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Question 169
Delivery suite → Haemorrhage
Classification
Question
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A woman at 28+6 weeks presents with 60 mL APH and regular contractions. Placenta praevia has been excluded. She is haemodynamically stable, the uterus is soft between contractions and CTG is reassuring. There is no clinical evidence of placental abruption. The cervix has changed from 1 cm to 2 cm over two hours. She has received her first dose of antenatal corticosteroids. Which is the most defensible management regarding tocolysis?
Question Stem
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Options
A
Tocolysis is mandatory because she is below 30 weeks
B
APH is an absolute contraindication to all tocolytic therapy
C
Tocolysis should be continued irrespective of subsequent maternal or fetal deterioration until corticosteroids are complete
D
Selective tocolysis may be considered under senior obstetric supervision provided no maternal or fetal indication for delivery develops
E
Tocolysis should be withheld until the bleeding reaches the definition of massive haemorrhage
Explanation
APH does not constitute an absolute contraindication to tocolysis in every circumstance. In a carefully selected preterm woman who is stable, has reassuring fetal assessment and has no evidence of placental abruption or other indication for immediate delivery, short-term tocolysis may be considered under senior obstetric supervision. The potential benefit is pregnancy prolongation, including time for antenatal corticosteroid effect. However, the decision must remain dynamic: increasing haemorrhage, suspected abruption or maternal/fetal compromise would remove the justification for delaying delivery.
Option Validity
A) Preterm gestation alone does not make tocolysis mandatory.
B) APH is not an absolute contraindication in every clinically selected case.
C) Maternal or fetal deterioration would require reassessment and may mandate delivery rather than continued tocolysis.
E) The decision is based on the overall clinical situation, not on waiting for a massive-haemorrhage threshold.
Further Reading
RCOG Green-top Guideline No. 63. Antepartum Haemorrhage. Royal College of Obstetricians and Gynaecologists; 2011.