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Question 190
Delivery suite → Haemorrhage
Classification
Question
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A woman at 34 weeks with severe polyhydramnios undergoes spontaneous rupture of membranes with a large rapid loss of liquor. Shortly afterwards she develops constant abdominal pain, a small vaginal bleed and a persistently tense uterus. Maternal observations are initially normal. Which interpretation is most appropriate?
Question Stem
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Options
A
The small volume of vaginal bleeding makes significant placental pathology unlikely
B
Normal maternal observations exclude clinically important abruption at this stage
C
The symptoms are most likely explained solely by uterine decompression and require no further fetal assessment
D
The combination should raise suspicion of placental abruption despite initially preserved maternal physiology
E
Abruption should be considered only if ultrasound subsequently identifies retroplacental blood
Explanation
Polyhydramnios is a recognised risk factor for placental abruption, and the subsequent development of constant pain, vaginal bleeding and persistent uterine tension should raise clinical suspicion. Early maternal observations may remain normal, and the visible vaginal loss may underestimate total haemorrhage if bleeding is concealed. The key reasoning is temporal and syndromic: a recognised risk context is followed by a characteristic clinical presentation. Maternal and fetal assessment should therefore not be deferred while awaiting haemodynamic deterioration or ultrasound confirmation.
Option Validity
A) Visible vaginal loss may substantially underestimate haemorrhage in abruption.
B) Initially normal maternal observations do not exclude evolving abruption.
C) Persistent pain, uterine tension and bleeding require assessment for placental pathology rather than attribution solely to decompression.
E) Ultrasound has insufficient sensitivity to make demonstration of retroplacental blood a prerequisite for diagnosis.
Further Reading
RCOG Green-top Guideline No. 63. Antepartum Haemorrhage. Royal College of Obstetricians and Gynaecologists; 2011.