ANTEPARTUM HEMORRHAGE MCQ
ASSESSMENT QUESTIONS: ANTEPARTUM HEMORRHAGE (REVISED)
SHORT ANSWER QUESTIONS (SAQs)
SAQ 1: Clinical Differentiation
Question: A 32-year-old G3P2 woman at 34 weeks gestation presents to the emergency department with vaginal bleeding.
a) List FOUR key clinical features you would elicit from history and examination to differentiate between placenta previa and placental abruption. (4 marks)
b) Explain why digital vaginal examination should NOT be performed until placenta previa has been excluded. (2 marks)
c) Name TWO investigations you would order immediately and justify each. (4 marks)
Model Answer:
a) Clinical features to differentiate (4 marks - 1 mark each):
Placenta Previa:
Painless vaginal bleeding
Bright red blood
Soft, non-tender uterus
High/unstable presenting part or malpresentation
Placental Abruption:
Painful vaginal bleeding with constant abdominal pain
Dark red blood (may be concealed)
Woody hard, tender, irritable uterus
Fetal distress or abnormal CTG
b) Digital vaginal examination contraindication (2 marks):
Digital examination can disrupt the placenta if it overlies the cervical os (1 mark)
This can precipitate massive, life-threatening hemorrhage (1 mark)
c) Two immediate investigations (4 marks - 2 marks each):
Ultrasound scan:
To localize the placenta and exclude placenta previa (1 mark)
To assess fetal wellbeing, presentation, and amniotic fluid volume (1 mark)
Full blood count and Group & Cross-match (4-6 units):
FBC to assess degree of anemia and baseline hemoglobin (1 mark)
Cross-match to have blood available for potential transfusion if hemorrhage worsens (1 mark)
Alternative acceptable investigations: Coagulation screen (especially if abruption suspected), Kleihauer test (if Rh-negative), CTG monitoring
SAQ 2: Management of Placenta Previa
Question: A 28-year-old primigravida at 32 weeks gestation is diagnosed with complete (major) placenta previa after presenting with her second episode of painless vaginal bleeding. The bleeding has stopped, and both mother and baby are stable.
a) Outline your immediate management plan (next 24-48 hours). (5 marks)
b) Discuss the timing and mode of delivery for this patient. (3 marks)
c) List TWO maternal complications specifically associated with placenta previa. (2 marks)
Model Answer:
a) Immediate management (5 marks):
Admission to hospital for observation and monitoring (1 mark)
Blood investigations: FBC, group and cross-match (keep 2-4 units available), coagulation screen (½ mark)
Corticosteroids (betamethasone or dexamethasone) for fetal lung maturity as she is <34 weeks (1 mark)
Anti-D immunoglobulin if she is Rh-negative (Kleihauer test to assess fetomaternal hemorrhage) (1 mark)
Iron supplementation to correct/prevent anemia (½ mark)
Bed rest during active bleeding, counsel to avoid intercourse and strenuous activity (½ mark)
Serial monitoring: Regular hemoglobin checks, fetal wellbeing assessments with CTG and ultrasound for growth (½ mark)
Patient education: Warning signs (heavy bleeding, contractions, reduced fetal movements) and ensure quick access to hospital (½ mark)
b) Timing and mode of delivery (3 marks):
Mode: Elective cesarean section (mandatory for major/complete placenta previa) (1 mark)
Timing: 36-37 weeks gestation (after course of corticosteroids if given) (1 mark)
Justification: Balance between fetal maturity and risk of hemorrhage; most bleeding episodes occur after 36 weeks (1 mark)
c) Two maternal complications (2 marks - 1 mark each):
Postpartum hemorrhage (lower uterine segment contracts poorly)
Morbidly adherent placenta (placenta accreta spectrum) - especially with previous cesarean section
Other acceptable answers: Need for blood transfusion, hysterectomy, maternal mortality, complications of cesarean section
SAQ 3: Placental Abruption Complications
Question: A 35-year-old woman with chronic hypertension presents at 36 weeks gestation with severe abdominal pain and vaginal bleeding. On examination, her uterus is woody hard and very tender. Fetal heart sounds are absent. She is tachycardic (120 bpm) and hypotensive (BP 90/60 mmHg), but visible blood loss is only approximately 200 mL.
a) What is the most likely diagnosis and explain why her clinical condition is worse than expected from visible blood loss? (3 marks)
b) List THREE blood investigations you would request urgently and explain the rationale for each. (6 marks)
c) Name ONE serious maternal complication this patient is at risk of developing and briefly describe its pathophysiology. (3 marks)
Model Answer:
a) Diagnosis and explanation (3 marks):
Diagnosis: Severe placental abruption with concealed hemorrhage/intrauterine fetal death (1 mark)
Explanation: The blood loss is concealed behind the placenta and retained in the uterus (1 mark)
The visible blood loss does not reflect the true extent of hemorrhage, leading to hypovolemic shock disproportionate to external bleeding (1 mark)
b) Three urgent blood investigations (6 marks - 2 marks each):
Coagulation screen (PT, APTT, fibrinogen, D-dimer):
To detect disseminated intravascular coagulation (DIC), which occurs in 10-20% of severe abruptions (1 mark)
Release of thromboplastin from placental tissue causes consumption of clotting factors and platelets (1 mark)
Full blood count:
To assess degree of anemia from blood loss and guide need for blood transfusion (1 mark)
To check platelet count, which falls in DIC (1 mark)
Group and cross-match (6 units minimum):
To have blood products immediately available for transfusion (1 mark)
Severe abruption has high risk of massive hemorrhage requiring multiple units (1 mark)
Alternative acceptable: Urea and electrolytes (assess renal function/acute tubular necrosis risk), Liver function tests
c) One serious complication and pathophysiology (3 marks):
Disseminated Intravascular Coagulation (DIC):
Pathophysiology: Placental tissue and decidua release thromboplastin into maternal circulation (1 mark)
This triggers widespread activation of the coagulation cascade throughout the body (1 mark)
Results in consumption of clotting factors and platelets, leading to paradoxical bleeding despite clot formation (1 mark)
Alternative acceptable complications: Acute renal failure/acute tubular necrosis (from hypovolemic shock and DIC), Couvelaire uterus (blood infiltration into myometrium causing uterine atony and PPH), Hypovolemic shock, Maternal death
SAQ 4: Vasa Previa
Question: a) Define vasa previa and describe its pathophysiology. (3 marks)
b) List THREE risk factors for vasa previa. (3 marks)
c) Explain why antenatal diagnosis of vasa previa is crucial and describe how it should be managed if diagnosed at 28 weeks gestation. (4 marks)
Model Answer:
a) Definition and pathophysiology (3 marks):
Definition: Vasa previa occurs when fetal blood vessels run through the membranes across the internal cervical os, unprotected by placental tissue or umbilical cord (1 mark)
Pathophysiology: When membranes rupture, these unprotected fetal vessels rupture (1 mark)
This causes fetal exsanguination as fetal blood volume is only 250-500 mL at term; small blood loss can be rapidly fatal (1 mark)
b) Three risk factors (3 marks - 1 mark each):
Velamentous cord insertion
Bilobed or succenturiate-lobed placenta
Low-lying placenta or placenta previa
Multiple pregnancy
IVF/assisted conception
Previous uterine surgery
Any 3 of the above
c) Importance of antenatal diagnosis and management (4 marks):
Importance of antenatal diagnosis:
Antenatal diagnosis allows planned cesarean section before rupture of membranes (1 mark)
Survival rate >95% with antenatal diagnosis vs. 60% mortality without diagnosis (1 mark)
Management at 28 weeks:
Hospital admission from 30-32 weeks (some advocate earlier or outpatient with strict precautions) (½ mark)
Corticosteroids for fetal lung maturity (betamethasone or dexamethasone) (½ mark)
Elective cesarean section at 35-37 weeks, before onset of labor or spontaneous rupture of membranes (1 mark)
Avoid vaginal examinations throughout pregnancy (½ mark)
Neonatal team alerted and prepared for potential neonatal resuscitation and transfusion (½ mark)
SAQ 5: Risk Assessment and Prevention
Question: A 38-year-old G4P3 woman presents for booking at 10 weeks gestation. She has had two previous cesarean sections and one normal vaginal delivery. She smokes 10 cigarettes per day and has chronic hypertension controlled on methyldopa.
a) Identify FOUR risk factors in this patient's history that increase her risk of antepartum hemorrhage. (4 marks)
b) For each risk factor identified, state the specific type(s) of APH it predisposes to. (4 marks)
c) Outline TWO preventive measures that could reduce her risk of APH. (2 marks)
Model Answer:
a) Four risk factors (4 marks - 1 mark each):
Previous cesarean sections (two)
Multiparity (G4P3)
Smoking
Chronic hypertension
Advanced maternal age (>35 years)
Any 4 of the above - 1 mark each
b) APH types associated with each risk factor (4 marks - 1 mark each):
Previous cesarean sections: Placenta previa, placenta accreta spectrum
Multiparity: Placenta previa, placental abruption
Smoking: Placental abruption, placenta previa
Chronic hypertension: Placental abruption (most important)
Advanced maternal age: Placenta previa, placental abruption
c) Two preventive measures (2 marks - 1 mark each):
Smoking cessation:
Provide counseling and support to quit smoking, which reduces risk of both abruption and previa (1 mark)
Optimal blood pressure control:
Continue antihypertensive medication and monitor BP closely to reduce risk of placental abruption (1 mark)
Alternative acceptable answers:
Second trimester ultrasound scan to identify placenta previa early
Low-dose aspirin if additional preeclampsia risk factors (may reduce abruption risk)
Folic acid supplementation
Early and regular antenatal care for close monitoring
Counseling about warning signs and when to seek help
MULTIPLE CHOICE QUESTIONS (MCQs)
MCQ 1
A 30-year-old woman at 32 weeks gestation presents with painless vaginal bleeding. What is the GOLD STANDARD investigation for diagnosing placenta previa?
A. Transabdominal ultrasound
B. Transvaginal ultrasound
C. Speculum examination
D. Digital vaginal examination
E. MRI pelvis
Correct Answer: B
Explanation: Transvaginal ultrasound is the gold standard for diagnosing placenta previa. It is safe (no evidence of harm), accurate, and superior to transabdominal ultrasound, which can miss low-lying placentas due to maternal bladder filling, fetal head shadowing, or posterior placentas. Digital vaginal examination is contraindicated when placenta previa is suspected as it can precipitate catastrophic hemorrhage. MRI is reserved for complex cases or suspected placenta accreta.
MCQ 2
A patient presents at 34 weeks gestation with abdominal pain and vaginal bleeding. On examination, the uterus feels woody hard and is very tender. What is the MOST characteristic clinical feature of her likely diagnosis?
A. Painless bright red bleeding
B. Soft non-tender uterus
C. Woody hard tender uterus
D. Malpresentation
E. Maternal shock corresponding to visible blood loss
Correct Answer: C
Explanation: A woody hard, tender, irritable uterus is the classic sign of placental abruption, which is the most likely diagnosis given the presentation. This occurs due to blood infiltrating into the myometrium and uterine irritability. Option A describes placenta previa. Option B is inconsistent with abruption. Option D is more common with placenta previa. Option E is incorrect because in concealed abruption, maternal shock is often disproportionate to visible blood loss.
MCQ 3
A 34-year-old woman at 35 weeks gestation with known placenta previa experiences heavy vaginal bleeding. She remains hypotensive at 85/50 mmHg despite 2 liters of IV crystalloid and 2 units of blood transfusion. What is the MOST appropriate next step in management?
A. Continue expectant management with bed rest
B. Administer tocolysis to prevent labor
C. Proceed to emergency cesarean section
D. Induce labor with oxytocin
E. Discharge home with outpatient follow-up
Correct Answer: C
Explanation: Emergency cesarean section is indicated for placenta previa with severe ongoing hemorrhage causing maternal hemodynamic instability despite adequate resuscitation (2L crystalloid + 2 units blood). This is a life-threatening emergency requiring immediate delivery. Expectant management (A) is only appropriate for stable patients with minor bleeding at preterm gestations. Tocolysis (B) is contraindicated with active bleeding. Induction of labor (D) is contraindicated in major placenta previa. Discharge (E) is dangerous given her ongoing instability and severe bleeding.
MCQ 4
A 29-year-old woman had placental abruption in her previous pregnancy. What is her approximate risk of recurrence in this pregnancy?
A. 1-2%
B. 5-17%
C. 20-30%
D. 35-40%
E. 50-60%
Correct Answer: B
Explanation: Previous placental abruption carries a recurrence risk of 5-17%, representing approximately a 10-fold increased risk compared to the general population. This makes previous abruption the strongest risk factor for recurrent abruption. The baseline risk of placental abruption in the general population is 0.5-1.5%, so option A underestimates the recurrence risk. Options C, D, and E overestimate the recurrence risk significantly.
MCQ 5
A woman at 36 weeks gestation presents with sudden minimal vaginal bleeding immediately after spontaneous rupture of membranes. Fetal heart rate monitoring shows a sudden bradycardia from 140 to 60 bpm. What is the MOST likely diagnosis?
A. Placenta previa
B. Placental abruption
C. Vasa previa
D. Cervical ectropion
E. Normal bloody show
Correct Answer: C
Explanation: Vasa previa classically presents with bleeding at the exact time of membrane rupture with immediate sudden fetal distress (bradycardia). The bleeding is typically small in volume (fetal blood) but catastrophic for the fetus due to rapid exsanguination. Placenta previa (A) presents with painless bleeding but not specifically triggered by membrane rupture with immediate fetal compromise. Placental abruption (B) presents with painful bleeding and the fetus becomes distressed due to hypoxia, not acute exsanguination. Cervical ectropion (D) causes minor spotting without fetal compromise. Bloody show (E) is normal at term and doesn't cause sudden fetal distress.
MCQ 6
A low-lying placenta is detected on routine anomaly ultrasound scan at 20 weeks gestation. What percentage of these cases will resolve by term through "placental migration"?
A. 10%
B. 30%
C. 50%
D. 70%
E. 90%
Correct Answer: E
Explanation: Approximately 90% of low-lying placentas detected in the second trimester (around 20 weeks) will resolve by term. This "placental migration" is actually due to the differential growth and development of the lower uterine segment, making the placenta appear to move away from the internal os. The true incidence of placenta previa is 0.3-0.5% at term, but the detection rate at 20 weeks is approximately 5%. This is why follow-up scans at 32 and 36 weeks are important for women with low-lying placenta detected early in pregnancy.
MCQ 7
A patient with severe placental abruption develops oozing from venipuncture sites and spontaneous bruising. Her fibrinogen level is 0.8 g/L (normal 2-4 g/L) and platelet count is 65 × 10⁹/L. What complication has developed?
A. Placenta accreta
B. Disseminated intravascular coagulation (DIC)
C. Amniotic fluid embolism
D. Uterine rupture
E. HELLP syndrome
Correct Answer: B
Explanation: The clinical presentation (oozing from venipuncture sites, bruising) combined with low fibrinogen and thrombocytopenia indicates disseminated intravascular coagulation (DIC). DIC occurs in 10-20% of severe placental abruption cases, resulting from release of thromboplastin from placental tissue into maternal circulation, causing widespread activation of coagulation and consumption of clotting factors and platelets. Placenta accreta (A) is associated with placenta previa, not abruption. Amniotic fluid embolism (C) presents differently with cardiovascular collapse. Uterine rupture (D) is a different entity. HELLP syndrome (E) would show elevated liver enzymes and hemolysis.
MCQ 8
A woman has major placenta previa diagnosed at 32 weeks gestation. She has had no bleeding episodes and both mother and baby are well. At what gestation should elective cesarean section ideally be scheduled?
A. 32-34 weeks
B. 34-36 weeks
C. 36-37 weeks
D. 38-39 weeks
E. 40 weeks (await spontaneous labor)
Correct Answer: C
Explanation: Elective cesarean section for major placenta previa should be performed at 36-37 weeks (after a course of corticosteroids if administered). This timing balances fetal maturity against the risk of emergency delivery due to hemorrhage, as most significant bleeding episodes requiring emergency delivery occur after 36 weeks. Earlier delivery (A, B) unnecessarily increases neonatal morbidity from prematurity. Later delivery (D, E) significantly increases the risk of emergency hemorrhage requiring category 1 cesarean section with associated maternal and fetal risks.
MCQ 9
A patient with suspected placental abruption at 36 weeks has intrauterine fetal death confirmed. She is hemodynamically stable with mild ongoing bleeding. Labor is progressing steadily. What is the PREFERRED mode of delivery?
A. Emergency cesarean section within 30 minutes
B. Elective cesarean section within 24 hours
C. Vaginal delivery with early amniotomy
D. Immediate forceps delivery
E. Await spontaneous delivery without intervention
Correct Answer: C
Explanation: Vaginal delivery with early amniotomy is preferred for placental abruption with intrauterine fetal death when the maternal condition is stable. Early amniotomy helps by reducing intrauterine pressure and may reduce entry of thromboplastin into maternal circulation, potentially limiting progression of DIC. Cesarean section increases maternal morbidity (surgical risks, infection, bleeding) and is reserved for maternal instability, failure to progress, or when vaginal delivery is not anticipated within 4-6 hours. With confirmed fetal death, there is no fetal indication for cesarean section unless maternal factors dictate otherwise.
MCQ 10
Vasa previa is diagnosed at 28 weeks gestation on transvaginal ultrasound with color Doppler. What is the expected fetal survival rate with appropriate antenatal diagnosis and management?
A. 40%
B. 60%
C. 75%
D. 85%
E. >95%
Correct Answer: E
Explanation: Antenatal diagnosis of vasa previa is associated with >95% fetal survival because it allows planned cesarean section before rupture of membranes and rupture of fetal vessels. This involves hospital admission from 30-32 weeks, corticosteroids for lung maturity, and elective cesarean section at 35-37 weeks before onset of labor. Without antenatal diagnosis, fetal mortality is approximately 60% due to exsanguination when membranes rupture and unprotected fetal vessels are torn. The dramatic difference in outcomes emphasizes the critical importance of antenatal diagnosis through screening high-risk pregnancies with transvaginal ultrasound and color Doppler.
END OF ASSESSMENT QUESTIONS
Answer key summary for MCQs: 1-B, 2-C, 3-C, 4-B, 5-C, 6-E, 7-B, 8-C, 9-C, 10-E