Undergraduate course lectures in Obstetrics&Gynecology .Faculty of medicine,Zagazig University .Prepared by DR Manal Behery

1. 1/15
MCQ

2. A 21-year-old nulliparous patient at 41
weeks’ gestation delivers vaginally after a
prolonged second stage and chorioamnio-nitis.
After placental separation, profound
uterine atony is noted, and the patient be-gins to
hemorrhage. The atony is unrespon-sive to bimanual
massage, intravenous oxy-tocin, and intramuscular
methylergonovine.
What can be done to stanch the flow?
• CASE 1 :Third Trimester Bleeding
A 32 yo G2P1 presents at 36 weeks
complaining of bright red vaginal bleeding.
Upon further questioning she does admit to
having had some light bleeding on 1 to 2
occasions last week.
Her previous pregnancy was delivered at
term by a Classical Cesarean Section for
footling breech presentation.

3. A 21-year-old nulliparous patient at 41
weeks’ gestation delivers vaginally after a
prolonged second stage and chorioamnio-nitis.
After placental separation, profound
uterine atony is noted, and the patient be-gins to
hemorrhage. The atony is unrespon-sive to bimanual
massage, intravenous oxy-tocin, and intramuscular
methylergonovine.
What can be done to stanch the flow?
• What is the “Differential Diagnosis”?
Placenta Previa
Placental Abruption
Uterine Rupture
Vasa Previa
Laceration
Vaginal mass

4. Placenta Previa
Painless third-trimester bleeding
Complicates 4-6% pregnancies between 10 and
20 wks, 0.5% pregnancies >20 weeks
Risk factors
Increasing parity, maternal age, prior CS,
curettages , myomectomy
Types?
Complete previa (20-30%)
Partial previa (does not completely cover)
Marginal (proximate to os)
Management:
pelvic rest, US, IV, T+S, C/S

5. Associated Conditions
• Placenta accreta, increta, percreta
– Risk inc w/ inc no. of prior c/s (50% risk in pt w/
previa and 2 prior c/s)
• Vasa Previa
– Vessels traverse the membranes in the lower
uterine segment in advance of the fetal head.
– Rupture can lead to fetal exsanguination
Placenta accreta, increta, percreta
Risk increase w/ inc no. of prior CS
PP+unscarred uterus-5 % risk of accreta
PP+one previous C/D-24% risk of accreta
PP+two previous C/D-47% risk of accreta
PP+three previous C/D-50% risk of accreta
PP+four previous C/D-67% risk of accreta

6. Associated Conditions
• Placenta accreta, increta, percreta
– Risk inc w/ inc no. of prior c/s (50% risk in pt w/
previa and 2 prior c/s)
• Vasa Previa
– Vessels traverse the membranes in the lower
uterine segment in advance of the fetal head.
– Rupture can lead to fetal exsanguination
Vasa Previa
Vessels traverse the membranes
in the lower uterine segment in
advance of the fetal head.
Rupture can lead to fetal exsanguination

7. Placental Abruption
Premature separation of placenta
Painful third-trimester bleeding
Risk Factors
smoking, trauma, HTN
cocaine, pprom, polyhydramnios, multiples
Trauma evaluation
bleeding, contractions, abdominal pain and NRFHT in 4hrs
U/s misses up to 50% of abruptions
Management:
IV, T+X, Continuous monitoring, C/S vs. vag delivery

8. Case Cont’d
U/S reveals active, vertex fetus. Placenta anterior
and free of os.
 Pt having contractions q 2-3 minuters. Bleeding
increases.
BP drops from 110/60 to palpable systolic
pressure of 70. FHT drops from 120 to 90 bpm.
What do you do???

9. Uterine Rupture
• Associated with Prior CS
Rates of uterine rupture?
 Spontaneous rupture
 (no C/S history): 1/2000 (0.05%)
 Low Transverse: 0
 .5%-1%risk rupture, VBAC 80% success rate
 Classical C/s:
 10% risk rupture, schedule amnio/c/s ~37 weeks.

10. A 21-year-old nulliparous patient at 41
weeks’ gestation delivers vaginally after a
prolonged second stage and chorioamnio-nitis.
After placental separation, profound
uterine atony is noted, and the patient be-gins to
hemorrhage. The atony is unrespon-sive to bimanual
massage, intravenous oxy-tocin, and intramuscular
methylergonovine.
What can be done to stanch the flow?
• CASE 2 Uterine atony leads to heavy bleeding
A 21-year-old nulliparous patient at 41
weeks’ gestation delivers vaginally after a
prolonged second stage and chorioamnio-
nitis.
After placental separation, profound
uterine atony is noted, and the patient begins
to hemorrhage. The atony is unresponsive to
bimanual massage, intravenous oxytocin, and
intramuscular methylergonovine.

11. What can be done to stop the flow
11/15

12. A stepwise approach to bleeding caused by
persistent uterine atony
STEP 2
Apply direct pressure
to the uterine cavity
STEP 3
Control the blood supply
to the uterus
STEP 4
Place uterine
compression sutures
STEP 5
Perform hysterectomy
STEP 1
Identify source of
bleeding,administer
uterotonic drugs

13. A stepwise approach to bleeding caused by
persistent uterine atony
STEP 1
Identify source of bleeding
administer
Uterotonic drugs
STEP 2
Apply direct pressure
to the uterine cavity
STEP 3
Control the blood supply
to the uterus
STEP 4
Place uterine
compression sutures
STEP 5
Perform
hysterectomy
13/15

14. • A 35 year old womanin her 4th
pregnancy, had a history of PPH in her
previous pregnancies.
• She was diagnosed to have pre eclampsia
during this pregnancy and was on oral
antihypertensive medication. At 38 weeks of
gestation she was admitted and LABOR was
induced with prostaglandins.
14/15
 A 35 year old womanin her 4th pregnancy,
had a history of PPH in her previous
pregnancies.
She was diagnosed to have pre eclampsia
during this pregnancy and was on oral
antihypertensive medication.
At 38 weeks of gestation she was admitted
and LABOR was induced with prostaglandins
CASE3 Postpartum hemorrhage with
Hypovolemic shock

15. • The labour was uneventful and she delivered
The labour was uneventful and she delivered
a 3.9kg baby. There was massive bleeding
after her delivery.
• Exploration did not reveal any retained
products.
• The uterus remained atonic despite repeated
injections of ergometrine and an oxytocin
infusion. No blood or blood products were
available.
The labour was uneventful and she delivered a
3.9kg baby. There was massive bleeding after her
delivery.
Exploration did not reveal any retained
products.
The uterus remained atonic despite repeated
injections of ergometrine and an oxytocin
infusion. No blood or blood products were
available.

16. • The labour was uneventful and she delivered
The labour was uneventful and she delivered
a 3.9kg baby. There was massive bleeding
after her delivery.
• Exploration did not reveal any retained
products.
• The uterus remained atonic despite repeated
injections of ergometrine and an oxytocin
infusion. No blood or blood products were
available.
She was transferred to a general hospital for
further resuscitation but arrived in a moribid
state and signs of hyovolemic shock was
evident
What should be your first step of
management?

17. At ANE: INITIAL ASSESSMENT AND START
BASIC TREATMENT
Call for help
Assess Airway, Breathing,
Circulation [ABC]
Provide Supplementary
Oxygen
Obtain an intravenous line
Start fluid replacement
with IV crystalloid
Monitor Vital Sign
Catheterize bladder and
monitor urine output
Assess need for blood
transfusion
Lab test
•FBC, Coagulation
•Blood Group
•Cross Match
17/15

18. ANE to OT: TEMPORIZING AND TRANSFER
INTERVENTION
Ready to
refer
Drugs
Uterine
Massage
Bimanual
Uterine
Compression
External
Aortic
Compression
Intrauterine
Balloon /
Condom
To OT
ANE to OT: DRUGS OF CHOICE
Oxytocin Ergometrine
Prostaglandin
•Misoprostol
•PG F2alpha
Tranexamic acid
If not available or bleeding still continue from previous drugs
ANE to OT: TORRENTIAL BLEEDING
18/15

19. • A 35 year old womanin her 4th pregnancy,
had a history of PPH in her previous
pregnancies.
• She was diagnosed to have pre eclampsia
during this pregnancy and was on oral
antihypertensive medication. At 38 weeks of
gestation she was admitted and LABOR was
induced with prostaglandins.
19/15
A 30 year women in her third pregnancy at
38 weeks of gestation came in labour at a
district hospital. Her antenatal period had been
uneventful.
She delivered vaginally. With active
management of 3rd stage and the placenta
was delivered by CCT.
CASE 4:

20. • The labour was uneventful and she delivered
The labour was uneventful and she delivered
a 3.9kg baby. There was massive bleeding
after her delivery.
• Exploration did not reveal any retained
products.
• The uterus remained atonic despite repeated
injections of ergometrine and an oxytocin
infusion. No blood or blood products were
available.
After the placenta was delivered , there was
active bleeding from the vagina. A green cannula
was inserted and the on-call doctor was informed.
 Over the phone the doctor ordered for uterine
massage to be done ,IV ergometrine 0.5mg and IV
Pitocin 40 unit in 500mls NS .

21. • The labour was uneventful and she delivered
The labour was uneventful and she delivered
a 3.9kg baby. There was massive bleeding
after her delivery.
• Exploration did not reveal any retained
products.
• The uterus remained atonic despite repeated
injections of ergometrine and an oxytocin
infusion. No blood or blood products were
available.
Blood pressure was normal but the pulse rate
was 96 b/min.
Abdominal examination done showed that the
uterus was contracted. Despite that the patient
was still actively bleeding.
 Another IV line was inserted and blood was
sent for CBC, GXM and PT/PTT. She was given NS
running fast.

22. • The labour was uneventful and she delivered
The labour was uneventful and she delivered
a 3.9kg baby. There was massive bleeding
after her delivery.
• Exploration did not reveal any retained
products.
• The uterus remained atonic despite repeated
injections of ergometrine and an oxytocin
infusion. No blood or blood products were
available.
Further examination showed a cervical
laceration trial to repair was failed.
The patient continued to bleed,
 so vaginal packing was done
a planning for transferre to the
general hospital.
The placenta was also re-examine for it’s
completeness.
 By this time, the patient’s blood loss was about
1 L. the patient was conscious but lethargic, her
BP was 90/60mmHg and PR was 110b/min.

23. 23/15
While awaiting for arrangements for transfer to
the referral center to be made, another 2 iv lines
inserted and she was rapidly infused with NS and
later transfused with blood.
 A Foley’s catheter was inserted to monitor urine
output and her vital signs was monitored every 15
minutes.

24. • Upon arrival the general hospital the estimated
blood loss was about 2L and she had 4 iv lines
(all green). 2 unit of blood has already been
transfused plus the crystalloids and the 3rd and
4th unit of blood transfusion was still in
progress.
Upon arrival the general hospital the estimated
blood loss was about 2L .
2 unit of blood has already been
transfused plus the crystalloids
Examination upon arrival showed very pale
patient, drowsy but still responding to call, the BP
was 80/40mmHg ,PR was 130b/min. The uterus
was contracted and still actively bleeding from the
vagina.

25. EUA was done and the cervical
laceration was sutured.
 Despite that patient continued
to bleed.

26. A laparotomy was done
26/15
it showed that there was
another cervical laceration
which extended up to the
lower segment of the uterus.
As it was not able to be repaired,
a hysterectomy was performed.

27. She was managed for 2 days in ICU. The
estimated blood loss through out was 5.4L
and she was transfused a total of 21 unit of
blood and 4 cycles of DIVC regime. She was
discharged well on day 6 post delivery.
Post operatively

28. CASE 5
A 37-year-old black female P7 at term admitted in early
labor. Her prenatal course was significant for gestational
diabetes controlled with diet. her last child weighing
4200KG. Her past medical history was significant only for a
strong family history of diabetes mellitus.
On admission, the CX 4cm/VTX/-1/AROM with clear
fluid contractions decreased in intensity and frequency
after AROM. A Pitocin® augmentation was begun and the
patient quickly progressed to C/C/VTX/+1.

29. • She delivered a 4300 kg baby with a moderate
shoulder dystocia that was treated effectively with
the McRobert’s maneuver and suprapubic
pressure after a left mediolateral episiotomy.
• The placenta delivered spontaneously without
difficulty
29/15
She delivered a 4300 kg baby with a moderate
shoulder dystocia that was treated effectively with
the McRobert’s maneuver and suprapubic pressure
after a left mediolateral episiotomy.
The placenta delivered spontaneously without
difficulty
Case cont’

30. • She delivered a 4300 kg baby with a moderate
shoulder dystocia that was treated effectively with
the McRobert’s maneuver and suprapubic
pressure after a left mediolateral episiotomy.
• The placenta delivered spontaneously without
difficulty
30/15
The patient had persistent bleeding after repair
of her episiotomy.
An immediate re-inspection ofher cervix and
vagina revealed no occult lacerations.
She was treated with continued IV Pitocin® and
given multiple doses of 15-methyl prostaglandin
F2-_ as well as a course of rectal misoprostol
without response
Case cont’

31. • She delivered a 4300 kg baby with a moderate
shoulder dystocia that was treated effectively with
the McRobert’s maneuver and suprapubic
pressure after a left mediolateral episiotomy.
• The placenta delivered spontaneously without
difficulty
31/15
Counseling regarding thepossible need for
hysterectomy. laparotomy was performed. The
uterus was persistently atonic. No evidence of
occult lacerations or other cause for the bleeding.
Hemostatic B-Lynch sutures were placed to stop
the bleeding. The bleeding markedly decreased
with this procedure. She received a total of 8 units
of packed red blood cells during and after the
surgery. She left the hospital without further
incident
Case cont’

32. Remmber : Aetiology of 1ry ppHg
TONE [Abnormality Of Uterine
Contraction]
• Over distended uterus
• Uterine muscle exhaustion / Uterine
Atony [90%]
• Intra amniotic infection
• Functional/anatomic distortion of the
uterus
TISSUE [Retained Product Of Conception]
• Retained products
• Abnormal placenta
• Placenta Praevia /Abruptio Placenta
• Blood clots and cotyledon
TRAUMA [At Genital Tract]
• Cervix, vagina , perineum laceration
• Caesarean section laceration
• Uterine rupture
• Uterine inversion
THROMBIN [Abnormality Of Coagulation]
• Coagulopathy
• therapeutic
4T’S AETIOLOGY
OF PRIMARY PPH
32/15

33. Finding the causes
33/15

34. Uterine compression sutures
• B-Lynch suture & modifications.
• Hemostatic suturing technique
Devascularisation procedure
• Bilateral uterine artery ligation.
• Bilateral internal iliac artery ligation.
• Utero-ovarian artery anastomosis ligation.
• Arterial embolization.
Indication of Hysterectomy (Supracervical / Total)
• Uterine atony
• Placenta accreta
• Placenta previa
• Uterine laceration
• Uterine rupture
• Uterine leiomyomata
34/15

35. Principles of managing PPH
• Speed Skills Priorities –
• Call For Help (Red Alert System) –
• Assess the patient’s condition –
• Find the cause of bleeding and stop it –
• Stabilize And Resuscitate The Patient –
• Prevent Further Bleeding
Speed
Skills
 Priorities
1-Call For Help (Red Alert System)
2-Assess the patient’s condition
3-Find the cause of bleeding and stop it
4-Stabilize And Resuscitate The Patient
5-Prevent Further Bleeding

36. MCQ on Hemorrhage in
Obstetrics

37. med-ed-online
1- A woman 35 years old /G4 L3 presents with couvelaire
uterus in C/S. When is hysterectomy indicated?
A-presence of hematoma in the broad ligament
B-presence of hematoma in mesosalpinx
C- atony retractable to treatment
D- presence of blood in abdominal cavity
Ans:C

38. med-ed-online
2-Which is wrong about platelet administration?
A- Platelet can not be reserved more than 5 days
B-platelets should be administered to patients with
hemorrhage and platelet counts less than 50000/ml
C-platelet should be administered after cross-match
D- If there is no hemorrhage, platelets should be
administered to patients with platelet counts less than
10000 /ml
Ans:D

39. med-ed-online
3-which is the most common reason of DIC in
Obstetrics?
A-IUFD
B-abruption
C-AF emboli
D- septic shock
Ans:B

40. med-ed-online
4-what is the first step in treating a G2 with late postpartum
hemorrhage (after stabilizing her condition)?
A-curettage
B-uterotonics
C-uterine artery ligation
D-hypogastric artery ligation
Ans:B

41. med-ed-online
5-A 16 year-old woman comes to you with heavy bleeding
after a two month delay in her periods. Pregnancy test is
negative. Ultrasound shows a thin endometrium. There is no
coagulation or anatomical problem. Which is the best
treatment?
A-high dose progesterone
B-curettage
C-IV conjugate estrogen
D-diagnostic hysteroscopy
Ans:C
Conjugate estrogen 25-40 mg IV q6h or PO
2.5 mg q6h

42. med-ed-online
6- what is the stage of shock in a woman
70 kg / HR=130 bpm/AP=55mmHg/mod tachycardia/
urinary output=10cc in a min
A-first
B-second
C-third
D-fourth
Ans:C

43. med-ed-online
7-Which is true about hemorrhagic shock?
A- central venous catheter is not recommended
B-lifting the feet is not recommended
C-colloids are superior to crystalloids
D-excess NS can cause alkalosis
Ans:A

44. med-ed-online
8-A woman suffers intractable heavy vaginal bleeding after C/S.
Laparatomy is performed. Retrovesical hematoma is evacuated
and the site of bleeding is sutured. The bleeding does not stop.
What is the second stage in management?
A-total hysterectomy
B-bilateral uterine and ovarian arteries ligation
C-bilateral hypogastric arteries ligation
D-bilateral hypogastric and ovarian arteries ligation
Ans:D
Ovarian artery is situated in infundibulopelvic and
mesosalpinx ligament

45. med-ed-online
9-Which is wrong in abruption?
A-It is more likely in heroin addicts
than cocaine addicts
B-fibroma is one of the causes
C-positive past history is a risk factor
D-there is no agreement on smoking as a risk factor
Ans:A

46. med-ed-online
10-A G2 with GA=14 wks is referred for spotting. Ultrasound
imaging shows twin pregnancy with one fetal demise. How the
coagulation profile may change?
A- The profile is like that of DIC
B-heavy bleeding will occur during labor
because of hypofibrinogenemia
C- repairable transient coagulopathy will occur
D-the live infant in the uterine will develop
coagulopathy
Ans:C

47. med-ed-online
11-Which is true about uterine inversion?
A-BP and MgSO4 can be the reason
B-it is more common in multiparas
C-it is never fatal
D-hemorrhage occurs with a delay
Ans:A

48. med-ed-online
12-If there is a coagulopathy disorder, which is an indication for
Heparin administration provided that circulation is intact?
A-IUFD
B-Abruption
C-septic abortion
D-HELLP syndrome
Ans:A
Heparin dose 5000 units TDS for IUFD
FFP and platelet for septic abortion

49. med-ed-online
13-Which is wrong about stage II of hypovolemic
shock?
A-Tachycardia is a constant finding
B-blood loss is more than 1000cc
C-systolic minus diastolic BP is increased
D-BP at rest is normal
Ans:C

50. 14-Which is true about int iliac artery ligation for
controlling pelvic hemorrhage?
A-Ext iliac artery should be checked
before ligation is attempted
B-ureter should not be located
C- both sides arteries should not be ligated
D-the artery should be ligated proximal to parietal
branch
Ans:A

51. med-ed-online
15-A 40 year old woman is hospitalized for hemorrhagic
shock. Her kidney function is normal. What is the most
sensitive and reliable clinical criteria for determining
severity of volume loss?
A- tachycardia
B-tachypnea
C-oliguria
D-hypotension
Ans:C

52. med-ed-online
16-An extension of C/S incision causes vaginal artery laceration
and heavy bleeding. What should be done for this case?
A-uterine artery ligation
B-ovarian artery ligation
C- hypogastric artery ligation
D-hysterectomy
Ans:C

53. med-ed-online
17- How many ml of blood does a soaked lap pad
absorbs?
A-30 cc
B-50 cc
C-80 cc
D-100 cc
Ans:B

54. med-ed-online
18-What is wrong for blood loss management?
A-after an hour in a critical case only 20% of
crystalloids remains in circulation
B- the volume of crystalloids replacement is
three times the volume of blood loss
C-in all cases of blood loss a Hb of less than 8
gr/dl mandates whole blood transfusion
D-colloids increase mortality rate
Ans:C

55. med-ed-online
19-What is wrong about vaginal hematoma after
delivery?
A-observation if hematoma is small
B- an incision on the site if pain is severe and
hematoma enlarges
C-mattress suturing the bed of hematoma
D-pressure dressing should be applied on the
hematoma bed for 12-24 hours
Ans:D

56. med-ed-online
20- A repeat C/S II has hemorrhage of the incision
site. Which can best control hemorrhage?
A-ligation of placental site above and below the
incision site
B-ligation of uterine artery
C- ligation of hypogastric artery
D- embolization of uterine artery
Ans:A

57. med-ed-online
21 Which is wrong about fetal complications of
abruption?
A- 20-25 percent of cases demise perinatally
B-40 % are delivered prematurely
C- 12-15 % are IUFD
D-if the fetus doesn’t die in uterus, there would
be no serious neonatal complication
Ans:D

58. med-ed-online
22A pregnant woman G2 GA=38 wks has the chief complaint of
vaginal spotting. There is no sign of abruption or previa by
ultrasound. What is the best management?
A- observation
B-termination of pregnancy
C-discharge
D-referring patient to another center
Ans:B

59. med-ed-online
24-Which is true about abruption?
A- The chance of repeated abruption is twice
B-fetal assessment techniques can predict
abruption with good precision
C-there is no means to predict abruption
D-The chance of repeated abruption is not
different
Ans:C

60. med-ed-online
25-Which is wrong in cases of placenta previa?
A-the safest means of diagnosing placenta previa
is transabdominal ultrasound
B-false positive results are because of full
bladder
C-low lying or total previa is best diagnosed by
trans vaginal ultrasound
D-NPV of transperineal ultrasound is 70 %
Ans: D (its NPV is 100% )

61. med-ed-online
26-What is the first surgical step in a case of retractable
uterine atony?
A-ligation of uterine and ovarian arteries
B-ligation of hypogastric arteries
C-subtotal hysterectomy
D- uterine artery embolization
Ans:A

62. •THANK YOU
62/15