Postpartum Hemorrhage

A 35-year-old woman immediately postpartum has an estimated blood loss of 1,500 mL and continues to bleed despite initial medical therapy. Which of the following medications can be considered in the setting of postpartum hemorrhage when initial medical therapy fails?

• Albumin
• Conjugated equine estrogen
• leuprolide
• medroxyprogesterone acetate
• Tranexamic acid

A 28-year-old pregnant woman with a history of postpartum hemorrhage secondary to uterine atony with her last delivery presents in active labor. In an attempt to prevent a subsequent postpartum hemorrhage, you initiate uterine massage and place gentle traction on the umbilical cord after delivery of the neonate. In addition to these measures, which medication should be administered during active management of the third stage of labor?

• 15-Methyl PGF 2a
• Methylergonovine
• Misoprostol
• Oxytocin
• Tranexamic acid

A 30-year-old G4P4004 woman is status post vaginal delivery of cephalic/breech twins. Her labor was also complicated by pre-eclampsia with severe features and she has a magnesium sulfate infusion running for seizure prophylaxis. Her delivery resulted in a second-degree perineal laceration that was easily repaired. However, her bleeding does not cease and she begins to experience a postpartum hemorrhage. Which of the following is the MOST LIKELY cause of her postpartum hemorrhage?

• Atony
• Pre-eclampsia
• Lacerations
• Retained placenta
• Multifetal gestation

A 30-year-old multiparous female at 41 weeks' gestation is undergoing labor induction by oxytocin infusion, and delivers vaginally a vigorous female infant weighing 4,056 g. After delivery of the placenta, excessive hemorrhage occurs and cannot be controlled by total 40 units of oxytocin infusion with intravenous fluids and vigorous uterine massage. The patient has a medical history of moderate persistent asthma. Which of the following medications, if given within 3 hours of birth, has been shown to reduce mortality rates from obstetrical hemorrhage?

• Magnesium sulfate
• Methylergonovine
• Tranexamic acid
• Terbutaline
• Carboprost

A 23-year-old G3P2002 woman at 38 weeks 4 days is admitted for active labor. She progresses through a rapid labor and delivers a healthy female infant weighing 3,100 g with APGAR scores of 8 and 9 at 1 and 5 minutes, respectively. Immediately after the third stage of labor, the physician notes brisk vaginal bleeding and uterine atony despite continuous IV pitocin. Her hemoglobin on admission was 12.2 g/dL. Her bleeding continues despite 0.2 mg of IM methylergonovine, 0.25 mg of IM 15-methyl PGF2E, and 1,000 µg of rectal misoprostol. Her total estimated blood loss at this point is greater than 1,000 mL. In the setting of postpartum hemorrhage, which of the following next management steps may decrease her risk of mortality?

• 1 g of IV tranexamic acid
• postpartum hysterectomy
• massive transfusion
• uterine artery embolization by interventinal radiology
• place Bakri balloon

After a prolonged induction of labor, a patient with diabetes, asthma, and preeclampsia has an uncomplicated delivery with an EBL of 300 cc. Three hours later her uterus is atonic and she hemorrhages 1000 cc. She has received oxytocin and her uterus is still atonic. What is the next BEST step?

• Bakri balloon
• B lynch sutures
• Hemabate
• Methergine
• Misoprostol

A 38-year-old G3P3003 just delivered vaginally. Prenatal course was uncomplicated. A third trimester growth ultrasound showed a fetus in cephalic presentation demonstrating appropriate growth, normal amniotic fluid index and a fundal placenta. Following the delivery of the placenta, the patient begins to bleed profusely. The uterus is explored, and a smooth, round mass is palpable at the cervix. Following diagnosis, anesthesia is paged and the massive transfusion protocol is activated. What is the next BEST step in the management of this patient?

• Administer pitocin
• Administer terbutaline
• Immediate replacement of the uterus
• Huntington procedure
• Hysterectomy

Following a spontaneous vaginal delivery, the placenta takes quite some time to deliver. While performing the delivery, the physician notices that the uterus has not quite clamped down. There is now concern over a possible uterine inversion. What is the MOST common presenting sign of uterine inversion?

• Complete protrusion of the uterus
• Fever
• Pain
• Postpartum hemorrhage
• Shock

A 36-year-old G4P4004 has just delivered a 3,800-g girl and suffered a first-degree perineal laceration. The placenta is delivered 5 minutes later. Immediately after delivery, postpartum hemorrhage occurs and is attributed to uterine atony. Uterine massage is performed. Oxytocin infusion, Methergine 0.2 mg IM, Hemabate 0.25 mg IM, and rectal misoprostol 800 mcg are given. However, uterine atony persists with significant bleeding. Her blood pressure level is 86/48 mm Hg, and her pulse rate is 112/min. The patient is moved to the operating room for placement of a Bakri balloon and possible surgical exploration. One colleague suggests proceeding with uterine artery embolization as an alternative to surgical intervention. Uterine artery embolization for the management of postpartum hemorrhage is APPROPRIATE in which of the following circumstances?

• Cesarean delivery complicated by persistent, slow uterine bleeding despite maximum medical management, blood pressure level of 105/75 mm Hg, and pulse rate of 90/min
• Cesarean delivery complicated by postpartum hemorrhage currently requiring massive transfusion to maintain vital signs
• Initial management following vaginal delivery complicated by 1,000-mL blood loss due to uterine atony
• Vaginal delivery complicated by blood loss of approximately 1,000 mL with continued brisk vaginal bleeding with suspected morbidly adherent placenta

A 30-year-old G2P2002 patient is status post vaginal delivery that was complicated by atonic postpartum hemorrhage (PPH). Uterine massage was performed, and IV oxytocin and IM methylergonovine maleate were administrated. Eventually, bleeding stopped after placement of an intrauterine Bakri balloon. Estimated blood loss was 1,300 cc. The obstetrics team decided to brief for the case after her general condition was stabilized. During the briefing, one of the residents was questioning whether tranexamic acid would have reduced her blood loss or prevented PPH. According to ACOG, which statement is TRUE about the use of tranexamic acid in PPH?

• As seen in the WOMAN trial, antifibrinolytic therapy may result in increased risk of thrombosis due to breakdown of fibrin clots
• Compared to placebo, tranexamic acid significantly reduces maternal morbidity
• IV administration of tranexamic acid is recommended over oral administration in the setting of obstetric hemorrhage
• Reduction in mortality is noted when the antifibrinolytic agent, TXA, is administered within 3 hours of delivery
• Tranexamic acid can be used as an alternative to ergot alkaloids, if they are contraindicated