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Obstetric hemorrhage cases and MCQ for undergraduate
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Undergraduate course lectures in Obstetrics&Gynecology .Faculty of medicine,Zagazig University .Prepared by DR Manal Behery

Undergraduate course lectures in Obstetrics&Gynecology .Faculty of medicine,Zagazig University .Prepared by DR Manal Behery

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  • Uterine packing – balloon, tampone, Torpin packer.

Obstetric hemorrhage cases and MCQ for undergraduate Obstetric hemorrhage cases and MCQ for undergraduate Presentation Transcript

  • 1/15MCQ
  • A 21-year-old nulliparous patient at 41weeks’ gestation delivers vaginally after aprolonged second stage and chorioamnio-nitis.After placental separation, profounduterine atony is noted, and the patient be-gins tohemorrhage. The atony is unrespon-sive to bimanualmassage, intravenous oxy-tocin, and intramuscularmethylergonovine.What can be done to stanch the flow?• CASE 1 :Third Trimester BleedingA 32 yo G2P1 presents at 36 weekscomplaining of bright red vaginal bleeding.Upon further questioning she does admit tohaving had some light bleeding on 1 to 2occasions last week.Her previous pregnancy was delivered atterm by a Classical Cesarean Section forfootling breech presentation.
  • A 21-year-old nulliparous patient at 41weeks’ gestation delivers vaginally after aprolonged second stage and chorioamnio-nitis.After placental separation, profounduterine atony is noted, and the patient be-gins tohemorrhage. The atony is unrespon-sive to bimanualmassage, intravenous oxy-tocin, and intramuscularmethylergonovine.What can be done to stanch the flow?• What is the “Differential Diagnosis”?Placenta PreviaPlacental AbruptionUterine RuptureVasa PreviaLacerationVaginal mass
  • Placenta PreviaPainless third-trimester bleedingComplicates 4-6% pregnancies between 10 and20 wks, 0.5% pregnancies >20 weeksRisk factorsIncreasing parity, maternal age, prior CS,curettages , myomectomyTypes?Complete previa (20-30%)Partial previa (does not completely cover)Marginal (proximate to os)Management:pelvic rest, US, IV, T+S, C/S
  • Associated Conditions• 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 loweruterine segment in advance of the fetal head.– Rupture can lead to fetal exsanguinationPlacenta accreta, increta, percretaRisk increase w/ inc no. of prior CSPP+unscarred uterus-5 % risk of accretaPP+one previous C/D-24% risk of accretaPP+two previous C/D-47% risk of accretaPP+three previous C/D-50% risk of accretaPP+four previous C/D-67% risk of accreta
  • Associated Conditions• 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 loweruterine segment in advance of the fetal head.– Rupture can lead to fetal exsanguinationVasa PreviaVessels traverse the membranesin the lower uterine segment inadvance of the fetal head.Rupture can lead to fetal exsanguination
  • Placental AbruptionPremature separation of placentaPainful third-trimester bleedingRisk Factorssmoking, trauma, HTNcocaine, pprom, polyhydramnios, multiplesTrauma evaluationbleeding, contractions, abdominal pain and NRFHT in 4hrsU/s misses up to 50% of abruptionsManagement:IV, T+X, Continuous monitoring, C/S vs. vag delivery
  • Case Cont’dU/S reveals active, vertex fetus. Placenta anteriorand free of os. Pt having contractions q 2-3 minuters. Bleedingincreases.BP drops from 110/60 to palpable systolicpressure of 70. FHT drops from 120 to 90 bpm.What do you do???
  • Uterine Rupture• Associated with Prior CSRates of uterine rupture? Spontaneous rupture (no C/S history): 1/2000 (0.05%) Low Transverse: 0 .5%-1%risk rupture, VBAC 80% success rate Classical C/s: 10% risk rupture, schedule amnio/c/s ~37 weeks.
  • A 21-year-old nulliparous patient at 41weeks’ gestation delivers vaginally after aprolonged second stage and chorioamnio-nitis.After placental separation, profounduterine atony is noted, and the patient be-gins tohemorrhage. The atony is unrespon-sive to bimanualmassage, intravenous oxy-tocin, and intramuscularmethylergonovine.What can be done to stanch the flow?• CASE 2 Uterine atony leads to heavy bleedingA 21-year-old nulliparous patient at 41weeks’ gestation delivers vaginally after aprolonged second stage and chorioamnio-nitis.After placental separation, profounduterine atony is noted, and the patient beginsto hemorrhage. The atony is unresponsive tobimanual massage, intravenous oxytocin, andintramuscular methylergonovine.
  • What can be done to stop the flow11/15
  • A stepwise approach to bleeding caused bypersistent uterine atonySTEP 2Apply direct pressureto the uterine cavitySTEP 3Control the blood supplyto the uterusSTEP 4Place uterinecompression suturesSTEP 5Perform hysterectomySTEP 1Identify source ofbleeding,administeruterotonic drugs
  • A stepwise approach to bleeding caused bypersistent uterine atonySTEP 1Identify source of bleedingadministerUterotonic drugsSTEP 2Apply direct pressureto the uterine cavitySTEP 3Control the blood supplyto the uterusSTEP 4Place uterinecompression suturesSTEP 5Performhysterectomy13/15
  • • A 35 year old womanin her 4thpregnancy, had a history of PPH in herprevious pregnancies.• She was diagnosed to have pre eclampsiaduring this pregnancy and was on oralantihypertensive medication. At 38 weeks ofgestation she was admitted and LABOR wasinduced with prostaglandins.14/15 A 35 year old womanin her 4th pregnancy,had a history of PPH in her previouspregnancies.She was diagnosed to have pre eclampsiaduring this pregnancy and was on oralantihypertensive medication.At 38 weeks of gestation she was admittedand LABOR was induced with prostaglandinsCASE3 Postpartum hemorrhage withHypovolemic shock
  • • The labour was uneventful and she deliveredThe labour was uneventful and she delivereda 3.9kg baby. There was massive bleedingafter her delivery.• Exploration did not reveal any retainedproducts.• The uterus remained atonic despite repeatedinjections of ergometrine and an oxytocininfusion. No blood or blood products wereavailable.The labour was uneventful and she delivered a3.9kg baby. There was massive bleeding after herdelivery.Exploration did not reveal any retainedproducts.The uterus remained atonic despite repeatedinjections of ergometrine and an oxytocininfusion. No blood or blood products wereavailable.
  • • The labour was uneventful and she deliveredThe labour was uneventful and she delivereda 3.9kg baby. There was massive bleedingafter her delivery.• Exploration did not reveal any retainedproducts.• The uterus remained atonic despite repeatedinjections of ergometrine and an oxytocininfusion. No blood or blood products wereavailable.She was transferred to a general hospital forfurther resuscitation but arrived in a moribidstate and signs of hyovolemic shock wasevidentWhat should be your first step ofmanagement?
  • At ANE: INITIAL ASSESSMENT AND STARTBASIC TREATMENTCall for helpAssess Airway, Breathing,Circulation [ABC]Provide SupplementaryOxygenObtain an intravenous lineStart fluid replacementwith IV crystalloidMonitor Vital SignCatheterize bladder andmonitor urine outputAssess need for bloodtransfusionLab test•FBC, Coagulation•Blood Group•Cross Match17/15
  • ANE to OT: TEMPORIZING AND TRANSFERINTERVENTIONReady toreferDrugsUterineMassageBimanualUterineCompressionExternalAorticCompressionIntrauterineBalloon /CondomTo OTANE to OT: DRUGS OF CHOICEOxytocin ErgometrineProstaglandin•Misoprostol•PG F2alphaTranexamic acidIf not available or bleeding still continue from previous drugsANE to OT: TORRENTIAL BLEEDING18/15
  • • A 35 year old womanin her 4th pregnancy,had a history of PPH in her previouspregnancies.• She was diagnosed to have pre eclampsiaduring this pregnancy and was on oralantihypertensive medication. At 38 weeks ofgestation she was admitted and LABOR wasinduced with prostaglandins.19/15A 30 year women in her third pregnancy at38 weeks of gestation came in labour at adistrict hospital. Her antenatal period had beenuneventful.She delivered vaginally. With activemanagement of 3rd stage and the placentawas delivered by CCT.CASE 4:
  • • The labour was uneventful and she deliveredThe labour was uneventful and she delivereda 3.9kg baby. There was massive bleedingafter her delivery.• Exploration did not reveal any retainedproducts.• The uterus remained atonic despite repeatedinjections of ergometrine and an oxytocininfusion. No blood or blood products wereavailable.After the placenta was delivered , there wasactive bleeding from the vagina. A green cannulawas inserted and the on-call doctor was informed. Over the phone the doctor ordered for uterinemassage to be done ,IV ergometrine 0.5mg and IVPitocin 40 unit in 500mls NS .
  • • The labour was uneventful and she deliveredThe labour was uneventful and she delivereda 3.9kg baby. There was massive bleedingafter her delivery.• Exploration did not reveal any retainedproducts.• The uterus remained atonic despite repeatedinjections of ergometrine and an oxytocininfusion. No blood or blood products wereavailable.Blood pressure was normal but the pulse ratewas 96 b/min.Abdominal examination done showed that theuterus was contracted. Despite that the patientwas still actively bleeding. Another IV line was inserted and blood wassent for CBC, GXM and PT/PTT. She was given NSrunning fast.
  • • The labour was uneventful and she deliveredThe labour was uneventful and she delivereda 3.9kg baby. There was massive bleedingafter her delivery.• Exploration did not reveal any retainedproducts.• The uterus remained atonic despite repeatedinjections of ergometrine and an oxytocininfusion. No blood or blood products wereavailable.Further examination showed a cervicallaceration trial to repair was failed.The patient continued to bleed, so vaginal packing was donea planning for transferre to thegeneral hospital.The placenta was also re-examine for it’scompleteness. By this time, the patient’s blood loss was about1 L. the patient was conscious but lethargic, herBP was 90/60mmHg and PR was 110b/min.
  • 23/15While awaiting for arrangements for transfer tothe referral center to be made, another 2 iv linesinserted and she was rapidly infused with NS andlater transfused with blood. A Foley’s catheter was inserted to monitor urineoutput and her vital signs was monitored every 15minutes.
  • • Upon arrival the general hospital the estimatedblood loss was about 2L and she had 4 iv lines(all green). 2 unit of blood has already beentransfused plus the crystalloids and the 3rd and4th unit of blood transfusion was still inprogress.Upon arrival the general hospital the estimatedblood loss was about 2L .2 unit of blood has already beentransfused plus the crystalloidsExamination upon arrival showed very palepatient, drowsy but still responding to call, the BPwas 80/40mmHg ,PR was 130b/min. The uteruswas contracted and still actively bleeding from thevagina.
  • EUA was done and the cervicallaceration was sutured. Despite that patient continuedto bleed.
  • A laparotomy was done26/15it showed that there wasanother cervical lacerationwhich extended up to thelower segment of the uterus.As it was not able to be repaired,a hysterectomy was performed.
  • She was managed for 2 days in ICU. Theestimated blood loss through out was 5.4Land she was transfused a total of 21 unit ofblood and 4 cycles of DIVC regime. She wasdischarged well on day 6 post delivery.Post operatively
  • CASE 5A 37-year-old black female P7 at term admitted in earlylabor. Her prenatal course was significant for gestationaldiabetes controlled with diet. her last child weighing4200KG. Her past medical history was significant only for astrong family history of diabetes mellitus.On admission, the CX 4cm/VTX/-1/AROM with clearfluid contractions decreased in intensity and frequencyafter AROM. A Pitocin® augmentation was begun and thepatient quickly progressed to C/C/VTX/+1.
  • • She delivered a 4300 kg baby with a moderateshoulder dystocia that was treated effectively withthe McRobert’s maneuver and suprapubicpressure after a left mediolateral episiotomy.• The placenta delivered spontaneously withoutdifficulty29/15She delivered a 4300 kg baby with a moderateshoulder dystocia that was treated effectively withthe McRobert’s maneuver and suprapubic pressureafter a left mediolateral episiotomy.The placenta delivered spontaneously withoutdifficultyCase cont’
  • • She delivered a 4300 kg baby with a moderateshoulder dystocia that was treated effectively withthe McRobert’s maneuver and suprapubicpressure after a left mediolateral episiotomy.• The placenta delivered spontaneously withoutdifficulty30/15The patient had persistent bleeding after repairof her episiotomy.An immediate re-inspection ofher cervix andvagina revealed no occult lacerations.She was treated with continued IV Pitocin® andgiven multiple doses of 15-methyl prostaglandinF2-_ as well as a course of rectal misoprostolwithout responseCase cont’
  • • She delivered a 4300 kg baby with a moderateshoulder dystocia that was treated effectively withthe McRobert’s maneuver and suprapubicpressure after a left mediolateral episiotomy.• The placenta delivered spontaneously withoutdifficulty31/15Counseling regarding thepossible need forhysterectomy. laparotomy was performed. Theuterus was persistently atonic. No evidence ofoccult lacerations or other cause for the bleeding.Hemostatic B-Lynch sutures were placed to stopthe bleeding. The bleeding markedly decreasedwith this procedure. She received a total of 8 unitsof packed red blood cells during and after thesurgery. She left the hospital without furtherincidentCase cont’
  • Remmber : Aetiology of 1ry ppHgTONE [Abnormality Of UterineContraction]• Over distended uterus• Uterine muscle exhaustion / UterineAtony [90%]• Intra amniotic infection• Functional/anatomic distortion of theuterusTISSUE [Retained Product Of Conception]• Retained products• Abnormal placenta• Placenta Praevia /Abruptio Placenta• Blood clots and cotyledonTRAUMA [At Genital Tract]• Cervix, vagina , perineum laceration• Caesarean section laceration• Uterine rupture• Uterine inversionTHROMBIN [Abnormality Of Coagulation]• Coagulopathy• therapeutic4T’S AETIOLOGYOF PRIMARY PPH32/15
  • Finding the causes33/15
  • Uterine compression sutures• B-Lynch suture & modifications.• Hemostatic suturing techniqueDevascularisation procedure• Bilateral uterine artery ligation.• Bilateral internal iliac artery ligation.• Utero-ovarian artery anastomosis ligation.• Arterial embolization.Indication of Hysterectomy (Supracervical / Total)• Uterine atony• Placenta accreta• Placenta previa• Uterine laceration• Uterine rupture• Uterine leiomyomata34/15
  • Principles of managing PPH• Speed Skills Priorities –• Call For Help (Red Alert System) –• Assess the patient’s condition –• Find the cause of bleeding and stop it –• Stabilize And Resuscitate The Patient –• Prevent Further BleedingSpeedSkills Priorities1-Call For Help (Red Alert System)2-Assess the patient’s condition3-Find the cause of bleeding and stop it4-Stabilize And Resuscitate The Patient5-Prevent Further Bleeding
  • MCQ on Hemorrhage inObstetrics
  • med-ed-online1- A woman 35 years old /G4 L3 presents with couvelaireuterus in C/S. When is hysterectomy indicated?A-presence of hematoma in the broad ligamentB-presence of hematoma in mesosalpinxC- atony retractable to treatmentD- presence of blood in abdominal cavityAns:C
  • med-ed-online2-Which is wrong about platelet administration?A- Platelet can not be reserved more than 5 daysB-platelets should be administered to patients withhemorrhage and platelet counts less than 50000/mlC-platelet should be administered after cross-matchD- If there is no hemorrhage, platelets should beadministered to patients with platelet counts less than10000 /mlAns:D
  • med-ed-online3-which is the most common reason of DIC inObstetrics?A-IUFDB-abruptionC-AF emboliD- septic shockAns:B
  • med-ed-online4-what is the first step in treating a G2 with late postpartumhemorrhage (after stabilizing her condition)?A-curettageB-uterotonicsC-uterine artery ligationD-hypogastric artery ligationAns:B
  • med-ed-online5-A 16 year-old woman comes to you with heavy bleedingafter a two month delay in her periods. Pregnancy test isnegative. Ultrasound shows a thin endometrium. There is nocoagulation or anatomical problem. Which is the besttreatment?A-high dose progesteroneB-curettageC-IV conjugate estrogenD-diagnostic hysteroscopyAns:CConjugate estrogen 25-40 mg IV q6h or PO2.5 mg q6h
  • med-ed-online6- what is the stage of shock in a woman70 kg / HR=130 bpm/AP=55mmHg/mod tachycardia/urinary output=10cc in a minA-firstB-secondC-thirdD-fourthAns:C
  • med-ed-online7-Which is true about hemorrhagic shock?A- central venous catheter is not recommendedB-lifting the feet is not recommendedC-colloids are superior to crystalloidsD-excess NS can cause alkalosisAns:A
  • med-ed-online8-A woman suffers intractable heavy vaginal bleeding after C/S.Laparatomy is performed. Retrovesical hematoma is evacuatedand the site of bleeding is sutured. The bleeding does not stop.What is the second stage in management?A-total hysterectomyB-bilateral uterine and ovarian arteries ligationC-bilateral hypogastric arteries ligationD-bilateral hypogastric and ovarian arteries ligationAns:DOvarian artery is situated in infundibulopelvic andmesosalpinx ligament
  • med-ed-online9-Which is wrong in abruption?A-It is more likely in heroin addictsthan cocaine addictsB-fibroma is one of the causesC-positive past history is a risk factorD-there is no agreement on smoking as a risk factorAns:A
  • med-ed-online10-A G2 with GA=14 wks is referred for spotting. Ultrasoundimaging shows twin pregnancy with one fetal demise. How thecoagulation profile may change?A- The profile is like that of DICB-heavy bleeding will occur during laborbecause of hypofibrinogenemiaC- repairable transient coagulopathy will occurD-the live infant in the uterine will developcoagulopathyAns:C
  • med-ed-online11-Which is true about uterine inversion?A-BP and MgSO4 can be the reasonB-it is more common in multiparasC-it is never fatalD-hemorrhage occurs with a delayAns:A
  • med-ed-online12-If there is a coagulopathy disorder, which is an indication forHeparin administration provided that circulation is intact?A-IUFDB-AbruptionC-septic abortionD-HELLP syndromeAns:AHeparin dose 5000 units TDS for IUFDFFP and platelet for septic abortion
  • med-ed-online13-Which is wrong about stage II of hypovolemicshock?A-Tachycardia is a constant findingB-blood loss is more than 1000ccC-systolic minus diastolic BP is increasedD-BP at rest is normalAns:C
  • 14-Which is true about int iliac artery ligation forcontrolling pelvic hemorrhage?A-Ext iliac artery should be checkedbefore ligation is attemptedB-ureter should not be locatedC- both sides arteries should not be ligatedD-the artery should be ligated proximal to parietalbranchAns:A
  • med-ed-online15-A 40 year old woman is hospitalized for hemorrhagicshock. Her kidney function is normal. What is the mostsensitive and reliable clinical criteria for determiningseverity of volume loss?A- tachycardiaB-tachypneaC-oliguriaD-hypotensionAns:C
  • med-ed-online16-An extension of C/S incision causes vaginal artery lacerationand heavy bleeding. What should be done for this case?A-uterine artery ligationB-ovarian artery ligationC- hypogastric artery ligationD-hysterectomyAns:C
  • med-ed-online17- How many ml of blood does a soaked lap padabsorbs?A-30 ccB-50 ccC-80 ccD-100 ccAns:B
  • med-ed-online18-What is wrong for blood loss management?A-after an hour in a critical case only 20% ofcrystalloids remains in circulationB- the volume of crystalloids replacement isthree times the volume of blood lossC-in all cases of blood loss a Hb of less than 8gr/dl mandates whole blood transfusionD-colloids increase mortality rateAns:C
  • med-ed-online19-What is wrong about vaginal hematoma afterdelivery?A-observation if hematoma is smallB- an incision on the site if pain is severe andhematoma enlargesC-mattress suturing the bed of hematomaD-pressure dressing should be applied on thehematoma bed for 12-24 hoursAns:D
  • med-ed-online20- A repeat C/S II has hemorrhage of the incisionsite. Which can best control hemorrhage?A-ligation of placental site above and below theincision siteB-ligation of uterine arteryC- ligation of hypogastric arteryD- embolization of uterine arteryAns:A
  • med-ed-online21 Which is wrong about fetal complications ofabruption?A- 20-25 percent of cases demise perinatallyB-40 % are delivered prematurelyC- 12-15 % are IUFDD-if the fetus doesn’t die in uterus, there wouldbe no serious neonatal complicationAns:D
  • med-ed-online22A pregnant woman G2 GA=38 wks has the chief complaint ofvaginal spotting. There is no sign of abruption or previa byultrasound. What is the best management?A- observationB-termination of pregnancyC-dischargeD-referring patient to another centerAns:B
  • med-ed-online24-Which is true about abruption?A- The chance of repeated abruption is twiceB-fetal assessment techniques can predictabruption with good precisionC-there is no means to predict abruptionD-The chance of repeated abruption is notdifferentAns:C
  • med-ed-online25-Which is wrong in cases of placenta previa?A-the safest means of diagnosing placenta previais transabdominal ultrasoundB-false positive results are because of fullbladderC-low lying or total previa is best diagnosed bytrans vaginal ultrasoundD-NPV of transperineal ultrasound is 70 %Ans: D (its NPV is 100% )
  • med-ed-online26-What is the first surgical step in a case of retractableuterine atony?A-ligation of uterine and ovarian arteriesB-ligation of hypogastric arteriesC-subtotal hysterectomyD- uterine artery embolizationAns:A
  • •THANK YOU62/15