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 cervical or vaginal lesion. Painless bleeding with a soft uterus and a placenta over the os argues for inspection.
2. Placental abruption Painful bleeding with a tender, firm uterus and fetal distress. Painless bleeding with a soft uterus and a placenta over the os raises it.
3. Vasa praevia Painless bleeding with rapid fetal compromise at membrane rupture. Painless bleeding with a soft uterus and a placenta over the os suggests it.
4. Placenta praevia correct Correct. Painless bright red bleeding with a soft non-tender uterus and a placenta over the os is placenta praevia.
5. Antepartum haemorrhage Bleeding after 20 weeks from placenta praevia, abruption or another cause. Painless bleeding with a soft uterus and a placenta over the os fits.

The point: Antepartum haemorrhage is bleeding from the genital tract after 20 weeks and before birth, and the two important causes behave very differently. Placenta praevia, where the placenta lies over or near the cervical os, causes painless bright red bleeding with a soft, non-tender uterus, and a digital vaginal examination must not be performed until praevia is excluded by ultrasound, because it can provoke torrential bleeding. Placental abruption, premature separation of a normally sited placenta, causes painful bleeding with a tender, firm or woody uterus and often fetal distress, and the bleeding may be concealed, so the degree of shock can exceed the visible loss. Both are managed by resuscitating the mother, assessing the fetus, giving anti-D to rhesus-negative women, and deciding on delivery by gestation, severity and fetal and maternal condition. Vasa praevia, where fetal vessels cross the os, causes painless bleeding with rapid fetal compromise at membrane rupture. The priority throughout is maternal resuscitation and fetal assessment.

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 initial investigation?

1. Ultrasound to locate the placenta before any vaginal examination correct Correct. The scan located the placenta over the os, which is exactly why a digital examination must not be done.
2. Maternal resuscitation assessment first Airway, breathing, circulation and the degree of shock come first. Painless bleeding with a soft uterus and a placenta over the os makes it central.
3. Assessment of the degree of concealed loss In abruption the shock can exceed the visible bleeding. Painless bleeding with a soft uterus and a placenta over the os makes it discriminating.
4. Cardiotocography for fetal wellbeing Assesses fetal distress, prominent in abruption. Painless bleeding with a soft uterus and a placenta over the os makes it necessary.
5. Kleihauer test in rhesus-negative women Quantifies fetomaternal haemorrhage and guides anti-D. Painless bleeding with a soft uterus and a placenta over the os indicates it.

The point: Antepartum haemorrhage is bleeding from the genital tract after 20 weeks and before birth, and the two important causes behave very differently. Placenta praevia, where the placenta lies over or near the cervical os, causes painless bright red bleeding with a soft, non-tender uterus, and a digital vaginal examination must not be performed until praevia is excluded by ultrasound, because it can provoke torrential bleeding. Placental abruption, premature separation of a normally sited placenta, causes painful bleeding with a tender, firm or woody uterus and often fetal distress, and the bleeding may be concealed, so the degree of shock can exceed the visible loss. Both are managed by resuscitating the mother, assessing the fetus, giving anti-D to rhesus-negative women, and deciding on delivery by gestation, severity and fetal and maternal condition. Vasa praevia, where fetal vessels cross the os, causes painless bleeding with rapid fetal compromise at membrane rupture. The priority throughout is maternal resuscitation and fetal assessment.

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 digital vaginal examination in praevia can provoke torrential bleeding, so it is avoided, correcting the junior doctor's plan.
2. Plan mode and timing of birth By cause, gestation and condition. Painless bleeding with a soft uterus and a placenta over the os makes it individualised.
3. Anti-D for rhesus-negative women Prevents sensitisation after the bleed. Painless bleeding with a soft uterus and a placenta over the os makes it routine.
4. Expectant management of a stable preterm praevia A stable preterm praevia is managed expectantly with admission and steroids rather than immediate delivery, and painless bleeding with a soft uterus and a placenta over the os here points elsewhere.
5. Emergency delivery for maternal or fetal compromise Where the mother or fetus is compromised. Painless bleeding with a soft uterus and a placenta over the os makes it the emergency step.

The point: Antepartum haemorrhage is bleeding from the genital tract after 20 weeks and before birth, and the two important causes behave very differently. Placenta praevia, where the placenta lies over or near the cervical os, causes painless bright red bleeding with a soft, non-tender uterus, and a digital vaginal examination must not be performed until praevia is excluded by ultrasound, because it can provoke torrential bleeding. Placental abruption, premature separation of a normally sited placenta, causes painful bleeding with a tender, firm or woody uterus and often fetal distress, and the bleeding may be concealed, so the degree of shock can exceed the visible loss. Both are managed by resuscitating the mother, assessing the fetus, giving anti-D to rhesus-negative women, and deciding on delivery by gestation, severity and fetal and maternal condition. Vasa praevia, where fetal vessels cross the os, causes painless bleeding with rapid fetal compromise at membrane rupture. The priority throughout is maternal resuscitation and fetal assessment.

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