Postpartum Haemorrhage Multiple Choice Questions for Vol. 22, No. 6
published online 22 September 2008.
Article Outline
1.The following statement(s) is/are true about PPH:
(a)One definition of PPH is when blood loss after delivery is=or>500ml
(b)The magnitude of loss is easily quantified
(c)Its prevalence is around 12%
(d)Its prevalence remains similar across different geographical regions
(e)Its prevalence is higher with active management of the 3rd stage of labour
2.Regarding Severe PPH:
(a)It is defined as blood loss=or>1000ml
(b)It is more prevalent in Europe
(c)It is more frequent in multipara
(d)It cannot be measured objectively
(e)Its prevalence has not been studied in Oceanía
3.The following statement(s) is/are true regarding the systematic review of PPH:
(a)Blood loss was measured objectively in most studies reporting incidences of PPH
(b)Studies assessing blood loss objectively report higher incidences of PPH
(c)Most studies reporting PPH were conducted in Africa, where the prevalence is higher
(d)This systematic review includes only data coming from RCTs
(e)This systematic review includes only studies published in English
4.In resource poor countries:
(a)Haemorrhage is the reported leading direct cause of maternal death
(b)The maternal mortality differential between rich and poor women has declined as a result of the Safe Motherhood Initiative
(c)User fees have improved the quality of care hospitals can offer and have increased utilisation
(d)To overcome socio-cultural and economic barriers to access, country-level analyses provide sufficient detail for service planning at district level
(e)A seed fund for community transport means there is a sum of money that is kept available for emergency use, then replenished
5.The following statement(s) is/are appropriately paired regarding the level of research evidence supporting each intervention:
(a)For retained placenta, oxytocin in saline solution injected into the umbilical vein reduces the risk of PPH: systematic review
(b)Control of PPH by balloon tamponade using an improvised condom and Foley catheter method: uncontrolled case series
(c)Misoprostol for the third stage of labour administered by traditional birth attendants: randomised controlled trial
(d)Use of voucher schemes to increase access to health facilities: agency reports
(e)Non-pneumatic anti-shock garment for PPH: pilot study
6.With respect to human resources for maternal health
(a)Traditional birth attendants have proved effective in reducing maternal mortality
(b)Task shifting means removing unnecessary procedures from routine clinical practice
(c)Non-medically qualified practitioners trained in surgery tend to remain in rural postings
(d)‘Skilled attendance at delivery’ means delivery by a health care professional who can recognise and manage complications
(e)Skills and equipment for placing uterine compression sutures should be located at facilities offering ‘comprehensive emergency obstetric care’
7.During the third stage of labour:
(a)Contraction of muscle fibres in the spiral arteriole walls plays an important part in haemostasis
(b)Estimated blood loss >1000ml occurred in more than 2% of women in randomized trials allocated to receive no active management of the third stage of labour
(c)Because of staining of linen, visual estimation gives an impression of more bleeding than has actually occurred
(d)Randomized trials have shown that ergometrine is effective in the treatment of postpartum haemorrhage
(e)The onset of uterine contractions measured with a postpartum intrauterine catheter is more rapid with oxytocin/ergometrine than with oral misoprostol
8.Misoprostol administered during the third stage of labour:
(a)Is approximately as effective as oxytocin 10 units in preventing blood loss >1000ml provided a dose of at least 600mcg orally is used
(b)May cause pyrexia >40 degrees C with dosages of 800mcg or more, but not with smaller dosages
(c)Has been assessed in randomized trials using several routes, including oral, sublingual and rectal, but not the vaginal route
(d)Has shown strikingly positive effects in uncontrolled and controlled studies for treatment of postpartum haemorrhage using subjective assessment of cessation of bleeding as the endpoint
(e)In a dose of 600mcg sublingually was shown to be effective in reducing blood loss >1000ml in a randomized trial in which active management of the third stage of labour was practised
9.Concerning the diagnosis of hypovolaemic shock:
(a)Signs and symptoms appear once 750–1000ml blood have been lost
(b)A drop in systolic blood pressure is an early sign
(c)Tachypnoea is not a sign of hypovolaemia
(d)Caplliary refill time of=/>3 seconds is prolonged
(e)A 2litre loss represents a 30–40% loss of circulating volume in a pregnant patient
10.During resuscitation of the haemorrhaging obstetric patient:
(a)Haemoglobin substitutes are available for patients refusing blood
(b)5% dextrose is not suitable for replacing lost intravascular volume
(c)Large volumes of 0.9% sodium chloride can cause a hyperchloraemic alkalosis
(d)Colloids are associated with an increased risk of anaphylactoid reactions compared with crystalloids
(e)Hydroxyethyl starch (HES) colloid solutions remain in the intravascular space longer than gelatin colloid solutions
11.Hypothermia:
(a)Is defined as a core temperature <35 degrees C
(b)Is uncommon during resuscitation of the pregnant patient
(c)Is usually caused by low ambient temperatures
(d)Increases oxygen consumption
(e)Causes coagulopathy
12.The physical principles that explain what changes in the circulatory system when Anti-Shock Garments (ASGs) are applied include:
(a)Laplace Principle: Flow rate through a blood vessel is related to the vessel's radius; rate per unit time is related to the fourth power of the radius
(b)Laplace Law: Flow rate through a blood vessel is related to the vessel's circumference; rate per unit time is related to the fourth power of the circumference
(c)Bernoulli Principle: Rate of leakage from open blood vessels depends on the size of the defect and the intraluminal pressure and the extraluminal pressure (together represented by transmural pressure)
(d)Poiseuile's Law: Flow rate through a blood vessel is related to the vessel's radius; rate per unit time is related to the fourth power of the radius
(e)By placing external pressure on the vessels and reducing the vessel radius by one half, an ASG will reduce the blood flow through the vessels by a factor of 16
13.Proper timing for the application of an ASG would include:
(a)On admission of a patient with postpartum haemorrhage (PPH) and hypovolaemic shock
(b)When a woman with PPH develops signs of hypovolaemic shock
(c)When a woman is at risk of PPH
(d)While awaiting arterial embolisation
(e)To stabilise before shifting to theatre
14.The mechanism of action of the ASG is circumferential counter-pressure, the effect of which will:
(a)Decrease blood flow above the superior mesenteric artery
(b)Translocate blood from the lower extremities and abdomen to the brain, heart and lungs
(c)Decrease total vascular volume (container size)
(d)Increase blood flow to the distal aorta
(e)Expand central circulation
15.During active haemorrhage, factors contributing to further blood loss include:
(a)Anaemia, through reduced platelet responses
(b)Dilutional effect on platelets and clotting factors
(c)Consumption of clotting factors through excess activation of coagulation pathways
16.The following statements are true of blood component therapy:
(a)Women of child bearing age should receive K negative blood to reduce the future risk of foetal haemolytic disease
(b)A full crossmatch takes 45 minutes to perform
(c)One adult dose of platelets contains up to 200×109/unit platelets
(d)FFP is the best source of fibrinogen
(e)Each dose of cryoprecipitate comes from a single donor
17.Recombinant rFVIIa:
(a)Can bind directly to activated platelets
(b)Stops bleeding in haemophilia patients with inhibitory antibodies
(c)Is free from adverse effects
(d)Has a short half life of around 1 hour
(e)Has proven efficacy in the PPH
18.Regarding surgical aspects of postpartum haemorrhage:
(a)Obstetric haemorrhage accounts for up to 25% of maternal deaths in the developing world.
(b)Almost three fifths of women, who died due to postpartum haemorrhage in the U.K. received less than optimal care
(c)Caesarean section deliveries have approximately three times higher odds of requiring a peri-partum hysterectomy to control bleeding than women who had not had any caesarean section deliveries
(d)More than ten women undergo a peri-partum hysterectomy for each woman who dies from haemorrhage
(e)Surgical measures to control bleeding are indicated for all cases of postpartum haemorrhage of more than 2 L
19.Regarding surgical management of perineal trauma:
(a)It is estimated that up to 20% of women who experience perineal trauma during a vaginal birth require suturing
(b)An episiotomy may increase the risk of postpartum haemorrhage by two fold
(c)Cervical tears extending above the internal os should be managed conservatively with pressure packing
(d)Incision and drainage of the large infra-levator haematomas should be attempted through the vaginal mucosa
(e)Approximately half of supra-levator haematomas present within the first 24 hours of delivery and conservative management is recommended as the first line
20.With regard to surgical measures to control postpartum haemorrhage:
(a)The main trunk of the internal iliac artery should be ligated for effective reduction in blood flow to the uterus
(b)Internal iliac artery ligation may reduce the pulse pressure in the distal branches by about approximately 30%
(c)Quadruple ligation is a technically easier surgical procedure, as compared to internal iliac artery ligation
(d)Uterine compression sutures may result in pyometra
(e)Approximately one in ten women may die following peri-partum hysterectomy
21.Regarding the patho-physiology of retained placenta:
(a)Most retained placentas are caused by a small area of placenta accreta
(b)The use of routine oxytocics for postpartum haemorrhage prophylaxis reduces the need for manual removal of placenta
(c)Placenta adherens is another term for placenta accreta
(d)Ultrasound can be helpful in determining the cause of a retained placenta
(e)There is a 20 times variation in retained placenta rate in different parts of the world
22.With a retained placenta following a vaginal delivery, medical treatment is an option. Which of the following statement(s) is/are true?
(a)An intravenous infusion of oxytocin has been shown to be an effective way of delivering the placenta
(b)An ultrasound scan is always necessary before attempting medical management
(c)An injection of 30 mls saline down the umbilical vein is an effective way of delivering the placenta
(d)Pulling on the umbilical cord so that it detaches from the placenta, prevents effective medical management of most forms of retained placenta
(e)Intramuscular methotrexate appears to be the most effective form of medical management for retained placentas
23.Regarding intra-umbilical injection for the treatment of retained placenta:
(a)The oxytocic is best injected into the umbilical cord through a catheter which has been threaded down the umbilical vein
(b)Ergometrine appears to be the most effective drug to inject
(c)The oxytocic is injected into the umbilical artery
(d)Early results suggest that dissolved misoprostol might also be effective when injected into the umbilical cord
(e)Intra-umbilical oxytocin injection reduces the need for manual removal by around 80%
24.In a pregnant woman with a placenta previa and prior Caesarean section with suspected accreta on imaging evidence:
(a)Delivery should be planned at around 36–37 weeks
(b)Intervention requires an appropriate setting with adequate resources
(c)There is conclusive evidence on the success rate of prophylactic embolization
(d)An interventional radiology unit in the hospital is ideal
(e)Temporary balloon occlusion of the internal iliac arteries appears to have no risks
25.Following conservantive management of placenta accreta that included arterial embolization one can reliably expect:
(a)The return of normal menses
(b)A subsequent uncomplicated pregnancy
(c)Uterine necrosis as a long term complication
(d)A high rate of intrauterine growth restriction in futures pregnancies
(e)Pelvic floor dysfunction in prolonged follow-up
26.With regard to PPH:
(a)The incidence has been declining over the years as reported in CEMACH
(b)The majority of adverse events are preventable
(c)It is the second most common cause of maternal morbidity in the Scottish audit
(d)Socially deprived women are at higher risk of PPH
(e)Ergometrine is routinely tried before resorting to hysterectomy in reviewed cases of mortality
27.In the context of root cause analysis:
(a)An inadequate staffing level is an example of a care delivery problem
(b)Inadequate supervision by senior medical staff is an example of a task related contributory factor
(c)Usually one error is enough to cause a serious adverse incident
(d)Safety barriers can sometimes cause harm instead of good
(e)The five why's is a very useful tool to understand the root cause of a problem
28.In relation to proposed solutions designed to reduce adverse events:
(a)Assessment of vaginal bleeding is one of the parameters used in Modified Early Obstetric Warning Scoring system (MEOWS)
(b)Use of ‘bundles’ results in better outcome
(c)The location of training and inclusion of formal teamwork training made a significant difference to the acquisition of knowledge and team working
(d)Situation-Background-Assessment-Recommendation (SBAR) is an important tool to improve communication between team members
(e)Identifying latent threats in the system helps in preventing systems failure
29.The following statement(s) is/are correct concerning management of known major anterior placenta praevia during acute bleeding with haemodynamic instability:
(a)Performing a lower segment Caesarean section and leave the placenta in situ is likely to be successful
(b)Performing a classical Caesarean, and then a hysterectomy without touching the placenta is the best first line option.
(c)Performing a classical Caesarean and leaving the placenta in situ is the preferred option
(d)Requesting serial haematological markers, and deferring the caesarean section is a reasonable option
(e)Giving tocolysis and completing the evaluation with other imagining modalities before proceeding is appropriate.
30.The following is/are true regarding post operative care of a patient with haemodynamic instability after a subtotal hysterectomy for placenta accrete:
(a)The most likely cause of the haemodynamic instability is cardiac dysfunction due to the peri-operative stress response
(b)The most likely site of any re-bleeding in this scenario is the cervical stump.
(c)If there is no extravasation on arteriography you can assume no re-bleeding has occured
(d)A negative ultrasound for intra-peritoneal bleeding is highly reliable for ruling out re-bleeding
(e)Transferring the patient to a tertiary referral unit is likely to reduce morbidity+mortality
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