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Question 156
Delivery suite → Haemorrhage
Classification
Question
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A woman at 29+4 weeks presents with APH and regular painful contractions. Placenta praevia has been excluded. She has received the first dose of antenatal corticosteroids. Initially her observations and CTG were reassuring, and selective tocolysis was being considered. Thirty minutes later the bleeding increases, her pulse rises to 122 beats/min and the CTG develops recurrent late decelerations. What is the most appropriate modification of the management plan?
Question Stem
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Options
A
Continue tocolysis until the corticosteroid course is complete because gestation is below 30 weeks
B
Increase the tocolytic dose because fetal compromise is likely to reflect prematurity
C
Stop considering pregnancy prolongation and proceed towards delivery while resuscitation continues
D
Continue tocolysis provided ultrasound shows no retroplacental clot
E
Delay the decision until haemoglobin demonstrates a significant fall
Explanation
Any potential benefit from prolonging a preterm pregnancy is subordinate to maternal and fetal safety. Tocolysis may be considered only selectively in APH when there is no maternal or fetal indication for delivery and under senior obstetric supervision. Increasing haemorrhage, maternal tachycardia and new pathological fetal heart rate changes fundamentally alter the risk-benefit balance. Delivery should no longer be delayed simply to complete corticosteroids. A negative ultrasound or initially preserved haemoglobin cannot override clinical deterioration.
Option Validity
A) Completion of an antenatal corticosteroid course must not delay indicated delivery when maternal or fetal compromise develops.
B) Pathological fetal heart rate changes during worsening antepartum haemorrhage cannot safely be attributed to prematurity and managed by increasing tocolysis.
D) Ultrasound cannot reliably exclude placental abruption and should not be used to justify delaying necessary delivery.
E) Severe acute blood loss may initially occur without a substantial reduction in haemoglobin concentration; clinical deterioration should determine management.
Further Reading
RCOG Green-top Guideline No. 63. Antepartum Haemorrhage. Royal College of Obstetricians and Gynaecologists; 2011.