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OG10.1-2,OG11.1 | Late Pregnancy Complications — Assignment

CLINICAL SCENARIO

You are the duty resident when a 29-year-old G2P1 at 32 weeks gestation arrives by ambulance with a history of painless, bright-red vaginal bleeding that began suddenly 90 minutes ago. She reports no abdominal pain, no trauma, and no preceding symptoms. Her previous pregnancy was an uncomplicated vaginal delivery at term. On arrival: BP 100/65 mmHg, pulse 110 bpm, respiratory rate 20/min. Her abdomen is soft, the uterus is non-tender and not contracting, and the fetal heart rate on Doppler is 148 bpm. You recognise this as antepartum haemorrhage requiring urgent evaluation. This assignment asks you to analyse this case comprehensively — from immediate clinical reasoning through investigation, diagnosis, management, and follow-up.

Instructions

Write a structured clinical analysis of the case described above. Work through each section in order, demonstrating your ability to apply the principles of APH management to this specific patient. Cite specific values (e.g. haemoglobin thresholds, gestational landmarks, product doses) where relevant. Address both the immediate acute management and the longer-term pregnancy management. Your response should be evidence-based and draw on current obstetric guidelines (DC Dutta, Williams, FOGSI/RCOG guidance where applicable).

Length: 900-1300 words total across all five sections

What to Submit

1. Immediate Clinical Assessment and Stabilisation

Guidance: Describe your immediate assessment priorities. What two things must you NOT do before ultrasonography? Outline the resuscitation steps for this haemodynamically borderline patient: IV access, investigations to order (and why each matters), and monitoring parameters. How would you classify the severity of this APH based on the information given?

2. Differential Diagnosis and Distinguishing Features

Guidance: List the three principal placental causes of APH. Using the clinical features given (painless, soft uterus, non-tender, unengaged presenting part — which you may contrast with what would be expected if the diagnosis were different), justify which diagnosis is most likely in this patient. Include one non-placental cause of late pregnancy bleeding and explain how you would exclude it.

3. Ultrasonography and Targeted Investigations

Guidance: Describe the role and priority of ultrasonography in this case. What specific USS features would confirm your suspected diagnosis? If USS is not immediately available, how does this affect your management? List the blood tests you would order, giving the specific clinical reason for each (e.g. why Kleihauer-Betke, why G&S/crossmatch, why coagulation screen).

4. Management of the Acute Episode and Ongoing Pregnancy

Guidance: Assuming your most likely diagnosis is confirmed: (a) describe the immediate inpatient management including corticosteroid administration and its indication at this gestational age; (b) outline the criteria that would prompt delivery now versus expectant management; (c) if expectant management is chosen, describe the follow-up surveillance plan until delivery. Specify the timing and mode of planned delivery for this type of praevia.

5. Blood Product Use — Indications and Selection

Guidance: The patient's Hb returns at 8.5 g/dL with a platelet count of 190,000/µL and a normal coagulation screen. At what haemoglobin threshold and in what clinical context would you decide to transfuse? If she were to deteriorate into a massive haemorrhage with DIC (fibrinogen 0.8 g/L, PT 28 s), name the specific products you would use and the reason each is chosen (include the target fibrinogen level to aim for in this obstetric setting). What complication of rapid transfusion specifically affects the lungs, and how is it distinguished from fluid overload?

Grading Rubric — APH Clinical Analysis Rubric

Criterion	Points	Full-marks descriptor
Clinical Safety Principles: Demonstrates that digital vaginal examination is never done before USS; identifies haemodynamic instability correctly; shows awareness of fetal vs maternal risk	20 pts	Explicitly states no DVE before USS localisation; correctly identifies haemodynamic compromise signs; clearly differentiates maternal and fetal risk indicators. No safety errors.
Differential Diagnosis and Clinical Reasoning: Correctly differentiates placenta praevia from abruption and vasa praevia using clinical features	20 pts	Names all three placental causes; accurately contrasts praevia (painless, soft uterus, unengaged) vs abruption (painful, tense uterus) vs vasa praevia (fetal blood, rupture of membranes); includes one non-placental cause with logical exclusion criteria.
Investigation Rationale: Demonstrates understanding of USS role and appropriately selects and justifies blood investigations	20 pts	Correctly states TVS is superior to transabdominal for lower-edge assessment; names specific USS features of praevia (distance of placental edge from internal os); justifies each blood test with a specific clinical reason (Kleihauer-Betke: feto-maternal haemorrhage; coag screen: DIC risk; G&S: transfusion readiness).
Management Plan: Appropriate acute and expectant management including corticosteroids, delivery timing, and mode	20 pts	Correctly indicates betamethasone/dexamethasone at 32 weeks for fetal lung maturation; lists evidence-based indications for immediate delivery (uncontrolled bleeding, fetal compromise) vs expectant criteria; specifies elective caesarean at 36-37 weeks for confirmed major praevia; describes appropriate surveillance (USS, inpatient vs outpatient considerations).
Blood Product Knowledge: Accurate selection, thresholds, and targets including knowledge of TRALI vs TACO	20 pts	States transfusion threshold (e.g. Hb <7-8 g/dL or symptomatic); names cryoprecipitate for fibrinogen replacement (NOT FFP alone) with target fibrinogen >2 g/L; correctly distinguishes TRALI (non-cardiogenic, normal PCWP) from TACO (elevated PCWP, responds to diuretics); FFP for clotting factor replacement in correct context.

PEER REVIEW

Review your peer's assignment using the rubric provided. For each of the five criteria, assign a score and write 2-3 sentences explaining your score. Specifically check: (1) Did they state that digital vaginal exam is NOT done before USS? (2) Did they correctly distinguish placenta praevia from abruption using clinical features? (3) Did they name cryoprecipitate (not just FFP) for fibrinogen replacement, and state a target fibrinogen of >2 g/L? (4) Did they mention corticosteroids at 32 weeks? Be constructive — note what was done well and one specific improvement that would strengthen the response.