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Active Bleeding Per Vagina at 37 Weeks - Clinical Assessment

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Differential Diagnosis: The "Big Three" + Other Causes

1. Placenta Previa (Most likely in this scenario)

• Painless, bright-red vaginal bleeding (the hallmark)
• No uterine tenderness
• Soft, non-tender uterus
• Fetal parts may be palpable (no engagement of presenting part - fetus may lie transversely or in breech because the placenta occupies the lower segment)
• Bleeding often self-limited initially but can recur and worsen

• Complete/Central (placenta completely covers os) - most dangerous
• Partial (partially covers os)
• Marginal (reaches but does not cover os)

At 37 weeks, the risk is highest because the lower uterine segment is actively elongating and dilating, tearing marginal placental vessels.

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2. Abruptio Placentae (Placental Abruption)

• Painful vaginal bleeding (key differentiator from previa)
• Blood is characteristically dark (old blood)
• Uterine tenderness and hypertonicity
• Board-like rigid abdomen in severe cases
• Tetanic contractions ("woody uterus")
• Bleeding may be concealed (only internal - hematoma between placenta and uterine wall) - visible bleeding does NOT correlate with actual blood loss
• Fetal distress / bradycardia on CTG

• Grade I (Mild): Slight bleeding, minimal uterine irritability, no fetal distress, normal coagulation
• Grade II (Moderate): More bleeding, uterine irritability, possible fetal distress
• Grade III (Severe - 15%): Tetanic uterus, very painful, maternal hypotension, fibrinogen <150 mg/dL, fetal death possible

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3. Vasa Previa

• Fetal blood - not maternal blood - exits per vagina
• Fetal exsanguination is rapid (fetal blood volume is only ~250 mL)
• Occurs when membranes rupture - Apt test or Kleihauer-Betke test distinguishes fetal vs. maternal blood
• Risk factors: placenta previa, IVF, velamentous cord insertion, bilobed placenta
• Treatment: Immediate cesarean delivery - prognosis depends on speed of delivery

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4. Other Causes (Less likely at 37 weeks but must exclude)

• Cervical/vaginal lesions (polyp, cervicitis, carcinoma)
• "Bloody show" - normal mucus plug passage with early labor (blood-tinged, not active hemorrhage)
• Uterine rupture (rare in primigravida without uterine surgery - presents with sudden sharp abdominal pain, cessation of contractions, fetal bradycardia, maternal shock)

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Key Differentiating Features: Previa vs. Abruption

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Immediate Management Protocol

Step 1 - Simultaneous Resuscitation

• Call obstetrics immediately - this is a maternal-fetal emergency
• Two large-bore IV lines (14-16G)
• Aggressive IV fluid resuscitation - crystalloid
• O2 via face mask
• Left lateral decubitus position (prevent aortocaval compression)
• Continuous CTG (cardiotocography) monitoring

Step 2 - Investigations (urgent, in parallel)

Normal pregnancy fibrinogen = 400-450 mg/dL. Values <300 mg/dL indicate significant coagulation factor consumption. Values <150 mg/dL = severe abruption / DIC.

Step 3 - Critical Rule: NO DIGITAL VAGINAL EXAMINATION

Step 4 - Ultrasound

• Transvaginal ultrasound (TVS) is the gold standard for placental localization - it is safe and more accurate than transabdominal US
• Empty the bladder first (overfull bladder can falsely suggest low-lying placenta)
• Assess:
  • Placental location relative to internal os
  • Presence of retroplacental hematoma (abruption)
  • Fetal heart rate and wellbeing
  • Amniotic fluid index

Note: A normal ultrasound does NOT exclude placental abruption - fresh blood is isoechoic to placenta.

Step 5 - Definitive Management

• Cesarean section - vaginal delivery is absolutely contraindicated
• If hemodynamically stable: neuraxial anesthesia preferred (less blood loss than GA)
• If active hemorrhage / hemodynamic instability: emergency cesarean under general anesthesia
• Two large-bore IVs, blood products available
• Warn of risk of placenta accreta spectrum (accreta/increta/percreta)

• Depends on severity and fetal status:
  • Mild abruption, normal fetal status: can consider augmentation/artificial rupture of membranes + oxytocin (at term)
  • Moderate-severe abruption or fetal distress: Emergency cesarean section
  • Severe abruption with fetal demise and stable mother: Vaginal delivery may be attempted
• Monitor fibrinogen closely - prepare for massive transfusion (pRBC, FFP, platelets, cryoprecipitate)
• If Rh-negative and not yet received Rh immunoglobulin at 28 weeks: administer 300 mcg Rh immune globulin within 72 hours

• Immediate emergency cesarean section - minutes matter (fetal exsanguination is rapid)

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Blood Transfusion and Coagulopathy Management

• Fresh Frozen Plasma (FFP) for coagulopathy/DIC
• Cryoprecipitate for fibrinogen replacement (<100 mg/dL target >150 mg/dL)
• Platelet transfusion if <50,000
• Consider tranexamic acid (antifibrinolytic) for hemorrhage
• Massive transfusion protocol: pRBC:FFP:platelets in 1:1:1 ratio

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Summary: This Clinical Scenario

• Primigravida (no prior cesarean - lower previa risk but not zero)
• 37 weeks (term - delivery is appropriate regardless of cause)
• Active bleeding

1. IV access + fluid resuscitation
2. Urgent TVS to localize placenta
3. Obstetric emergency team activation
4. Prepare for emergency cesarean

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OBSTETRICS - Paper I | Model Answers (MBBS University Exam Pattern)

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QUESTION 1

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i) What is the diagnosis? (1 mark)

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ii) How can you differentiate the causes for this clinical condition? (3 marks)

Key clinical rule: NEVER perform digital vaginal examination until placenta previa is excluded by ultrasound - it can precipitate catastrophic hemorrhage.

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iii) Write down the immediate management. (4 marks)

A - Assess & Airway

• Call for obstetric emergency team immediately
• Place patient in left lateral decubitus position (prevent aortocaval compression)
• Maintain airway; administer O2 by face mask (8-10 L/min)

B - Bleeding Control / IV Access

• Establish two large-bore IV cannulas (14-16G)
• Start rapid IV crystalloid (Normal saline / Ringer's lactate)
• Do NOT perform digital vaginal examination until US done

C - Investigations (urgent, simultaneous)

D - Monitoring

• Continuous CTG (cardiotocography) - fetal heart rate monitoring
• Urine output monitoring via catheter (target >30 mL/hour)
• Maternal pulse, BP, SpO2 monitoring

E - Ultrasound

• Transvaginal ultrasound (TVS) - gold standard for placental localization
• Empty bladder before scan (full bladder falsely suggests low placenta)
• Assess placental position relative to internal os

F - Rh Status

• If patient is Rh-negative: administer 300 mcg Rh immune globulin within 72 hours

G - Blood Products (if actively bleeding)

• Fresh Frozen Plasma (FFP) if coagulopathy present
• Cryoprecipitate if fibrinogen <100 mg/dL
• Platelets if count <50,000
• Massive transfusion protocol: pRBC : FFP : Platelets = 1:1:1

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iv) What is the definitive management of this patient? (7 marks)

A. If Placenta Previa (most likely)

• 2 large-bore IVs in situ
• 4 units cross-matched blood available
• Anesthetic assessment: Neuraxial (spinal/epidural) anesthesia preferred if hemodynamically stable (less blood loss than GA); General anesthesia if actively hemorrhaging/unstable
• Warn of risk of Placenta Accreta Spectrum (accreta/increta/percreta) - incidence increases with prior cesarean + previa

• Lower segment cesarean section (LSCS)
• Senior obstetrician should perform (risk of excessive blood loss from lower segment)
• Have uterotonics ready: Oxytocin 10 IU IV/IM after delivery
• Prepare for possible hysterectomy if accreta spectrum found

• Monitor for postpartum hemorrhage - lower uterine segment contracts poorly
• Continue IV oxytocin infusion
• Monitor Hb, coagulation, urine output

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B. If Abruptio Placentae (confirmed)

• Monitor fibrinogen every 4-6 hours
• FFP: 15 mL/kg to restore coagulation factors
• Cryoprecipitate: if fibrinogen <100 mg/dL (target >150 mg/dL)
• Tranexamic acid: 1 g IV over 10 minutes (antifibrinolytic)
• Watch for DIC: platelet transfusion if <50,000

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C. If Vasa Previa

• Immediate emergency cesarean section - minutes determine fetal survival
• Neonatal resuscitation team on standby
• Fetal blood transfusion may be required neonatally

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Neonatal Management

• Neonatologist/NICU team present at delivery
• At 37 weeks: risk of respiratory distress syndrome (mild)
• Cord blood for Hb, blood group, Coombs test
• Vitamin K 1 mg IM to neonate

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QUESTION 2

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i) What are the predisposing factors for twin pregnancy? (2 marks)

Dizygotic (Fraternal) Twins - Most Common (2/3 of twins):

• Family history of twins (maternal side - hereditary hypergonadotropism)
• Advanced maternal age (>35 years) - higher FSH levels
• Multiparity - increased parity
• Assisted Reproductive Technology (ART) - ovulation induction (clomiphene, gonadotropins), IVF with multiple embryo transfer
• African race - highest rate of spontaneous twinning
• Nutritional factors - tall stature, high dietary intake (IGF-1)
• Previous twin pregnancy

Monozygotic (Identical) Twins:

• Random/spontaneous - rate is constant worldwide (~3-4/1000 births)
• ART can also increase MZ twinning (zona pellucida manipulation)

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ii) How can you determine chorionicity? (3 marks)

Timing - FIRST TRIMESTER is BEST (11-14 weeks)

Ultrasound Signs:

Additional Methods:

• Amniocentesis with karyotyping (DNA analysis for zygosity)
• Placental examination after delivery

Mnemonic: "DC has a T-peak (Twin Peak/Lambda), MC has a T-sign"

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iii) What are the complications of multiple pregnancy? (4 marks)

Maternal Complications:

Fetal Complications:

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iv) Outline the management of the case till delivery. (6 marks)

At Presentation (34 weeks, mild abdominal pain):

• Admit to hospital
• Rule out threatened preterm labor: cervical assessment, CTG, fetal fibronectin
• Assess chorionicity (already known ideally from first trimester scan)
• Rule out PPROM: speculum exam, fluid analysis (ferning, PAMG-1)

Antenatal Management:

• Betamethasone 12 mg IM x 2 doses 24 hours apart (for fetal lung maturity at 34 weeks - consider if preterm delivery imminent)

• Nifedipine 10-20 mg orally (first-line) OR
• Atosiban (oxytocin antagonist) IV
• Contraindicated: beta-sympathomimetics (may worsen cardiac effects with twins)

• Magnesium sulphate IV if delivery anticipated <34 weeks (neuroprotection for cerebral palsy prevention)
• Note: at 34 weeks, benefit is marginal

Ongoing Antenatal Surveillance:

Timing of Delivery:

Mode of Delivery:

• Cephalic-cephalic presentation: Trial of vaginal delivery possible
• First twin non-cephalic (breech/transverse): Cesarean section
• Second twin malpresentation after first delivery: Internal podalic version + breech extraction
• All MCMA twins: Cesarean section
• Preterm (<34 weeks), IUGR, TTTS: Cesarean section preferred

During Labor:

• Two neonatologists/NICU team at delivery
• Continuous fetal monitoring of BOTH twins (twin CTG)
• IV access, blood crossmatch
• Anesthesia team on standby
• Interval between twins: ideally <30 minutes
• Active management of third stage (oxytocin 10 IU IM after delivery of 2nd twin)

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QUESTION 3

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i) WHO Labor Care Guide vs. Modified WHO Partograph (3 marks)

The WHO LCG replaces the partograph and emphasizes positive birth experience, focusing on preventing unnecessary interventions while identifying truly abnormal labor.

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ii) Active Management of Third Stage of Labor (AMTSL) (7 marks)

Definition:

Components of AMTSL (WHO 2012 - 3 key components):

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Component 1: Uterotonic Drug Administration (Most Important)

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Component 2: Controlled Cord Traction (CCT)

1. Clamp and cut cord at 1-3 minutes after delivery (delayed cord clamping)
2. Wait for signs of placental separation:
   • Gush of blood per vagina
   • Cord lengthening
   • Uterus becomes globular and rises in abdomen
3. Apply suprapubic counter-pressure (guard the uterus with one hand above pubic symphysis)
4. Apply steady, gentle downward traction on the cord in direction of birth canal
5. As placenta descends, change traction direction upward (follows vaginal curve)
6. Ask patient to push/bear down with contractions
7. Never apply cord traction without uterine counter-pressure (risk of uterine inversion)

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Component 3: Uterine Massage (After delivery of placenta)

• After placenta is delivered, immediately massage the uterine fundus through the abdomen
• Confirm uterus is well-contracted (hard, globular)
• Sustained uterine massage is NO LONGER recommended (2012 WHO guidelines) - only fundal massage to assess tone
• Empty bladder (full bladder displaces uterus → atony)

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Additional Steps (Post-placenta):

1. Inspect the placenta and membranes for completeness (retained placenta → PPH)
2. Inspect the perineum/cervix for lacerations (repair if present)
3. Monitor uterine tone every 15 minutes for the first 2 hours
4. Monitor maternal pulse, BP, blood loss

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Benefits of AMTSL:

• Reduces incidence of PPH by 60-70%
• Reduces need for blood transfusion
• Reduces maternal mortality from PPH
• Reduces duration of third stage of labor

Normal Third Stage Duration:

• Usually completed within 15-30 minutes
• If placenta not delivered within 30 minutes after uterotonic → retained placenta (manual removal under anesthesia)

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QUESTION 4

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i) Causes of Hyperglycemia in Pregnancy (3 marks)

A. Gestational Diabetes Mellitus (GDM) - Most common

• Placental hormones (human placental lactogen/hPL, progesterone, cortisol, estrogen) → peripheral insulin resistance
• Normally compensated by increased maternal insulin secretion
• GDM occurs when pancreatic beta-cells cannot overcome this resistance
• hPL peaks at 24-28 weeks → hence GDM screening at 24-28 weeks

B. Pre-existing (Overt) Diabetes in Pregnancy

C. Other Causes (Secondary)

• Cushing syndrome (excess cortisol)
• Acromegaly (excess growth hormone)
• Steroid therapy (betamethasone given for fetal lung maturity → transient maternal hyperglycemia)
• Pancreatitis / pancreatic disease
• Pheochromocytoma

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ii) How will you screen the patient? (3 marks)

Universal Screening Recommended at 24-28 weeks

One-Step Approach (WHO/IADPSG Recommended):

Two-Step Approach (ACOG / North American):

• Step 1: 50g Glucose Challenge Test (GCT) - no fasting required
  • 1-hour plasma glucose >140 mg/dL = positive (proceed to Step 2)
  • Sensitivity: ~80%; not diagnostic
• Step 2: 100g OGTT (fasting) - Carpenter-Coustan criteria (2 or more values must be met):
  • Fasting ≥95 mg/dL
  • 1-hour ≥180 mg/dL
  • 2-hour ≥155 mg/dL
  • 3-hour ≥140 mg/dL

Early Screening (First Visit / <13 weeks) - For HIGH RISK patients:

• BMI >30 kg/m²
• Previous GDM
• Previous macrosomic baby (>4 kg)
• Family history of DM (first-degree relative)
• Polycystic ovarian syndrome (PCOS)
• Glycosuria on 2+ occasions
• Previous unexplained stillbirth

• FPG ≥126 mg/dL = Overt DM
• HbA1c ≥6.5% = Overt DM
• FPG 92-125 mg/dL = GDM

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iii) Fetal Complications of Hyperglycemia in Pregnancy (4 marks)

Mnemonic for neonatal complications of GDM: MACROSOMIA

• Macrosomia
• Anomalies (congenital)
• Cardiomegaly
• RDS
• Organomegaly
• Stillbirth
• Obesity (long-term)
• Metabolic (hypoglycemia, hypocalcemia)
• IUGR (in vascular DM)
• Anemia/polycythemia

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QUESTION 5

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i) Guidelines for Antenatal Anti-D Prophylaxis in Rh-Negative Pregnancy (6 marks)

Background:

• Rh(D) negative women (approx. 15% of population) are at risk of sensitization when exposed to Rh(D) positive fetal red cells
• Sensitization → maternal anti-D IgG antibodies → cross placenta → destroy fetal RBCs → Hemolytic Disease of the Fetus and Newborn (HDFN)
• Anti-D immunoglobulin (RhIG) prevents sensitization by clearing fetal RBCs before maternal immune response

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A. ROUTINE ANTENATAL ANTI-D PROPHYLAXIS (RAADP)

Regimen Options:

• Given IM (deltoid muscle)
• Kleihauer-Betke (KB) test or flow cytometry done at 28 weeks to exclude already sensitized women (if antibodies found → RAADP not needed; fetal surveillance begins instead)
• Routine prophylaxis is given regardless of father's Rh status (paternity uncertain)

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B. ANTI-D FOR SENSITIZING EVENTS (Prophylaxis after each event)

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C. DOSE ADJUSTMENT FOR LARGE FETOMATERNAL HEMORRHAGE

• Kleihauer-Betke (KB) test / flow cytometry performed after sensitizing events >20 weeks
• Estimates volume of fetal RBCs in maternal circulation
• Standard dose (500 IU) covers up to 4 mL fetal RBCs
• If FMH >4 mL: additional Anti-D required (125 IU per additional mL of fetal blood)

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D. WHEN NOT TO GIVE ANTI-D

• Already sensitized (anti-D antibodies present on booking screen)
• Fetus/baby confirmed Rh(D) negative
• Patient is Rh(D) positive

E. POST-NATAL PROPHYLAXIS

• Cord blood taken at delivery: ABO and Rh grouping + Direct Coombs Test (DCT)
• If baby is Rh(D) positive → give 500 IU Anti-D IM to mother within 72 hours
• If baby is Rh(D) negative → no Anti-D needed
• KB test on maternal blood to check for large FMH → increase dose if needed

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ii) Neonatal Complications in Rh-Negative Pregnancy (4 marks)

Hemolytic Disease of the Fetus and Newborn (HDFN) / Erythroblastosis Fetalis

Severity Classification:

• Mild HDFN: Mild anemia only; cord Hb >12 g/dL; bilirubin manageable with phototherapy
• Moderate HDFN: Cord Hb 8-12 g/dL; significant jaundice → phototherapy + may need exchange transfusion
• Severe HDFN: Cord Hb <8 g/dL; hydrops; intrauterine transfusion may be needed antenatally; exchange transfusion postnatally

Neonatal Treatment:

• Phototherapy - converts unconjugated bilirubin to water-soluble forms for excretion
• Exchange transfusion - removes sensitized RBCs + antibodies + bilirubin; replaces with Rh-negative blood
• IV immunoglobulin (IVIG) - reduces hemolysis rate
• Intrauterine transfusion - if hydrops detected antenatally (cordocentesis + intravascular transfusion)

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Exam tip: In MBBS university exams, marks are awarded for organized presentation with headings, clear tables where appropriate, and covering all sub-parts in proportion to the marks allocated. Use the mark distribution (e.g., 1+3+4+7) to gauge how much to write for each sub-part.