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Vaginal bleeding late in pregnancy

Clinical Discipline(s)/Organ System(s)
Obstetrics & Gynaecology, Reproduction & Development, Haematology
Progress Test Topic(s)
Women's health
A 26 year old NZ European woman presents to the Emergency Maternity Assessment area, in her second pregnancy. She is 31 weeks pregnant and has developed vaginal bleeding and lower abdominal pain. She had a Caesarean section for her first pregnancy.
Progress Test-Type Questions:   Question 1 | Question 2 | Question 3
Applied Science for Medicine 
   - Anatomy and function of the placenta
   - Physiological changes of the cardiovascular and haematological systems at different stages of pregnancy
   - Perinatal physiology
   - Risk factors for abnormal implantation of the placenta
   - Basic features of blood group antigens and antibodies; Rh(D) status
   - Blood transfusion in pregnancy
   - Pathophysiology of isoimmunisation, haemolytic disease of the newborn (HDN)
Clinical and Communication Skills 
   - Elicit a history from a woman with bleeding late in her pregnancy, with specific reference to risk factors for placenta praevia/abruption/uterine rupture
   - Assessment of severity of clinical bleeding (vital signs, signs of shock)
   - Examination of a pregnant woman, including abdominal assessment of uterine tone and activity, and fetal size and well-being
   - Appropriate use of speculum and/or vaginal examination pending review of ultrasound for placental localisation
   - Interpret relevant investigations: full blood count, blood group, Kleihauer test, blood group and hold or crossmatch as indicated, coagulation screen, cardiotocography (CTG), ultrasound
   - Appropriate administration of anti-D
   - Emergency management of acute haemorrhage including resuscitation
   - List the causes of overt and hidden bleeding late in pregnancy
   - Treatment options for late pregnancy bleeding and their urgency, including consideration of antenatal corticosteroids, transfer to hospital with appropriate level neonatal intensive care unit (NICU), mode of delivery
   - Complications of massive antepartum haemorrhage (disseminated intravascular coagulation, multiple organ failure, hysterectomy)
Personal and Professional Skills 
   - Intimate examination and use of a chaperone
   - Screening for family violence in a sensitive manner
   - Balance fetal and maternal wellbeing in clinical decision making
   - Develop the ability to simultaneously clinically assess and manage an acute obstetric scenario
   - Coping with stressful and emotional events
   - Appreciating the role of the anaesthetic team and need for ongoing communication
Hauora Māori 
   - Consideration of patient and whānau needs with regards to ‘breaking bad news
   - Consideration of access to cultural/spiritual support for patient/whānau (including accommodating return of any body parts to whānau if requested)
Population Health 
   - Risk of late pregnancy bleeding and most common contributing factors
   - Consequences of high Caesarean section rate on maternal and perinatal outcomes
   - Appreciation of increased incidence of family violence during pregnancy
Conditions to be considered relating to this scenario
preterm labour, placenta praevia, placental abruption, vaginal trauma, cervical polyps, family violence, haemolytic disease of the newborn (HDN)
Less common but 'important not to miss'
uterine rupture, coagulopathies, cervical cancer
vasa praevia
Related Scenarios
[Late pregnancy complications], [Labour]