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Question 120
Delivery suite → Haemorrhage
Classification
Question
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A woman at 34 weeks presents with severe constant abdominal pain after a small amount of vaginal bleeding. Her uterus is tense and tender. Pulse is 124 beats/min and blood pressure is 88/54 mmHg. The sanitary pad contains approximately 40 mL of blood. Which interpretation should most strongly guide management?
Question Stem
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Options
A
A) The haemorrhage is minor because measured external blood loss is below 50 mL
B
B) The cardiovascular abnormalities are most likely caused by pain because visible bleeding is minimal
C
C) Significant concealed placental haemorrhage should be presumed until the maternal condition is stabilised and assessed
D
D) Placental abruption is unlikely because major abruption normally produces proportionate external bleeding
E
E) Quantitative measurement of vaginal blood loss should determine whether resuscitation is required
Explanation
The visible volume of blood loss in placental abruption may substantially underestimate total haemorrhage because blood can remain concealed behind the placenta or within the uterus. The combination of severe constant pain, a tense tender uterus, tachycardia and hypotension is therefore far more important than the approximately 40 mL of observed vaginal blood. Management must be driven by maternal physiology and the overall clinical picture, with immediate resuscitation and assessment for significant abruption.
Option Validity
A) The numerical definition of minor external bleeding must not override evidence of maternal shock and possible concealed haemorrhage.
B) Hypotension and marked tachycardia in this setting must be assumed to represent haemorrhagic compromise until adequately assessed.
D) Placental abruption can produce predominantly concealed rather than external haemorrhage.
E) Observed vaginal blood loss may seriously underestimate the true blood loss in abruption.
Further Reading
RCOG Green-top Guideline No. 63. Antepartum Haemorrhage. Royal College of Obstetricians and Gynaecologists; 2011.