Obstetrics & Gynecology Management of Catastrophic Obstetrical Hemorrhages: Review Questions Serdar H. Ural, MD, FACOG Dr. Ural is an Assistant Professor of Obstetrics and Gynecology, University of Pennsylvania School of Medicine, Philadelphia, PA. Choose the single best answer for each question. Questions 1–4 refer to the following case study. A 31-year-old gravida 3 para 2 patient just had a successful vaginal delivery at 41 weeks and 4 days of gestation. A midline episiotomy is performed in anticipation of a macrosomic infant. Her past medical history is remarkable for hypothyroidism, which is well controlled. Her past surgical history is remarkable for laser laparoscopy for endometriosis 2 years ago. She has no known drug allergies and an unremarkable family history. Her 2 prior pregnancies ended in normal spontaneous vaginal deliveries at term; there were no notable complications. Suddenly, a large quantity of blood gushes from her vagina, and she continues to bleed profusely.
	1. What is the first thing that should be done? Observe for 10 more minutes Perform a cesarean hysterectomy Perform a pelvic ultrasound to rule out retained products of conception Check a complete blood count Perform a pelvic examination to assess for uterine atony and the extent of the episiotomy Click here to compare your answer. 2. What is the first medication that should be ordered to control the hemorrhage based on the most likely diagnosis? Methergine 0.2 mg intramuscular injection Prostaglandin F2a 0.25 mg intramuscular injection Levothyroxine 100 µg orally Pitocin 10 mg in 1000 µL of crystalloid intravenous solution Leuprolide acetate 1.25 mg intramuscular injection Click here to compare your answer.		3. The patient’s hemorrhage is unresponsive to medical management. In addition to infusing blood products, what surgical procedure can be performed initially to control the bleeding and preserve the patient’s fertility? Aortic compression Bilateral uterine artery ligation Cesarean hysterectomy External iliac artery ligation Internal iliac artery ligation Click here to compare your answer. 4. The surgical procedure performed to control bleeding and preserve fertility did not work; the uterus still is atonic. The anesthesiologist states that the patient is becoming hypotensive. She also is tachycardiac, tachypnic, and has hypothenar blanching. What is the next step in this patient’s management? Aortic compression Bilateral uterine artery ligation Cesarean hysterectomy External iliac artery ligation Internal iliac artery ligation Click here to compare your answer. 5. Which of the following factors does not increase the risk of postpartum hemorrhage? Fetal macrosomia Polyhydramnios Postpartum hemorrhage in prior pregnancy Amniotic fluid embolism Hypothyroidism Click here to compare your answer.
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