Postpartum Hemorrhage: Midterm Exam (Units 1-7) - Questions
with Correct Answers
100 questions
1. Secondary postpartum hemorrhage is most commonly caused by:
A. Uterine atony immediately after delivery
B. Vaginal lacerations noticed at birth
C. Retained products of conception, infection, or subinvolution of the placental site
D. Amniotic fluid embolism
Correct Answer: C. Retained products of conception, infection, or subinvolution of the
placental site
Rationale: Late bleeding, from 24 hours to 12 weeks, often results from retained tissue or endometritis
preventing normal involution; bleeding disorders such as von Willebrand disease may also present this
way. Atony and fresh lacerations cause primary PPH.
2. Uterine involution after birth refers to:
A. Inversion of the uterus
B. Enlargement of the uterus
C. Infection of the uterus
D. The process by which the uterus returns to its nonpregnant size and condition
Correct Answer: D. The process by which the uterus returns to its nonpregnant size and
condition
Rationale: The uterus shrinks from about 1,000 g at birth to about 60 to 100 g over 6 weeks, and the
placental site heals. Subinvolution can cause late bleeding. Involution is a normal process, not inversion
or infection.
3. The lethal triad in massive hemorrhage refers to:
A. Hypertension, bradycardia, and fever
B. Hypothermia, acidosis, and coagulopathy
C. Hyperglycemia, hyperkalemia, and alkalosis
D. Tachycardia, hypertension, and fever
Correct Answer: B. Hypothermia, acidosis, and coagulopathy
Rationale: Each element worsens the others: cold impairs clotting enzymes, acidosis reduces clotting
factor activity, and coagulopathy increases bleeding. Warming, avoiding excess crystalloid and early
blood products break the cycle. The other combinations are not the triad.
,4. Normal fibrinogen levels at term are typically:
A. About 350 to 650 mg/dL, higher than in nonpregnant adults
B. Below 100 mg/dL
C. The same as in nonpregnant adults at 200 mg/dL or less
D. Above 2,000 mg/dL
Correct Answer: A. About 350 to 650 mg/dL, higher than in nonpregnant adults
Rationale: Fibrinogen rises in pregnancy, so a level that would be normal in a nonpregnant person, such
as 200 mg/dL, may indicate significant consumption in a bleeding postpartum woman. A fibrinogen below
200 mg/dL predicts progression to severe PPH. Very high values are not normal.
5. Anemia before birth increases the danger of postpartum hemorrhage because:
A. Anemia causes clotting
B. Anemia prevents bleeding
C. It has no effect
D. Women have less oxygen-carrying reserve to tolerate blood loss
Correct Answer: D. Women have less oxygen-carrying reserve to tolerate blood loss
Rationale: A woman with anemia may become unstable after a smaller blood loss and is more likely to
need transfusion; anemia is also associated with atony. Correcting anemia in pregnancy is a key
prevention strategy.
6. The three delays model for maternal mortality describes delays in:
A. Deciding to seek care, reaching a health facility, and receiving adequate care
B. Labor, delivery, and breastfeeding
C. Pregnancy, birth, and postpartum
D. Diagnosis, billing, and discharge
Correct Answer: A. Deciding to seek care, reaching a health facility, and receiving adequate
care
Rationale: Each delay can turn a manageable hemorrhage into a death, so solutions include community
education, transport systems and facility readiness. The other sequences are not the model.
,7. In the United States, the rate of postpartum hemorrhage has:
A. Disappeared
B. Decreased to near zero
C. Increased in recent decades, driven largely by uterine atony
D. Stayed exactly the same since 1950
Correct Answer: C. Increased in recent decades, driven largely by uterine atony
Rationale: Rising PPH rates have been associated with increasing atony, higher cesarean rates, obesity,
induction and older maternal age. This trend underscores the importance of hemorrhage bundles. PPH
has not disappeared.
8. During pregnancy, trophoblast cells remodel the spiral arteries into wide, low-resistance
vessels. After birth this means that:
A. The vessels constrict strongly without help
B. The vessels cannot constrict well on their own, so bleeding control depends heavily on myometrial
contraction
C. Bleeding is impossible
D. Clotting is not needed
Correct Answer: B. The vessels cannot constrict well on their own, so bleeding control
depends heavily on myometrial contraction
Rationale: Remodeled spiral arteries lose their muscular walls, which allows high placental blood flow but
means they rely on surrounding muscle compression after delivery. This explains why atony causes rapid
bleeding. Clotting also contributes.
9. At term, uterine blood flow is approximately:
A. 50 mL per minute
B. 5 mL per minute
C. 2,000 mL per minute
D. 500 to 700 mL per minute
Correct Answer: D. 500 to 700 mL per minute
Rationale: This large flow, about 10 to 15% of cardiac output, explains why uncontrolled bleeding from
the placental bed can cause life-threatening hemorrhage within minutes. Lower values underestimate the
danger. Rapid response is essential.
, 10. The United Nations Sustainable Development Goal for maternal health aims to reduce the
global maternal mortality ratio to:
A. Less than 700 per 100,000
B. Zero by 2025
C. Less than 70 per 100,000 live births by 2030
D. 1,000 per 100,000
Correct Answer: C. Less than 70 per 100,000 live births by 2030
Rationale: Reducing PPH deaths is essential to meet SDG target 3.1, and global agencies have
prioritized PPH roadmaps and guidelines. Many countries remain far from the target. The other figures are
incorrect.
11. Total blood volume in a woman at term is approximately:
A. About 100 mL per kg, or roughly 6 to 7 liters for a 70 kg woman
B. About 2 liters
C. About 15 liters
D. Unchanged from nonpregnant volume of 3 liters
Correct Answer: A. About 100 mL per kg, or roughly 6 to 7 liters for a 70 kg woman
Rationale: Knowing the expected blood volume helps estimate the percentage lost; a 1,500 mL loss is
about a quarter of volume. Values of 2 or 3 liters underestimate pregnancy expansion. Fifteen liters is far
too high.
12. ACOG defines postpartum hemorrhage as:
A. Any blood loss over 250 mL after vaginal birth
B. Blood loss over 2,000 mL only after cesarean
C. Any bleeding after the first postpartum week
D. Cumulative blood loss of 1,000 mL or more, or blood loss with signs or symptoms of hypovolemia,
within 24 hours of birth regardless of route
Correct Answer: D. Cumulative blood loss of 1,000 mL or more, or blood loss with signs or
symptoms of hypovolemia, within 24 hours of birth regardless of route
Rationale: The reVITALize definition adopted by ACOG uses 1,000 mL or hypovolemia for both vaginal
and cesarean births, while loss over 500 mL after vaginal birth is still considered abnormal and warrants
closer attention. Smaller amounts are expected, and later bleeding is classified as secondary PPH.
with Correct Answers
100 questions
1. Secondary postpartum hemorrhage is most commonly caused by:
A. Uterine atony immediately after delivery
B. Vaginal lacerations noticed at birth
C. Retained products of conception, infection, or subinvolution of the placental site
D. Amniotic fluid embolism
Correct Answer: C. Retained products of conception, infection, or subinvolution of the
placental site
Rationale: Late bleeding, from 24 hours to 12 weeks, often results from retained tissue or endometritis
preventing normal involution; bleeding disorders such as von Willebrand disease may also present this
way. Atony and fresh lacerations cause primary PPH.
2. Uterine involution after birth refers to:
A. Inversion of the uterus
B. Enlargement of the uterus
C. Infection of the uterus
D. The process by which the uterus returns to its nonpregnant size and condition
Correct Answer: D. The process by which the uterus returns to its nonpregnant size and
condition
Rationale: The uterus shrinks from about 1,000 g at birth to about 60 to 100 g over 6 weeks, and the
placental site heals. Subinvolution can cause late bleeding. Involution is a normal process, not inversion
or infection.
3. The lethal triad in massive hemorrhage refers to:
A. Hypertension, bradycardia, and fever
B. Hypothermia, acidosis, and coagulopathy
C. Hyperglycemia, hyperkalemia, and alkalosis
D. Tachycardia, hypertension, and fever
Correct Answer: B. Hypothermia, acidosis, and coagulopathy
Rationale: Each element worsens the others: cold impairs clotting enzymes, acidosis reduces clotting
factor activity, and coagulopathy increases bleeding. Warming, avoiding excess crystalloid and early
blood products break the cycle. The other combinations are not the triad.
,4. Normal fibrinogen levels at term are typically:
A. About 350 to 650 mg/dL, higher than in nonpregnant adults
B. Below 100 mg/dL
C. The same as in nonpregnant adults at 200 mg/dL or less
D. Above 2,000 mg/dL
Correct Answer: A. About 350 to 650 mg/dL, higher than in nonpregnant adults
Rationale: Fibrinogen rises in pregnancy, so a level that would be normal in a nonpregnant person, such
as 200 mg/dL, may indicate significant consumption in a bleeding postpartum woman. A fibrinogen below
200 mg/dL predicts progression to severe PPH. Very high values are not normal.
5. Anemia before birth increases the danger of postpartum hemorrhage because:
A. Anemia causes clotting
B. Anemia prevents bleeding
C. It has no effect
D. Women have less oxygen-carrying reserve to tolerate blood loss
Correct Answer: D. Women have less oxygen-carrying reserve to tolerate blood loss
Rationale: A woman with anemia may become unstable after a smaller blood loss and is more likely to
need transfusion; anemia is also associated with atony. Correcting anemia in pregnancy is a key
prevention strategy.
6. The three delays model for maternal mortality describes delays in:
A. Deciding to seek care, reaching a health facility, and receiving adequate care
B. Labor, delivery, and breastfeeding
C. Pregnancy, birth, and postpartum
D. Diagnosis, billing, and discharge
Correct Answer: A. Deciding to seek care, reaching a health facility, and receiving adequate
care
Rationale: Each delay can turn a manageable hemorrhage into a death, so solutions include community
education, transport systems and facility readiness. The other sequences are not the model.
,7. In the United States, the rate of postpartum hemorrhage has:
A. Disappeared
B. Decreased to near zero
C. Increased in recent decades, driven largely by uterine atony
D. Stayed exactly the same since 1950
Correct Answer: C. Increased in recent decades, driven largely by uterine atony
Rationale: Rising PPH rates have been associated with increasing atony, higher cesarean rates, obesity,
induction and older maternal age. This trend underscores the importance of hemorrhage bundles. PPH
has not disappeared.
8. During pregnancy, trophoblast cells remodel the spiral arteries into wide, low-resistance
vessels. After birth this means that:
A. The vessels constrict strongly without help
B. The vessels cannot constrict well on their own, so bleeding control depends heavily on myometrial
contraction
C. Bleeding is impossible
D. Clotting is not needed
Correct Answer: B. The vessels cannot constrict well on their own, so bleeding control
depends heavily on myometrial contraction
Rationale: Remodeled spiral arteries lose their muscular walls, which allows high placental blood flow but
means they rely on surrounding muscle compression after delivery. This explains why atony causes rapid
bleeding. Clotting also contributes.
9. At term, uterine blood flow is approximately:
A. 50 mL per minute
B. 5 mL per minute
C. 2,000 mL per minute
D. 500 to 700 mL per minute
Correct Answer: D. 500 to 700 mL per minute
Rationale: This large flow, about 10 to 15% of cardiac output, explains why uncontrolled bleeding from
the placental bed can cause life-threatening hemorrhage within minutes. Lower values underestimate the
danger. Rapid response is essential.
, 10. The United Nations Sustainable Development Goal for maternal health aims to reduce the
global maternal mortality ratio to:
A. Less than 700 per 100,000
B. Zero by 2025
C. Less than 70 per 100,000 live births by 2030
D. 1,000 per 100,000
Correct Answer: C. Less than 70 per 100,000 live births by 2030
Rationale: Reducing PPH deaths is essential to meet SDG target 3.1, and global agencies have
prioritized PPH roadmaps and guidelines. Many countries remain far from the target. The other figures are
incorrect.
11. Total blood volume in a woman at term is approximately:
A. About 100 mL per kg, or roughly 6 to 7 liters for a 70 kg woman
B. About 2 liters
C. About 15 liters
D. Unchanged from nonpregnant volume of 3 liters
Correct Answer: A. About 100 mL per kg, or roughly 6 to 7 liters for a 70 kg woman
Rationale: Knowing the expected blood volume helps estimate the percentage lost; a 1,500 mL loss is
about a quarter of volume. Values of 2 or 3 liters underestimate pregnancy expansion. Fifteen liters is far
too high.
12. ACOG defines postpartum hemorrhage as:
A. Any blood loss over 250 mL after vaginal birth
B. Blood loss over 2,000 mL only after cesarean
C. Any bleeding after the first postpartum week
D. Cumulative blood loss of 1,000 mL or more, or blood loss with signs or symptoms of hypovolemia,
within 24 hours of birth regardless of route
Correct Answer: D. Cumulative blood loss of 1,000 mL or more, or blood loss with signs or
symptoms of hypovolemia, within 24 hours of birth regardless of route
Rationale: The reVITALize definition adopted by ACOG uses 1,000 mL or hypovolemia for both vaginal
and cesarean births, while loss over 500 mL after vaginal birth is still considered abnormal and warrants
closer attention. Smaller amounts are expected, and later bleeding is classified as secondary PPH.
