Obstetric hemorrhage case scenario and MCQ for undergraduate

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A 21-year-old nulliparous patient at 41 weeks
gestation delivers vaginally after a prolonged
second stage and chorioamnio-nitis. After
placental separation, profound uterine atony is
noted, and the patient be-gins to hemorrhage. The
atony is unrespon-sive to bimanual massage,
intravenous oxy-tocin, and intramuscular
methylergonovine.What can be done to stanch the
?ow?

• CASE 1 Third Trimester Bleeding

• A 32 yo G2P1 presents at 36 weeks complaining of
  bright red vaginal bleeding. Upon further
  questioning she does admit to having had some
  light bleeding on 1 to 2 occasions last week.
• Her previous pregnancy was delivered at term by a
  Classical Cesarean Section for footling breech
  presentation.

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A 21-year-old nulliparous patient at 41 weeks
gestation delivers vaginally after a prolonged
second stage and chorioamnio-nitis. After
placental separation, profound uterine atony is
noted, and the patient be-gins to hemorrhage. The
atony is unrespon-sive to bimanual massage,
intravenous oxy-tocin, and intramuscular
methylergonovine.What can be done to stanch the
?ow?

• What is the Differential Diagnosis?

• Placenta Previa
• Placental Abruption
• Uterine Rupture
• Vasa Previa
• Laceration
• Vaginal mass

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Placenta Previa
Painless third-trimester bleeding Complicates
4-6 pregnancies between 10 and 20 wks, 0.5
pregnancies gt20 weeks Risk factors Increasing
parity, maternal age, prior CS, curettages
, myomectomy Types? Complete previa
(20-30) Partial previa (does not completely
cover) Marginal (proximate to os) Management
pelvic rest, US, IV, TS, C/S
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Associated Conditions
Placenta accreta, increta, percreta Risk increase
w/ inc no. of prior CS PPunscarred uterus-5
risk of accreta PPone previous C/D-24 risk of
accreta PPtwo previous C/D-47 risk of
accreta PPthree previous C/D-50 risk of
accreta PPfour previous C/D-67 risk of accreta

• Placenta accreta, increta, percreta
• Risk inc w/ inc no. of prior c/s (50 risk in pt
  w/ previa and 2 prior c/s)
• Vasa Previa
• Vessels traverse the membranes in the lower
  uterine segment in advance of the fetal head.
• Rupture can lead to fetal exsanguination

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Associated Conditions

• Vasa Previa
• Vessels traverse the membranes
• in the lower uterine segment in
• advance of the fetal head.
• Rupture can lead to fetal exsanguination

• Placenta accreta, increta, percreta
• Risk inc w/ inc no. of prior c/s (50 risk in pt
  w/ previa and 2 prior c/s)
• Vasa Previa
• Vessels traverse the membranes in the lower
  uterine segment in advance of the fetal head.
• Rupture can lead to fetal exsanguination

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Placental Abruption
Premature separation of placenta Painful
third-trimester bleeding Risk Factors smoking,
trauma, HTN cocaine, pprom, polyhydramnios,
multiples Trauma evaluation bleeding,
contractions, abdominal pain and NRFHT in
4hrs U/s misses up to 50 of abruptions Management
IV, TX, Continuous monitoring, C/S vs. vag
delivery
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Case Contd

• U/S reveals active, vertex fetus. Placenta
  anterior and free of os.
• Pt having contractions q 2-3 minuters. Bleeding
  increases.
• BP drops from 110/60 to palpable systolic
  pressure of 70. FHT drops from 120 to 90 bpm.
• What do you do???

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Uterine Rupture

• Associated with Prior CS
• Rates of uterine rupture?
• Spontaneous rupture
• (no C/S history) 1/2000 (0.05)
• Low Transverse 0
• .5-1risk rupture, VBAC 80 success rate
• Classical C/s
• 10 risk rupture, schedule amnio/c/s 37 weeks.

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A 21-year-old nulliparous patient at 41 weeks
gestation delivers vaginally after a prolonged
second stage and chorioamnio-nitis. After
placental separation, profound uterine atony is
noted, and the patient be-gins to hemorrhage. The
atony is unrespon-sive to bimanual massage,
intravenous oxy-tocin, and intramuscular
methylergonovine.What can be done to stanch the
?ow?

• CASE 2 Uterine atony leads to heavy bleeding

• A 21-year-old nulliparous patient at 41 weeks
  gestation delivers vaginally after a prolonged
  second stage and chorioamnio-nitis.
• After placental separation, profound uterine
  atony is noted, and the patient begins to
  hemorrhage. The atony is unresponsive to bimanual
  massage, intravenous oxytocin, and intramuscular
  methylergonovine.

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What can be done to stop the ?ow
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A stepwise approach to bleeding caused by
persistent uterine atony
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A stepwise approach to bleeding caused by
persistent uterine atony
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CASE3 Postpartum hemorrhage with Hypovolemic
shock

• A 35 year old womanin her 4th pregnancy, had a
  history of PPH in her previous pregnancies.
• She was diagnosed to have pre eclampsia during
  this pregnancy and was on oral antihypertensive
  medication.
• At 38 weeks of gestation she was admitted and
  LABOR was induced with prostaglandins

• A 35 year old womanin her 4th pregnancy, had a
  history of PPH in her previous pregnancies.
• She was diagnosed to have pre eclampsia during
  this pregnancy and was on oral antihypertensive
  medication. At 38 weeks of gestation she was
  admitted and LABOR was induced with
  prostaglandins.

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• The labour was uneventful and she delivered The
  labour was uneventful and she delivered a 3.9kg
  baby. There was massive bleeding after her
  delivery.
• Exploration did not reveal any retained products.
  
• The uterus remained atonic despite repeated
  injections of ergometrine and an oxytocin
  infusion. No blood or blood products were
  available.

• The labour was uneventful and she delivered a
  3.9kg baby. There was massive bleeding after her
  delivery.
• Exploration did not reveal any retained products.
  
• The uterus remained atonic despite repeated
  injections of ergometrine and an oxytocin
  infusion. No blood or blood products were
  available.

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• The labour was uneventful and she delivered The
  labour was uneventful and she delivered a 3.9kg
  baby. There was massive bleeding after her
  delivery.
• Exploration did not reveal any retained products.
  
• The uterus remained atonic despite repeated
  injections of ergometrine and an oxytocin
  infusion. No blood or blood products were
  available.

• She was transferred to a general hospital for
  further resuscitation but arrived in a moribid
  state and signs of hyovolemic shock was evident
  
• What should be your first step of management?

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At ANE INITIAL ASSESSMENT AND START BASIC
TREATMENT
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ANE to OT TEMPORIZING AND TRANSFER INTERVENTION
ANE to OT DRUGS OF CHOICE
If not available or bleeding still continue from
previous drugs
ANE to OT TORRENTIAL BLEEDING
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CASE 4

• A 30 year women in her third pregnancy at 38
  weeks of gestation came in labour at a district
  hospital. Her antenatal period had been
  uneventful.
• She delivered vaginally. With active management
  of 3rd stage and the placenta was delivered by
  CCT.

• A 35 year old womanin her 4th pregnancy, had a
  history of PPH in her previous pregnancies.
• She was diagnosed to have pre eclampsia during
  this pregnancy and was on oral antihypertensive
  medication. At 38 weeks of gestation she was
  admitted and LABOR was induced with
  prostaglandins.

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• After the placenta was delivered , there was
  active bleeding from the vagina. A green cannula
  was inserted and the on-call doctor was informed.
• Over the phone the doctor ordered for uterine
  massage to be done ,IV ergometrine 0.5mg and IV
  Pitocin 40 unit in 500mls NS .

• The labour was uneventful and she delivered The
  labour was uneventful and she delivered a 3.9kg
  baby. There was massive bleeding after her
  delivery.
• Exploration did not reveal any retained products.
  
• The uterus remained atonic despite repeated
  injections of ergometrine and an oxytocin
  infusion. No blood or blood products were
  available.

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• Blood pressure was normal but the pulse rate was
  96 b/min.
• Abdominal examination done showed that the uterus
  was contracted. Despite that the patient was
  still actively bleeding.
• Another IV line was inserted and blood was sent
  for CBC, GXM and PT/PTT. She was given NS running
  fast.

• The labour was uneventful and she delivered The
  labour was uneventful and she delivered a 3.9kg
  baby. There was massive bleeding after her
  delivery.
• Exploration did not reveal any retained products.
  
• The uterus remained atonic despite repeated
  injections of ergometrine and an oxytocin
  infusion. No blood or blood products were
  available.

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• Further examination showed a cervical laceration
  trial to repair was failed.
• The patient continued to bleed,
• so vaginal packing was done
• a planning for transferre to the
• general hospital.
• The placenta was also re-examine for its
  completeness.
• By this time, the patients blood loss was about
  1 L. the patient was conscious but lethargic, her
  BP was 90/60mmHg and PR was 110b/min.

• The labour was uneventful and she delivered The
  labour was uneventful and she delivered a 3.9kg
  baby. There was massive bleeding after her
  delivery.
• Exploration did not reveal any retained products.
  
• The uterus remained atonic despite repeated
  injections of ergometrine and an oxytocin
  infusion. No blood or blood products were
  available.

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• While awaiting for arrangements for transfer to
  the referral center to be made, another 2 iv
  lines inserted and she was rapidly infused with
  NS and later transfused with blood.
• A Foleys catheter was inserted to monitor urine
  output and her vital signs was monitored every 15
  minutes.

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• Upon arrival the general hospital the estimated
  blood loss was about 2L .
• 2 unit of blood has already been
• transfused plus the crystalloids
• Examination upon arrival showed very pale
  patient, drowsy but still responding to call, the
  BP was 80/40mmHg ,PR was 130b/min. The uterus was
  contracted and still actively bleeding from the
  vagina.

• Upon arrival the general hospital the estimated
  blood loss was about 2L and she had 4 iv lines
  (all green). 2 unit of blood has already been
  transfused plus the crystalloids and the 3rd and
  4th unit of blood transfusion was still in
  progress.

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• EUA was done and the cervical
• laceration was sutured.
• Despite that patient continued
• to bleed.

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A laparotomy was done

• it showed that there was
• another cervical laceration
• which extended up to the
• lower segment of the uterus.
• As it was not able to be repaired,
• a hysterectomy was performed.

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Post operatively

• She was managed for 2 days in ICU. The estimated
  blood loss through out was 5.4L and she was
  transfused a total of 21 unit of blood and 4
  cycles of DIVC regime. She was discharged well on
  day 6 post delivery.

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CASE 5

• A 37-year-old black female P7 at term admitted in
  early labor. Her prenatal course was significant
  for gestational diabetes controlled with diet.
  her last child weighing 4200KG. Her past medical
  history was significant only for a strong family
  history of diabetes mellitus.
• On admission, the CX 4cm/VTX/-1/AROM with clear
  fluid contractions decreased in intensity and
  frequency after AROM. A Pitocin augmentation was
  begun and the patient quickly progressed to
  C/C/VTX/1.

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Case cont

• She delivered a 4300 kg baby with a moderate
  shoulder dystocia that was treated effectively
  with the McRoberts maneuver and suprapubic
  pressure after a left mediolateral episiotomy.
• The placenta delivered spontaneously without
  difficulty

• She delivered a 4300 kg baby with a moderate
  shoulder dystocia that was treated effectively
  with the McRoberts maneuver and suprapubic
  pressure after a left mediolateral episiotomy.
• The placenta delivered spontaneously without
  difficulty

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Case cont

• She delivered a 4300 kg baby with a moderate
  shoulder dystocia that was treated effectively
  with the McRoberts maneuver and suprapubic
  pressure after a left mediolateral episiotomy.
• The placenta delivered spontaneously without
  difficulty

• The patient had persistent bleeding after repair
  of her episiotomy.
• An immediate re-inspection ofher cervix and
  vagina revealed no occult lacerations.
• She was treated with continued IV Pitocin and
  given multiple doses of 15-methyl prostaglandin
  F2-_ as well as a course of rectal misoprostol
  without response

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Case cont

• Counseling regarding thepossible need for
  hysterectomy. laparotomy was performed. The
  uterus was persistently atonic. No evidence of
  occult lacerations or other cause for the
  bleeding.
• Hemostatic B-Lynch sutures were placed to stop
  the bleeding. The bleeding markedly decreased
  with this procedure. She received a total of 8
  units of packed red blood cells during and after
  the surgery. She left the hospital without
  further incident

• She delivered a 4300 kg baby with a moderate
  shoulder dystocia that was treated effectively
  with the McRoberts maneuver and suprapubic
  pressure after a left mediolateral episiotomy.
• The placenta delivered spontaneously without
  difficulty

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Remmber Aetiology of 1ry ppHg
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Principles of managing PPH

• Speed
• Skills
• Priorities
• 1-Call For Help (Red Alert System)
• 2-Assess the patients condition
• 3-Find the cause of bleeding and stop it
• 4-Stabilize And Resuscitate The Patient
• 5-Prevent Further Bleeding

• Speed Skills Priorities
• Call For Help (Red Alert System)
• Assess the patients condition
• Find the cause of bleeding and stop it
• Stabilize And Resuscitate The Patient
• Prevent Further Bleeding

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1- A woman 35 years old /G4 L3 presents with
couvelaire uterus in C/S. When is hysterectomy
indicated?

• A-presence of hematoma in the broad ligament
• B-presence of hematoma in mesosalpinx
• C- atony retractable to treatment
• D- presence of blood in abdominal cavity
• AnsC

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2-Which is wrong about platelet administration?

• A- Platelet can not be reserved more than 5 days
• B-platelets should be administered to patients
  with hemorrhage and platelet counts less than
  50000/ml
• C-platelet should be administered after
  cross-match
• D- If there is no hemorrhage, platelets should be
  administered to patients with platelet counts
  less than 10000 /ml
• AnsD

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3-which is the most common reason of DIC in
Obstetrics?

• A-IUFD
• B-abruption
• C-AF emboli
• D- septic shock
• AnsB

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4-what is the first step in treating a G2 with
late postpartum hemorrhage (after stabilizing her
condition)?

• A-curettage
• B-uterotonics
• C-uterine artery ligation
• D-hypogastric artery ligation
• AnsB

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5-A 16 year-old woman comes to you with heavy
bleeding after a two month delay in her periods.
Pregnancy test is negative. Ultrasound shows a
thin endometrium. There is no coagulation or
anatomical problem. Which is the best treatment?

• A-high dose progesterone
• B-curettage
• C-IV conjugate estrogen
• D-diagnostic hysteroscopy
• AnsC
• Conjugate estrogen 25-40 mg IV q6h or PO
• 2.5 mg q6h

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6- what is the stage of shock in a woman 70 kg
/ HR130 bpm/AP55mmHg/mod tachycardia/urinary
output10cc in a min

• A-first
• B-second
• C-third
• D-fourth
• AnsC

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7-Which is true about hemorrhagic shock?

• A- central venous catheter is not recommended
• B-lifting the feet is not recommended
• C-colloids are superior to crystalloids
• D-excess NS can cause alkalosis
• AnsA

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8-A woman suffers intractable heavy vaginal
bleeding after C/S. Laparatomy is performed.
Retrovesical hematoma is evacuated and the site
of bleeding is sutured. The bleeding does not
stop. What is the second stage in management?

• A-total hysterectomy
• B-bilateral uterine and ovarian arteries ligation
• C-bilateral hypogastric arteries ligation
• D-bilateral hypogastric and ovarian arteries
  ligation
• AnsD
• Ovarian artery is situated in infundibulopelvic
  and mesosalpinx ligament

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9-Which is wrong in abruption?

• A-It is more likely in heroin addicts
• than cocaine addicts
• B-fibroma is one of the causes
• C-positive past history is a risk factor
• D-there is no agreement on smoking as a risk
  factor
• AnsA

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10-A G2 with GA14 wks is referred for spotting.
Ultrasound imaging shows twin pregnancy with one
fetal demise. How the coagulation profile may
change?

• A- The profile is like that of DIC
• B-heavy bleeding will occur during labor because
  of hypofibrinogenemia
• C- repairable transient coagulopathy will occur
• D-the live infant in the uterine will develop
  coagulopathy
• AnsC

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11-Which is true about uterine inversion?

• A-BP and MgSO4 can be the reason
• B-it is more common in multiparas
• C-it is never fatal
• D-hemorrhage occurs with a delay
• AnsA

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12-If there is a coagulopathy disorder, which is
an indication for Heparin administration provided
that circulation is intact?

• A-IUFD
• B-Abruption
• C-septic abortion
• D-HELLP syndrome
• AnsA
• Heparin dose 5000 units TDS for IUFD
• FFP and platelet for septic abortion

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13-Which is wrong about stage II of hypovolemic
shock?

• A-Tachycardia is a constant finding
• B-blood loss is more than 1000cc
• C-systolic minus diastolic BP is increased
• D-BP at rest is normal
• AnsC

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14-Which is true about int iliac artery ligation
for controlling pelvic hemorrhage?

• A-Ext iliac artery should be checked
• before ligation is attempted
• B-ureter should not be located
• C- both sides arteries should not be ligated
• D-the artery should be ligated proximal to
  parietal branch
• AnsA

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15-A 40 year old woman is hospitalized for
hemorrhagic shock. Her kidney function is normal.
What is the most sensitive and reliable clinical
criteria for determining severity of volume loss?

• A- tachycardia
• B-tachypnea
• C-oliguria
• D-hypotension
• AnsC

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16-An extension of C/S incision causes vaginal
artery laceration and heavy bleeding. What should
be done for this case?

• A-uterine artery ligation
• B-ovarian artery ligation
• C- hypogastric artery ligation
• D-hysterectomy
• AnsC

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17- How many ml of blood does a soaked lap pad
absorbs?

• A-30 cc
• B-50 cc
• C-80 cc
• D-100 cc
• AnsB

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18-What is wrong for blood loss management?

• A-after an hour in a critical case only 20 of
  crystalloids remains in circulation
• B- the volume of crystalloids replacement is
  three times the volume of blood loss
• C-in all cases of blood loss a Hb of less than 8
  gr/dl mandates whole blood transfusion
• D-colloids increase mortality rate
• AnsC

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19-What is wrong about vaginal hematoma after
delivery?

• A-observation if hematoma is small
• B- an incision on the site if pain is severe and
  hematoma enlarges
• C-mattress suturing the bed of hematoma
• D-pressure dressing should be applied on the
  hematoma bed for 12-24 hours
• AnsD

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20- A repeat C/S II has hemorrhage of the
incisionsite. Which can best control hemorrhage?

• A-ligation of placental site above and below the
  incision site
• B-ligation of uterine artery
• C- ligation of hypogastric artery
• D- embolization of uterine artery
• AnsA

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21 Which is wrong about fetal complications of
abruption?

• A- 20-25 percent of cases demise perinatally
• B-40 are delivered prematurely
• C- 12-15 are IUFD
• D-if the fetus doesnt die in uterus, there would
  be no serious neonatal complication
• AnsD

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22A pregnant woman G2 GA38 wks has the chief
complaint of vaginal spotting. There is no sign
of abruption or previa by ultrasound. What is the
best management?

• A- observation
• B-termination of pregnancy
• C-discharge
• D-referring patient to another center
• AnsB

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24-Which is true about abruption?

• A- The chance of repeated abruption is twice
• B-fetal assessment techniques can predict
  abruption with good precision
• C-there is no means to predict abruption
• D-The chance of repeated abruption is not
  different
• AnsC

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25-Which is wrong in cases of placenta previa?

• A-the safest means of diagnosing placenta previa
  is transabdominal ultrasound
• B-false positive results are because of full
  bladder
• C-low lying or total previa is best diagnosed by
  trans vaginal ultrasound
• D-NPV of transperineal ultrasound is 70
• Ans D (its NPV is 100 )

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26-What is the first surgical step in a case of
retractable uterine atony?

• A-ligation of uterine and ovarian arteries
• B-ligation of hypogastric arteries
• C-subtotal hysterectomy
• D- uterine artery embolization
• AnsA

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