; used in specific coagulopathies. B. IV bolus of oxytocin – Contraindicated due to risk of hypotension. C. Carbetocin – Used for prevention, especially in high-risk cases, but not superior for treatment.

Question 42

Which of the following cases has the highest risk for Placenta Accreta Spectrum (PAS)? Choices: A. 45-year-old primigravid at 40 weeks with cesarean for tumor previa B. 35-year-old, G4P3(3-0-0-3), 36 weeks with low-lying placenta and 3 prior CS C. 32-year-old primigravid at 40 weeks with placenta previa totalis D. 40-year-old, G4P3(2-1-0-3) with placenta previa and 1 prior CS

Answer 42

B. 35-year-old with low-lying placenta and 3 prior cesarean sections High-Yield Rationale: Multiple prior cesarean deliveries + low-lying placenta dramatically increase the risk of abnormal placental implantation (PAS), especially accreta. Why not the others: A. Primigravid – No uterine scar; low risk. C. No uterine scar – Placenta previa alone isn’t highest risk. D. 1 prior CS – Moderate risk, but not as high as with 3 prior CS.

Question 43

A 30-year-old primigravid at 39 weeks had a cesarean for prolonged labor due to midpelvic contraction. She bleeds profusely post-op due to uterine atony. What is the pathophysiology? Choices: A. Overdistended uterus B. Uterine muscle fatigue C. Intrauterine infection D. Uterine distortion

Answer 43

B. Uterine muscle fatigue High-Yield Rationale: Prolonged labor causes uterine muscle exhaustion, impairing its ability to contract effectively, leading to atony and hemorrhage. Why not the others: A. Overdistended uterus – Common with twins or polyhydramnios, not here. C. Infection – Rarely causes immediate postpartum bleeding. D. Uterine distortion – More linked to anomalies or malposition, not atony.