Postpartum Hemorrhage & Obstetric Emergencies — Practice

Question 1

What causes the majority of postpartum haemorrhage?

Accepted Answer

B

Question 2

A woman at 34 weeks has painless bright red vaginal bleeding with a soft non-tender uterus. What is the likely diagnosis?

Accepted Answer

B

Question 3

A woman with severe pre-eclampsia has atonic postpartum haemorrhage unresponsive to oxytocin. Which drug should be avoided?

Accepted Answer

C

Question 4

A woman with 7 weeks amenorrhoea has abdominal pain, an empty uterus on transvaginal ultrasound and hCG of 3,000 mIU/mL. What does this suggest?

Accepted Answer

B

Question 5

After delivery, controlled cord traction is applied and the woman collapses with profound shock and a mass at the introitus. What has happened?

Accepted Answer

B

Question 6

Why did the E-MOTIVE trial achieve a 60 per cent reduction in severe outcomes using treatments that were already available?

Accepted Answer

Because the failure being corrected was in detection and sequencing rather than in the drugs themselves. Every component of the bundle, uterine massage, oxytocics, tranexamic acid and intravenous fluids, was already standard and already available in the participating hospitals.

Two things changed. First, blood loss was measured objectively using a calibrated collection drape rather than estimated visually. Visual estimation systematically underestimates large volumes, so haemorrhage was routinely being recognised late, after the woman had already lost more than anyone realised.

Second, the treatments were given together as a bundle rather than sequentially. Conventional practice escalates one intervention at a time, reassessing between each, which means the woman continues to bleed through each interval. Delivering everything at once compresses that timeline.

The trial therefore demonstrates that in emergency care, the system for recognising and responding can matter more than the therapeutic options available, which is a lesson well beyond obstetrics.

Question 7

A woman at 33 weeks with pre-eclampsia has continuous abdominal pain, a tense tender uterus, modest vaginal bleeding, pulse 132 and blood pressure 86/54. What is happening and what must be anticipated?

Accepted Answer

This is placental abruption. The continuous pain and the tense, tender, irritable uterus distinguish it from praevia, and pre-eclampsia is a recognised risk factor.

The modest visible bleeding is the trap. Blood accumulates behind the placenta and within the myometrium rather than escaping through the cervix, so the external loss bears no relation to the actual loss. Her tachycardia and hypotension indicate substantial haemorrhage, and in a pregnant woman hypotension is a late sign, so she has already lost a great deal.

Two things must be anticipated. First, disseminated intravascular coagulation, because thromboplastin released from the damaged placenta activates the coagulation cascade, and abruption causes this more often than any other obstetric condition. Coagulation studies are sent and blood products are ordered before they are needed.

Second, fetal compromise or death, since the placental surface available for gas exchange has been reduced abruptly. Resuscitation and delivery proceed together.

Question 8

Why is placenta accreta becoming more common, and why does antenatal diagnosis matter so much?

Accepted Answer

Accreta occurs where the decidua basalis is deficient, so the placenta implants directly onto or into myometrium with no cleavage plane. The commonest cause of a deficient decidua is a uterine scar, and the commonest uterine scar is a previous caesarean section.

Incidence therefore tracks the caesarean rate directly, and since caesarean rates have risen steeply, so has accreta. The risk multiplies when a placenta praevia implants over a previous scar, because the lower segment scar is precisely where a praevia sits, and it rises further with each additional caesarean.

Antenatal diagnosis matters because the difference in outcome is enormous. An unrecognised accreta is discovered when the placenta will not separate at delivery, at which point attempts at removal cause massive haemorrhage in an unprepared theatre. A recognised accreta allows delivery to be scheduled at a centre with cross-matched blood, cell salvage, interventional radiology, senior surgeons and intensive care available, with a planned caesarean hysterectomy or a decision to leave the placenta in situ.

Question 9

Why does deep vein thrombosis in pregnancy predominantly affect the left leg?

Accepted Answer

B

Practice — Postpartum Hemorrhage & Obstetric Emergencies

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