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Question 175
Delivery suite → Haemorrhage
Classification
Question
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A woman at 32+3 weeks is admitted following unexplained APH. Bleeding initially settles, maternal observations remain normal and CTG is reassuring. Six hours later she develops recurrent bleeding, constant abdominal pain, uterine tenderness and a new pathological CTG. Which principle should govern management?
Question Stem
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Options
A
The reassuring assessment six hours earlier remains valid unless haemoglobin has fallen
B
Prematurity should prevent delivery until a complete corticosteroid course has been achieved
C
Repeat ultrasound should determine whether management changes
D
The initial diagnosis of unexplained APH should not be revised during the same admission
E
Management must be revised according to the new maternal and fetal findings, including consideration of abruption and expedited delivery
Explanation
APH is a dynamic clinical condition. An initially reassuring assessment cannot be extrapolated indefinitely when symptoms and fetal status subsequently change. Recurrent bleeding accompanied by constant pain, uterine tenderness and a pathological CTG should prompt immediate reassessment for placental abruption and maternal/fetal compromise. The benefits of prematurity avoidance or completion of corticosteroids cannot override a developing indication for delivery.
Option Validity
A) Earlier reassuring findings do not override subsequent clinical deterioration.
B) Indicated delivery must not be delayed solely to complete corticosteroids.
C) Ultrasound cannot reliably exclude abruption and should not delay action in a deteriorating clinical situation.
D) The working diagnosis must evolve when new clinical evidence emerges.
Further Reading
RCOG Green-top Guideline No. 63. Antepartum Haemorrhage. Royal College of Obstetricians and Gynaecologists; 2011.