Asthma exacerbation — USMLE Step 2 CK MCQ

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EasyInternal MedicineAsthma exacerbationUSMLE Step 2 CK

Ten minutes after an uncomplicated vaginal delivery, a 31-year-old woman has brisk vaginal bleeding. The placenta appears intact. Blood pressure is 104/68 mm Hg and pulse is 108/min. The uterus is enlarged and boggy, and no genital tract laceration is seen. Intravenous access is in place and the hemorrhage protocol is activated. Which intervention should be performed first?

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Correct answer: E — Begin bimanual uterine massage and administer oxytocin

A boggy enlarged uterus with brisk bleeding immediately after delivery indicates uterine atony, the most common cause of postpartum hemorrhage. Initial treatment is prompt uterine massage together with a first-line uterotonic, typically oxytocin, while resuscitation and quantitative blood-loss assessment proceed. The bladder should be emptied and the team should reassess uterine tone and bleeding. If hemorrhage persists, additional uterotonics are selected according to contraindications, followed by measures such as tranexamic acid, uterine balloon tamponade, interventional radiology or surgery as clinically indicated. Immediate hysterectomy is not the first intervention in a patient who has not received basic atony treatment, although it may become lifesaving when conservative control fails. Methotrexate treats selected ectopic or gestational trophoblastic disease, not uterine atony. Observation is unsafe during active hemorrhage. Curettage is considered when retained placental tissue is suspected, but the placenta is intact and the examination points to atony.

Reference: American College of Obstetricians and Gynecologists. Postpartum Hemorrhage. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2017/10/postpartum-hemorrhage