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Question 119
Delivery suite → Haemorrhage
Classification
Question
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A woman at 38 weeks presents with a major placental abruption. Ultrasound confirms intrauterine fetal death. Her cervix is 2 cm dilated. She is hypotensive despite initial resuscitation, vaginal bleeding is continuing and coagulation studies suggest evolving DIC. Which principle should determine the immediate management?
Question Stem
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Options
A
A) Maternal resuscitation and control of haemorrhage take priority; the route and urgency of delivery should be determined by the maternal condition
B
B) Caesarean birth is mandatory because DIC is present
C
C) Vaginal birth must be pursued regardless of the degree of maternal deterioration because the fetus has died
D
D) Induction should be postponed until the coagulation screen has completely normalised
E
E) Delivery should be delayed because removal of the placenta may worsen consumptive coagulopathy
Explanation
Following fetal death associated with placental abruption, vaginal birth is generally preferable when the mother is stable and there is no separate indication for caesarean birth. However, fetal death does not reduce the priority of maternal resuscitation. In this case, continuing haemorrhage, cardiovascular instability and evolving DIC make maternal condition the dominant determinant of management. Resuscitation, correction of coagulopathy and expeditious control of the obstetric source must proceed together. Neither vaginal nor caesarean birth should be treated as an absolute rule independent of maternal status.
Option Validity
B) Fetal death plus DIC does not automatically make caesarean birth mandatory; operative delivery may itself carry substantial haemorrhagic risk.
C) Vaginal birth is generally preferred after fetal death only when compatible with safe maternal management.
D) Significant ongoing abruption should not simply be left untreated while waiting for complete laboratory normalisation.
E) Continuing placental separation and haemorrhage can perpetuate maternal deterioration and coagulopathy.
Further Reading
RCOG Green-top Guideline No. 63. Antepartum Haemorrhage. Royal College of Obstetricians and Gynaecologists; 2011.