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Question 195
Delivery suite → Haemorrhage
Classification
Question
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A woman at 30 weeks presents with recurrent postcoital APH. Placental location is normal, fetal assessment is reassuring and the uterus is soft and non-tender. Speculum examination demonstrates an irregular friable cervical lesion. Review of her records shows previous abnormal cervical cytology with incomplete follow-up. What is the most appropriate next diagnostic step?
Question Stem
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Options
A
Reassure her that pregnancy-related ectropion is the most likely explanation and defer assessment until postpartum
B
Perform a digital examination repeatedly to determine whether the lesion bleeds on contact
C
Diagnose placenta praevia despite the normal placental location
D
Treat empirically as placental abruption because cervical malignancy rarely presents with APH
E
Refer for colposcopic evaluation of the suspicious cervix
Explanation
APH is not always placental. Previous cervical smear history is relevant because symptomatic cervical cancer in pregnancy may present with APH, often as postcoital bleeding or vaginal discharge. When speculum examination demonstrates a clinically suspicious cervix, referral for colposcopic evaluation is recommended in accordance with cervical pathology guidance. A visible lesion should therefore not automatically be attributed to physiological ectropion, particularly in the presence of abnormal previous cytology.
Option Validity
A) A clinically suspicious cervical lesion with abnormal previous cytology should not simply be deferred until after pregnancy.
B) Repeated digital examination is not the appropriate diagnostic evaluation of a suspicious cervical lesion.
C) A normal placental location and direct visualization of a cervical lesion do not support placenta praevia.
D) Cervical malignancy is uncommon but may present with APH, especially postcoital bleeding, and must be appropriately assessed.
Further Reading
RCOG Green-top Guideline No. 63. Antepartum Haemorrhage. Royal College of Obstetricians and Gynaecologists; 2011.