Women's health for AMC MCQ

A 31 year old woman at 32 weeks has sudden painless bright red vaginal bleeding. Her uterus is soft and non-tender, and the fetal heart rate is normal. She is haemodynamically stable. An ultrasound shows the placenta lying over the cervical os. A junior doctor is about to perform a digital vaginal examination to assess the bleeding. What is the most likely diagnosis?

1. Local genital tract cause Bleeding from a local spot on the cervix or vagina. That does not match the picture of painless bleeding with a soft womb and a placenta lying over the cervix.
2. Placental abruption Painful bleeding with a tender, firm womb and a distressed baby. Here, the picture of painless bleeding with a soft womb and a placenta lying over the cervix points elsewhere.
3. Vasa praevia Painless bleeding with the baby becoming distressed quickly when the waters break. It does not fit the picture of painless bleeding with a soft womb and a placenta lying over the cervix.
4. Placenta praevia correct Correct. Painless bright red bleeding with a soft, non-tender womb, and a placenta lying over the cervix, is placenta praevia.
5. Antepartum haemorrhage Bleeding after 20 weeks of pregnancy, from placenta praevia, abruption or another cause. But the picture of painless bleeding with a soft womb and a placenta lying over the cervix does not point to it.

The point: Antepartum haemorrhage means bleeding from the vagina after 20 weeks of pregnancy and before the baby is born. The two important causes behave very differently. Placenta praevia is when the placenta lies over or close to the opening of the cervix. It causes painless, bright red bleeding, and the womb (uterus) feels soft and is not tender. A finger (digital) vaginal examination must not be done until an ultrasound scan has ruled out praevia, because the examination can cause very heavy bleeding. Placental abruption is when a normally placed placenta starts to come away early. It causes painful bleeding, and the uterus feels tender, firm or hard like wood, and the baby's heart rate often shows distress. Some of the bleeding can stay hidden inside, so the mother can be more in shock than the amount of visible blood loss suggests. Both conditions are managed by treating the mother's shock, checking the baby, giving an anti-D injection to mothers with rhesus-negative blood, and deciding when to deliver based on how many weeks pregnant she is, how severe it is, and how the mother and baby are doing. Vasa praevia is when the baby's own blood vessels run across the opening of the cervix. It causes painless bleeding with the baby becoming distressed very quickly once the waters break. Throughout all of these, the priority is to treat the mother first and check the baby closely.

Source: RANZCOG — Antepartum haemorrhage: placenta praevia and placental abruption RANZCOG · tier 2, specialty society or college

A 31 year old woman at 32 weeks has sudden painless bright red vaginal bleeding. Her uterus is soft and non-tender, and the fetal heart rate is normal. She is haemodynamically stable. An ultrasound shows the placenta lying over the cervical os. A junior doctor is about to perform a digital vaginal examination to assess the bleeding. What is the most appropriate next step in management?

1. Avoid vaginal examination until praevia is excluded correct Correct. A finger examination in praevia can set off very heavy bleeding, so it is avoided, correcting the junior doctor's plan.
2. Resuscitate the mother with access, fluids and blood Give a drip, fluids and blood as needed; the priority in any significant bleed. But the picture of painless bleeding with a soft womb and a placenta lying over the cervix does not point to it.
3. Anti-D for rhesus-negative women Prevents the mother's body reacting against future rhesus-positive pregnancies. Here, the picture of painless bleeding with a soft womb and a placenta lying over the cervix points elsewhere.
4. Plan mode and timing of birth Choose how and when to deliver based on the cause, how many weeks pregnant she is, and how mother and baby are doing. That does not match the picture of painless bleeding with a soft womb and a placenta lying over the cervix.
5. Emergency delivery for maternal or fetal compromise Given when the mother or baby is in danger. It does not fit the picture of painless bleeding with a soft womb and a placenta lying over the cervix.

The point: Antepartum haemorrhage means bleeding from the vagina after 20 weeks of pregnancy and before the baby is born. The two important causes behave very differently. Placenta praevia is when the placenta lies over or close to the opening of the cervix. It causes painless, bright red bleeding, and the womb (uterus) feels soft and is not tender. A finger (digital) vaginal examination must not be done until an ultrasound scan has ruled out praevia, because the examination can cause very heavy bleeding. Placental abruption is when a normally placed placenta starts to come away early. It causes painful bleeding, and the uterus feels tender, firm or hard like wood, and the baby's heart rate often shows distress. Some of the bleeding can stay hidden inside, so the mother can be more in shock than the amount of visible blood loss suggests. Both conditions are managed by treating the mother's shock, checking the baby, giving an anti-D injection to mothers with rhesus-negative blood, and deciding when to deliver based on how many weeks pregnant she is, how severe it is, and how the mother and baby are doing. Vasa praevia is when the baby's own blood vessels run across the opening of the cervix. It causes painless bleeding with the baby becoming distressed very quickly once the waters break. Throughout all of these, the priority is to treat the mother first and check the baby closely.

Source: RANZCOG — Antepartum haemorrhage: placenta praevia and placental abruption RANZCOG · tier 2, specialty society or college

A 31 year old woman at 32 weeks has sudden painless bright red vaginal bleeding. Her uterus is soft and non-tender, and the fetal heart rate is normal. She is haemodynamically stable. An ultrasound shows the placenta lying over the cervical os. A junior doctor is about to perform a digital vaginal examination to assess the bleeding. What is the most appropriate definitive management?

1. Plan mode and timing of birth Choose how and when to deliver based on the cause, how many weeks pregnant she is, and how mother and baby are doing. Here, the picture of painless bleeding with a soft womb and a placenta lying over the cervix points elsewhere.
2. Anti-D for rhesus-negative women Prevents the mother's body reacting against future rhesus-positive pregnancies. But the picture of painless bleeding with a soft womb and a placenta lying over the cervix does not point to it.
3. Correct coagulopathy in abruption Give blood products for the clotting problem that abruption can cause. It does not fit the picture of painless bleeding with a soft womb and a placenta lying over the cervix.
4. Resuscitate the mother with access, fluids and blood Give a drip, fluids and blood as needed; the priority in any significant bleed. That does not match the picture of painless bleeding with a soft womb and a placenta lying over the cervix.
5. Expectant management of a stable preterm praevia correct Correct. A stable praevia before term is managed by admission and steroids while watching closely, rather than delivering straight away.

The point: Antepartum haemorrhage means bleeding from the vagina after 20 weeks of pregnancy and before the baby is born. The two important causes behave very differently. Placenta praevia is when the placenta lies over or close to the opening of the cervix. It causes painless, bright red bleeding, and the womb (uterus) feels soft and is not tender. A finger (digital) vaginal examination must not be done until an ultrasound scan has ruled out praevia, because the examination can cause very heavy bleeding. Placental abruption is when a normally placed placenta starts to come away early. It causes painful bleeding, and the uterus feels tender, firm or hard like wood, and the baby's heart rate often shows distress. Some of the bleeding can stay hidden inside, so the mother can be more in shock than the amount of visible blood loss suggests. Both conditions are managed by treating the mother's shock, checking the baby, giving an anti-D injection to mothers with rhesus-negative blood, and deciding when to deliver based on how many weeks pregnant she is, how severe it is, and how the mother and baby are doing. Vasa praevia is when the baby's own blood vessels run across the opening of the cervix. It causes painless bleeding with the baby becoming distressed very quickly once the waters break. Throughout all of these, the priority is to treat the mother first and check the baby closely.

Source: RANZCOG — Antepartum haemorrhage: placenta praevia and placental abruption RANZCOG · tier 2, specialty society or college