Postpartum haemorrhage and puerperium

33 NEET-PG practice questions on Postpartum haemorrhage and puerperium, part of Obstetrics & Gynaecology. The first 25 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

1. Question 1 · Easy

   Twenty minutes after a vaginal delivery at a Community Health Centre, a 26-year-old with gestational hypertension (BP 150/100 mm Hg) bleeds heavily. The placenta is complete and the uterus is soft and boggy. Uterine massage has begun. Which uterotonic is the first choice?

   1. AOxytocin
   2. BMethylergometrine
   3. CMisoprostol
   4. DCarboprost

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   Answer: A · Oxytocin

   A soft, boggy uterus with a complete placenta means atonic PPH, the commonest cause (tone among the 4 Ts). Oxytocin, by IV infusion or IM, is the first-line uterotonic for treating PPH as well as for its prevention in active management of the third stage. Methylergometrine is contraindicated in this woman because it raises blood pressure. WHO also advises tranexamic acid 1 g IV within 3 hours of birth for every woman with PPH, alongside uterotonics.

   • B: Ergometrine raises BP and is contraindicated in hypertension.
   • C: Misoprostol is used when oxytocin is not available or fails.
   • D: Carboprost is second-line and is avoided in asthma.

2. Question 2 · Medium

   A 22-year-old primigravida delivers a 3.8 kg baby after a rapid second stage at a CHC. The placenta and membranes are complete and the uterus is firm and well contracted at the umbilicus, but bright red blood keeps trickling steadily from the vagina. Pulse is 104/min. What is the most appropriate next step?

   1. AExamine the cervix and vagina for tears
   2. BExplore the uterine cavity manually
   3. CGive a second dose of oxytocin IM
   4. DStart a carboprost injection schedule

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   Answer: A · Examine the cervix and vagina for tears

   Continuous bright red bleeding with a firm, contracted uterus and a complete placenta points to trauma, the second commonest cause of PPH. A large baby and a precipitate second stage tear the cervix, vagina or perineum. The genital tract is inspected under good light with retractors (and anaesthesia if needed), and tears are sutured, starting above the apex. More uterotonics will not help a uterus that is already contracted.

   • B: Manual exploration is for retained tissue, but the placenta is complete.
   • C: More oxytocin cannot stop bleeding from a tear.
   • D: Carboprost treats atony; this uterus is firm.

3. Question 3 · Medium

   Ten days after delivery, a 27-year-old is brought by her husband because for three days she has slept little, talks excessively, believes her baby has been exchanged by the hospital staff and has said the baby is 'evil'. Her mother had a bipolar illness. What is the most appropriate step?

   1. AUrgent psychiatric admission, keeping the baby safe
   2. BStart sertraline and review in the OPD after a month
   3. CArrange counselling sessions only
   4. DReassure the family that this is postpartum blues

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   Answer: A · Urgent psychiatric admission, keeping the baby safe

   Delusions about the baby, insomnia and pressured speech within weeks of delivery are postpartum psychosis, usually a manifestation of bipolar disorder; a family history of bipolar illness raises the risk. It is a psychiatric emergency because of the risk of suicide and infanticide, so she needs urgent admission, ideally to a mother-baby unit, with antipsychotics and mood stabilisers; ECT works quickly in severe cases. The baby must not be left alone with her until she is assessed. Blues never include delusions.

   • B: Outpatient antidepressant treatment is unsafe and can trigger mania.
   • C: Counselling alone does not treat psychosis or remove the risk.
   • D: Blues are mild and never include delusions.

4. Question 4 · Medium

   At an FRU, a 25-year-old para 2 has continued atonic bleeding after oxytocin infusion, methylergometrine, carboprost and tranexamic acid. The placenta was complete and the genital tract shows no tear. Pulse is 118/min and BP 96/60 mm Hg with fluids running. She wants more children. Before arranging transfer for surgery, what is the most appropriate measure?

   1. AA further dose of methylergometrine
   2. BPacking the vagina with gauze rolls
   3. CImmediate subtotal hysterectomy
   4. DIntrauterine balloon tamponade

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   Answer: D · Intrauterine balloon tamponade

   Bleeding from atony despite first- and second-line uterotonics and tranexamic acid is refractory PPH. Intrauterine balloon tamponade, which in India is often a condom tied over a catheter and filled with 300-500 mL of saline, presses on the placental bed and stops bleeding in most cases, buying time for transfer. Bimanual compression and a non-pneumatic anti-shock garment are other temporising measures. If tamponade fails, compression sutures, devascularisation and hysterectomy follow in that order.

   • A: Uterotonics have already failed; more of the same is futile.
   • B: Vaginal packing hides bleeding from the uterus and does not compress it.
   • C: Hysterectomy comes last, after conservative steps have failed.

5. Question 5 · Medium

   In a district hospital audit of maternal deaths from PPH, the team classifies causes by the '4 Ts'. A 35-year-old para 5 bled after a normal delivery; the uterus stayed soft and boggy despite massage, the placenta was complete and there was no tear or clotting defect. Under which 'T' does her PPH fall?

   1. ATrauma
   2. BTissue
   3. CThrombin
   4. DTone

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   Answer: D · Tone

   The 4 Ts are Tone (atony, about 70-80% of cases), Trauma (tears, rupture, inversion), Tissue (retained placenta, accreta) and Thrombin (coagulopathy). A soft, boggy uterus after the placenta is complete and with no tear or clotting defect is atony, a problem of tone; grand multiparity is a classic risk. Using the 4 Ts at the bedside makes the team check each cause in turn. Treatment of atony is massage, uterotonics and tranexamic acid, then tamponade and surgery.

   • A: There was no genital tract tear.
   • B: The placenta was complete, so tissue was not retained.
   • C: There was no clotting defect.

6. Question 6 · Medium

   A 30-year-old Jehovah's Witness with full mental capacity is bleeding heavily after a caesarean. She clearly refuses blood transfusion, as recorded in her signed advance directive, even after being told she may die. Her husband asks the team to transfuse her anyway. What should the team do?

   1. ARespect her refusal and use all non-blood measures
   2. BSeek the hospital director's consent to transfuse
   3. CTransfuse because the husband has given consent
   4. DTransfuse under the doctrine of emergency

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7. Question 7 · Medium

   A pharmacology postgraduate preparing a PPH protocol for a district labour room checks four statements about uterotonics: 1. Misoprostol is stable at room temperature and can be given orally or sublingually. 2. Carboprost is contraindicated in bronchial asthma. 3. Methylergometrine is the uterotonic of choice in women with heart disease. 4. Oxytocin in high doses with large volumes of dextrose can cause water intoxication. Which statements are correct?

   1. A2, 3 and 4 only
   2. B1, 2 and 4 only
   3. C1 and 2 only
   4. D1, 2, 3 and 4

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8. Question 8 · Easy

   Thirty minutes after a vaginal birth at a CHC, a 27-year-old loses an estimated 700 mL of blood. Oxytocin has been given and the uterus is being massaged. The medical officer also decides to give tranexamic acid. Which regimen is recommended?

   1. A10 mg/kg IV only after fibrinogen is known
   2. B1 g IV only if bleeding persists beyond 24 hours
   3. C1 g IV over 10 minutes, within 3 hours of birth
   4. D500 mg orally every 8 hours for 5 days

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9. Question 9 · Medium

   In a labour room drill at a district hospital, the nursing officers are asked which steps make up active management of the third stage of labour as now recommended by WHO. 1. Oxytocin 10 IU intramuscularly within one minute of the baby's birth. 2. Controlled cord traction when a skilled attendant is present. 3. Assessment of uterine tone through the abdomen after the placenta is delivered. 4. Clamping the cord within 30 seconds of birth in every baby. Which steps are correct?

   1. A1 and 2 only
   2. B1, 2 and 4 only
   3. C1, 2, 3 and 4
   4. D1, 2 and 3 only

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10. Question 10 · Medium

    On the second day after a normal delivery, a 21-year-old develops high fever, diffuse abdominal pain, hypotension and a red, sunburn-like rash. Lochia is thin and not foul-smelling. Blood culture grows Gram-positive cocci in chains with a clear zone of beta-haemolysis on blood agar, sensitive to bacitracin. Which organism is the most likely cause?

    1. AStaphylococcus aureus
    2. BStreptococcus agalactiae
    3. CEnterococcus faecalis
    4. DStreptococcus pyogenes

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11. Question 11 · Easy

    On the seventh day after a normal vaginal delivery, a 24-year-old first-time mother visits the PHC worried that her vaginal discharge has changed from red to a pinkish-brown, scanty flow without odour. She is afebrile, the uterus is non-tender and the fundus is well below the umbilicus. How is this discharge best described?

    1. ALochiometra with infection
    2. BLochia rubra persisting
    3. CNormal lochia alba
    4. DNormal lochia serosa

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12. Question 12 · Hard

    A 33-year-old with severe pre-eclampsia (BP 166/108 mm Hg on labetalol) and known bronchial asthma delivers vaginally at a district hospital. She has atonic bleeding despite an oxytocin infusion, uterine massage and tranexamic acid; the placenta is complete and there is no tear. Which additional uterotonic is most appropriate for her?

    1. AMethylergometrine
    2. BErgometrine with oxytocin
    3. CCarboprost
    4. DMisoprostol

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13. Question 13 · Medium

    A 24-year-old has fever of 39 °C on the third day after an emergency caesarean done for prolonged labour with membranes ruptured for 20 hours. Lochia is foul-smelling and the uterus is tender. The wound and breasts are normal and the chest is clear. Which antibiotic regimen is the standard first choice?

    1. AIV vancomycin alone
    2. BIV clindamycin plus gentamicin
    3. COral amoxicillin alone
    4. DOral metronidazole alone

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14. Question 14 · Medium

    A 24-year-old presents on day 10 after a vaginal delivery at a private nursing home with heavy fresh bleeding, fever of 38.4 °C and foul-smelling lochia. Pulse is 102/min and BP 112/70 mm Hg. The uterus is bulky and tender and the os is open. Ultrasound shows a 3 cm echogenic mass with vascularity in the uterine cavity. What is the most appropriate management?

    1. AAntibiotics alone until the fever settles fully
    2. BMethylergometrine tablets and review in a week
    3. CEmergency hysterectomy
    4. DIV antibiotics and evacuation of retained products

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15. Question 15 · Medium

    Thirty-five minutes after the birth of her baby at a district hospital, a 29-year-old's placenta has not delivered despite oxytocin 10 IU IM and controlled cord traction. She is now bleeding briskly; pulse is 112/min and BP 100/64 mm Hg. An IV line is running. What is the next step?

    1. AWait another 30 minutes with cord traction
    2. BInject oxytocin into the umbilical vein
    3. CManual removal of placenta under anaesthesia
    4. DEmergency hysterectomy

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16. Question 16 · Hard

    A 32-year-old para 3 delivers at a CHC. While the attendant pulls on the cord to hurry the third stage, the woman suddenly becomes pale and sweaty, with pulse 56/min and BP 70/40 mm Hg. Little blood is visible. No uterine fundus can be felt per abdomen, and a dark red mass with the placenta still attached lies in the vagina. What is the immediate management?

    1. AGive methylergometrine, then attempt replacement
    2. BPeel off the placenta, then push the uterus back
    3. CPack the vagina and transfer to a medical college
    4. DPush the uterus back at once, placenta attached

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17. Question 17 · Medium

    During an emergency caesarean for obstructed labour in a 31-year-old, the uterus remains soft and keeps bleeding from the placental bed after delivery of the placenta, despite oxytocin infusion and intramyometrial carboprost. Bimanual compression of the uterus reduces the bleeding markedly. Which procedure is most appropriate now?

    1. ABilateral internal iliac artery ligation
    2. BB-Lynch compression suture
    3. CTotal abdominal hysterectomy
    4. DPacking of the uterine cavity

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18. Question 18 · Medium

    A 25-year-old is bleeding after a vaginal delivery at a CHC. Her pulse is 124/min and systolic BP 92 mm Hg; before delivery they were 84/min and 118 mm Hg. Estimated blood loss on the drapes is recorded as 400 mL. The shock index (heart rate divided by systolic BP) in a healthy postpartum woman is usually 0.7-0.9. What does her shock index indicate?

    1. AA value that is meaningless during PPH
    2. BA normal value for the first hour postpartum
    3. CCompensated loss that needs observation only
    4. DSignificant blood loss, underestimated

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19. Question 19 · Hard

    After a PPH from atony, a 26-year-old has been on a high-dose oxytocin infusion in 5% dextrose for 18 hours, receiving about 4 litres of fluid in that time. She becomes confused and has a generalised convulsion. BP is 124/80 mm Hg and urine shows no protein. Serum sodium is 118 mmol/L (reference 135-145). What is the mechanism of her convulsion?

    1. AWater retention from oxytocin's ADH-like action
    2. BCerebral venous thrombosis of the puerperium
    3. CEclampsia from undiagnosed pre-eclampsia
    4. DHypoglycaemia from prolonged dextrose infusion

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20. Question 20 · Medium

    A 28-year-old with rheumatic mitral stenosis delivers vaginally in a tertiary labour room. The obstetrician tells the intern to give oxytocin, not methylergometrine, for the third stage. Why is methylergometrine avoided in her?

    1. AIt acts as a potent negative inotrope on the heart
    2. BIt causes profound vasodilation and hypotension
    3. CIt prolongs the QT interval and causes arrhythmia
    4. DIt sharply raises venous return and afterload

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21. Question 21 · Easy

    At the postnatal clinic, an intern palpates the abdomen of a woman who delivered vaginally 2 weeks ago and cannot feel the uterus. By which stage of the puerperium does a normally involuting uterus usually become a pelvic organ?

    1. AWithin the first 48 hours
    2. BBy the end of the sixth week
    3. COnly after menstruation returns
    4. DBy the end of the second week

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22. Question 22 · Hard

    A 31-year-old, 4 months after a massive PPH with shock, has failed lactation, amenorrhoea, fatigue and postural dizziness. Results: serum sodium 128 mmol/L, 8 am cortisol 2 µg/dL (reference 5-25), free T4 0.5 ng/dL (reference 0.8-1.8), TSH 1.1 mIU/L (reference 0.5-4.5), prolactin low. Which treatment must be started first?

    1. AHydrocortisone replacement
    2. BOral sodium chloride supplements
    3. CLevothyroxine replacement
    4. DCyclical oestrogen and progestogen

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23. Question 23 · Hard

    A 30-year-old with an abruption and an intrauterine death delivers vaginally and has continuing PPH despite a well-contracted uterus and no tears; blood oozes from IV sites. Results: Hb 6.8 g/dL, platelets 70,000/µL, PT 22 s (control 13 s), fibrinogen 90 mg/dL (reference 300-600 in pregnancy), D-dimer markedly raised. Besides packed red cells, what is the most important blood product for her?

    1. AWhole blood stored over 14 days
    2. BPlatelet concentrate alone
    3. CCryoprecipitate
    4. DAlbumin infusion

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24. Question 24 · Medium

    At a sub-centre without a refrigerator, an ANM attends a 23-year-old who is bleeding heavily after a normal delivery. The placenta is complete and the uterus is soft. Oxytocin is not available. Which drug and route should she use while arranging referral?

    1. AMisoprostol 800 µg sublingually
    2. BCarboprost 250 µg sublingually
    3. CMisoprostol 200 µg vaginally
    4. DMethylergometrine 0.2 mg orally

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25. Question 25 · Easy

    A 26-year-old comes to the gynae casualty on the 12th day after a home delivery with fresh, heavy vaginal bleeding. She had been told the placenta 'came out in pieces'. The uterus is larger than expected for the day and the internal os admits a finger. What is the most likely cause of the bleeding?

    1. AChoriocarcinoma after delivery
    2. BRetained placental fragments
    3. CUnrepaired cervical laceration
    4. DUterine atony of the third stage

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