Antepartum haemorrhage — structured SAQ (15 marks)

(a) Immediate assessment and resuscitation, first fifteen minutes (5 marks)

One mark per point, maximum five. A mark is available for stating that maternal resuscitation and fetal assessment happen in parallel. ^[1][2]

• Call for help and declare the emergency — obstetric consultant, anaesthetist, midwifery coordinator, blood bank; escalate to the massive obstetric haemorrhage protocol if loss exceeds 1000 mL or she becomes shocked.^[1]
• Mother: left lateral tilt, oxygen if hypoxic, two large-bore cannulae, warmed crystalloid then blood; quantify loss rather than estimate it; compute the shock index (112 divided by 108 equals 1.04, already above the 1.0 threshold despite a reassuring blood pressure).^[1][2]
• Bloods: full blood count, coagulation profile with fibrinogen, group and antibody screen, crossmatch, U&E and liver function, and a Kleihauer because she is RhD negative.^[3][4]
• Fetus: auscultate then apply continuous CTG — at 32+3 weeks the trace determines whether this pregnancy continues tonight.^[2]
• No digital vaginal examination until the placental site is known. Arrange urgent ultrasound for placental localisation; a speculum examination is acceptable once the site is known or in a setting where immediate caesarean is possible.^[1]
• Catheterise, warm, and document a running quantitative loss total.^[1]

(b) Differential diagnosis with discriminators (4 marks)

One mark per cause with its discriminating feature. No mark for a bare list. ^[1][2]

A mark is available for stating that a normal ultrasound does not exclude abruption because sonographic sensitivity is low. ^[7]

(c) Rhesus management (3 marks)

One mark each for the agent with dose and route, the timing, and the laboratory testing with its purpose. ^[3][4]

• Give Rh D immunoglobulin 625 IU IM in Australia and New Zealand (500 IU IM is the United Kingdom dose after 20 weeks) as soon as possible, ideally within 72 hours; a dose given up to 10 days later still offers some protection.^[3]
• Do not wait for the laboratory. The first dose is given on clinical grounds; testing determines whether an additional dose is required, not whether to give the first one.^[3][4]
• Send a maternal sample for fetomaternal haemorrhage quantification — Kleihauer acid-elution screening, with flow cytometry as the more accurate confirmatory method — and give a calculated top-up dose on laboratory advice if the bleed is large.^[4][3]
• Repeat with repeat bleeds at approximately six-weekly intervals with re-quantification, and continue routine antenatal prophylaxis at 28 and 34 weeks in addition to sensitising-event doses.^[3]

(d) Ongoing management and disposition (3 marks)

One mark each for corticosteroids with the correct regimen, neuroprotection with the correct threshold, and a defensible plan for the place and timing of birth. ^[5][6]

• Admit. A 400 mL bleed is a major antepartum haemorrhage; she stays until stable, and given the previous caesarean the placental site report must comment explicitly on accreta features if she has a praevia.^[1]
• Betamethasone 11.4 mg IM, two doses 24 hours apart (or dexamethasone 6 mg IM for four doses 12 hours apart) — a single course reduces perinatal death, respiratory distress syndrome and intraventricular haemorrhage.^[5]
• Magnesium sulphate 4 g IV over 20 to 30 minutes then 1 g/h for fetal neuroprotection only if birth under 30 weeks is anticipated in Australia and New Zealand — at 32+3 weeks she is above the ANZ threshold, and saying so earns the mark.^[6]
• Ongoing surveillance: serial growth scans, fetal wellbeing assessment, iron optimisation, a valid group and screen maintained, and a documented plan for the place and timing of birth with a third-stage plan written in advance.^[1][8]
• Discharge criteria if she settles: no further bleeding, normal CTG, anti-D given, close to hospital with reliable transport and a companion, and explicit instructions to return immediately with any further loss.^[1]