Prevention and Management of Postpartum Haemorrhage

1. Which of the following is true for Regarding Postpartum Haemorrhage

A. Secondary Postpartum Haemorrhage is the most common form of major obstetric haemorrhage
B. PPH can be major if blood loss is 500 ml
C. Secondary PPH is defined as abnormal or excessive bleeding from the birth canal with in 24 hours .
D. In women with lower body mass (e.g. less than 60 kg), a lower level of blood loss may be clinically significant.
E. Primary PPH is the loss of 500 ml or more of blood from the genital tract afer 24 hours of the birth of a baby.

2. All are true regarding Postpartum Haemorrhage except

A. The most common cause of Postpartum Haemorrhage is uterine atony.
B. Care plans must be modified as and when risk factors arise.
C. Clinicians must counsel the women with risk factors about place of delivery.
D. Women with known risk factors for PPH should only be delivered in a hospital with a blood bank on site
E. Most cases of PPH always have identifiable risk factors

3. Studies have indicated association between antenatal anaemia and blood loss. Haemoglobin levels less than ——-g/L has shown greater chances of PPH

A. 90 g/L
B. 100 g/L
C. 110 g/L
D. 9 g/L
E. 10 g/L

4. All are true regarding Minimizing risk –reducing blood loss at delivery except

A. For women without risk factors for PPH delivering vaginally, oxytocin (10 iu by intramuscular injection) is the agent of choice for prophylaxis in the third stage of labour.
B. Prophylactic uterotonics should be routinely offered in the management of the third stage of labour in all women as they reduce the risk of PPH
C. Uterine massage is of benefit in the prophylaxis of PPH.
D. For women delivering by caesarean section, oxytocin (5 iu by slow intravenous injection) should be used to encourage contraction of the uterus and to decrease blood loss.
E. Clinicians should consider the use of intravenous tranexamic acid (0.5–1.0 g), in addition to oxytocin, at caesarean section to reduce blood loss in women at increased risk of PPH.

5. Tina has been booked in consultant led care unit for anaemia, she was treated with Parenteral iv, at present her Hb is 85 g/L. She is admitted in active labour now. Regarding her plan of care all are true except

A. She is at high risk of PPH as her Hb is 85g/L
B. Need to give prophylactic oxytocin 10 iu by intramuscular injection in the third stage of labour.
C. Active management results in a lower birthweight of baby
D. NICE recommends that the umbilical cord should be clamped earlier than 1 minute from delivery of the baby if there are no concerns over cord integrity or the baby’s wellbeing.
E. Compared to oxytocin alone ergometrine–oxytocin carrying a five-fold increased risk of adverse effects

6. Regarding use of oxytocin use in Prevention of PPH all are true except

A. For vaginal delivery oxytocin 10 iu by intramuscular injection is the regimen of choice for prophylaxis in the third stage of labour.
B. Compared to oxytocin alone ergometrine–oxytocin carrying a five-fold increased risk of adverse effects
C. Intramuscular oxytocin should be administered with the birth of the anterior shoulder,
D. Intramuscular oxytocin should be given immediately after the birth of the baby and before the cord is clamped and cut.
E. Misoprostol is superior to Oxytocin in prevention of PPH

7. All are true regarding carbetocin except

A. It’s longer acting oxytocin derivative
B. It is used for prophylaxis of PPH in elective cesarean delivery
C. It’s given in dose of 100mg given over 1minute
D. Use of carbetocin resulted in a statistically significant reduction in the need for further uterotonics compared with oxytocin in vaginal delivery.
E. It’s licensed in UK specifically for prophylaxis of PPH in cesarean delivery

8. Regarding severity of haemorrhage in PPH which of the following is true

A. Visual estimations are accurate in estimating blood loss
B. In laboring woman with PPH if her pulse is 80bpm and her Blood pressure wis 104/70mm of Hg then blood loss would be around 1500ml
C. Communication with birthing partner is not important .
D. Shock index is calculated from Blood pressure /Heart rate for hemodynamic compromise
E. Shock index identifies women at risk of adverse outcomes secondary to PPH

9. Regarding teamwork in Management of PPH all are true except

A. The midwife in charge and the first-line obstetric and anaesthetic staff should be alerted when women present with minor PPH (blood loss 500–1000 ml) without clinical shock.
B. Multidisciplinary team to be alerted with major PPH (blood loss of more than 1000 ml) and ongoing bleeding or clinical shock.
C. Early involvement of appropriate senior staff (including the anaesthetic team and laboratory specialists) is fundamental to the management of PPH.
D. Senior obstetric staff need not be receptive to concerns expressed by less experienced or junior medical practitioners, and by midwives.
E. The RCOG recommends that the consultant obstetrician should attend in person when there is a PPH of more than 1500 ml where the haemorrhage is continuing.

10. According to guidance from British committee for standards in haematology, the main therapeutic goals of management of massive blood loss is to maintain

A. Haemoglobin of80g/L
B. Platelet count of 50 x 10 9 per liters
C. Partial thromboplastin time more than 1.5 times normal
D. Fibrinogen levels more Aton 2 g/L

11. Regarding fluid management in PPH all are true except

A. The nature of fluid infused is of less importance than rapid administration and warming of the infusion.
B. Dilutional coagulopathy may occur when large volumes of crystalloid, colloid or red cells are used with insufficient transfusion of fresh frozen plasma (FFP) and platelets.
C. Traditionally, a total volume of 3.5 l of clear fluids maximum that should be infused while awaiting compatible packed red cells.
D. The woman needs to be kept warm using appropriate measures to prevent hypothermia which in turn could exacerbate acidosis
E. Resuscitation with colloids is associated with an improvement in survival and that the use of one particular colloid, hydroxyethyl starch, might increase survival rates

12. Regarding red cell antibodies and blood transfusions in PPH all are true except

A. Pregnant women (and women of childbearing age) who are RhD negative must only receive RhD-negative blood to avoid the risk of D alloimmunisation.
B. Anti-K, antibody is important as it causes severe haemolytic disease of the fetus and newborn
C. Woman is known to be K positive, only K-negative blood should be used for transfusion in women of childbearing age.
D. All delivery units, especially small units without a blood bank on site, should maintain a supply of group O, RhD-positive blood.
E. Close liaison with the transfusion laboratory is essential, with input if needed from the clinical haematology team and specialist advice from the national blood service.

13. Regarding blood transfusion in PPH all are true except

A. Universal leucocyte depletion substantially reduces the risk of CMV transmission.
B. In an emergency, such as PPH, standard leucocyte-depleted components should be given to avoid delay,
C. CMV-negative blood or platelets are needed for transfusion during delivery or in the postpartum period.
D. Cell salvage does not appear to impact adversely on clinical outcom Cell salvage does not appear to impact adversely on clinical outcomes.
E. Intra operative cell salvage reduces need for absolute risk reduction by 21%.

14. Regarding coagulation profile in ongoing PPH all are true except

A. Methods to assess haemostatic impairment during PPH include laboratory-based tests PT, APTT, Clauss fibrinogen and platelet count)
B. In patients following surgery show that laboratory testing leads to appropriate use of blood components and both may be used simultaneously.
C. Coagulopathies may evolve rapidly and repeated testing (such as every 30 minutes) during continued bleeding and observation of trends are more useful than single measurement
D. Clauss fibrinogen need not be measured as part of the routine coagulation screen
E. Platelet number should be measured as part of the full blood count.

15. Regarding transfusion of FFP in PPH all are true except

A. In major ongoing PPH,waiting for lab results after 4 units of RBCs,FFP should be infused at a dose of 12–15 ml/kg until results are known
B. In absence of lab results , early FFP should be considered for conditions os suspects coagulopathy placental abruption or amniotic fluid embolism, or where detection of PPH has been delayed.
C. If transfused early , FFP is associated with an increased risk of transfusion-associated circulatory overload (TACO)and transfusion-related acute lung injury
D. Before FFP is transfused , there is need for thawing.
E. FFP results in large increments in fibrinogen level.

16. Regarding Fibrinogen in Postpartum Haemorrhage, all are true except

A. A plasma fibrinogen level of greater than 2g/l should be maintained during ongoing PPH.
B. Cryoprecipitate should be used for fibrinogen replacement.
C. Fibrinogen below 3 g/l and especially below 2 g/l is associated with progression of bleeding
D. It is expected that 2 pools of cryoprecipitate (1 pool is taken from five donors) would increase the fibrinogen level by about 0.5 g/l
E. Fibrinogen loss can be replaced by cryoprecipitate or fibrinogen concentrate, although fibrinogen concentrate is not licensed for acquired hypofibrinogenaemia in the UK

17. Role for recombinant factor VIIa (rFVIIa) therapy-in PPH

A. The routine use of rFVIIa is not recommended in the management of major PPH unless as part of a clinical trial.
B. Significant increase in the risk of arterial, thromboembolic events when compared with placebo
C. It reduces blood loss through enhancement of tissue factor-dependent coagulation.
D. Its effectiveness is markedly diminished by hypothermia, alkalosis and Thrombocytosis.
E. It should not be considered a substitute for a life-saving procedure, such as embolization or surgery, or transfer to a referral centre.

18. Regarding use of Misoprostol use in PPH all are true except

A. Oxytocin infusion should be recommended as first-line treatment for primary PPH Not Misoprostol
B. When used following prophylactic uterotonics, misoprostol and oxytocin infusion work similarly.
C. Regardless of the route of administration misoprostol takes 1.0–2.5 hours to increase uterine tone.
D. Guidelines from WHO recommend that in the management of PPH, misoprostol is administered per rectally
E. All Clinicians should be aware of the in the clinical effect of misoprostol

19. Rachel, 24 year old, primigravida, is fully dilated and pushing. Due to prolonged bradycardia she needed operative delivery -forceps. After delivery she started bleeding , the uterus is atonic . Which of the following uterotonics is correct to give her?

A. Carboprost 250 mg Intramuscular
B. Ergometrine 500 microgram Intramuscular
C. Misoprostolol 200 microgram PR
D. Syntocinon 10 units Intravenous
E. Syntocinon 20 units in 500 ml saline IV

20. Ms. Briganza, 34year old, multigravida had a forceps delivery followed by which she had massive PPH. She receives a transfusion of 18 units of both O negative and cross matches red blood cells, 12 units of fresh frozen plasma, 5 units of platelets and 3 units of cryoprecipitate. All are complications of massive blood transfusion except

A. Sensitisation to c antigens
B. Hypocalcaemia
C. Citrate toxicity
D. Lactic acidosis
E. Hypokalemia

Prevention and Management of Postpartum Haemorrhage

Prevention and Management of Postpartum Haemorrhage

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