SBA — Single Best Answer · Review
Question 167
Delivery suite → Haemorrhage
Classification
Question
SSBAQuestion Header
Two women at 35 weeks present simultaneously with APH. Woman 1 has 900 mL measured vaginal blood loss, pulse 96 beats/min, blood pressure 118/72 mmHg and a soft non-tender uterus. Woman 2 has 120 mL measured vaginal blood loss, pulse 136 beats/min, blood pressure 78/44 mmHg and a tense, tender uterus. Which interpretation is most appropriate?
Question Stem
—
Options
A
Woman 1 necessarily has the greater total blood loss because her measured vaginal loss is larger
B
Woman 2 should initially be classified as minor haemorrhage because visible loss is below 50–1000 mL thresholds
C
The two women should receive identical urgency because APH severity is determined only after haemoglobin results return
D
Woman 1 requires resuscitation first because measured blood loss is the most objective severity marker
E
Woman 2 may have substantially greater concealed haemorrhage and should be managed according to her shock rather than the visible blood volume
Explanation
The difficulty lies in distinguishing measured external loss from physiological severity. Placental abruption can produce extensive concealed haemorrhage, making vaginal blood loss a poor estimate of total loss. Woman 2 has profound cardiovascular shock together with a tense, tender uterus, strongly suggesting severe abruption with concealed bleeding. RCOG's classification recognises shock itself as sufficient to place haemorrhage in the massive category irrespective of whether visible loss exceeds 1000 mL. Clinical condition therefore overrides apparently reassuring external blood-loss measurements.
Option Validity
A) External loss does not reliably represent total blood loss in placental abruption.
B) Profound clinical shock means the haemorrhage cannot appropriately be treated as minor on the basis of visible volume.
C) Acute haemoglobin may initially remain misleadingly preserved, and management should not await the result.
D) Measured external loss should not override profound physiological evidence of concealed haemorrhage.
Further Reading
RCOG Green-top Guideline No. 63. Antepartum Haemorrhage. Royal College of Obstetricians and Gynaecologists; 2011.