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Question 159
Delivery suite → Haemorrhage
Classification
Question
SSBAQuestion Header
A woman at 32 weeks presents for the third time with unexplained small-volume APH. Ultrasound confirms a normally situated placenta. During history-taking she appears anxious and her partner repeatedly answers questions for her. Examination shows bruising of different ages over the abdomen and upper arms. Which additional assessment is most important?
Question Stem
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Options
A
Arrange serial Kleihauer testing as the primary investigation for recurrent abruption
B
Explore the possibility of domestic violence in an appropriate confidential setting
C
Reassure her that recurrent minor APH excludes traumatic placental pathology
D
Restrict further questioning because social history is unrelated to APH
E
Diagnose a bleeding disorder on the basis of bruising and recurrent APH
Explanation
Abdominal trauma and domestic violence are recognised risk factors for placental abruption and should be considered when evaluating APH. The combination of recurrent unexplained bleeding, bruising of different ages and controlling behaviour by a partner should prompt sensitive assessment for domestic violence in a confidential setting. The visible amount of vaginal bleeding does not exclude significant placental pathology because abruption may involve concealed haemorrhage. Kleihauer testing has a specific role in quantifying fetomaternal haemorrhage in RhD-negative women but is not a screening test for recurrent abruption.
Option Validity
A) Kleihauer testing does not diagnose or screen for placental abruption.
C) Small-volume external bleeding does not exclude traumatic placental abruption or concealed haemorrhage.
D) Trauma and domestic violence are clinically relevant risk factors when assessing antepartum haemorrhage.
E) Bruising requires appropriate assessment but does not by itself establish a maternal bleeding disorder.
Further Reading
RCOG Green-top Guideline No. 63. Antepartum Haemorrhage. Royal College of Obstetricians and Gynaecologists; 2011.