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Suspected placental abruption with persistent fetal bradycardia — MRCEM SBA MCQ

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EasyObstetric and gynaecological emergenciesSuspected placental abruption with persistent fetal bradycardiaMRCEM SBA

A 31-year-old woman at 34+2 weeks’ gestation presents to an emergency department with an on-site consultant-led maternity unit. She has sudden, continuous abdominal pain and vaginal bleeding. Her pulse is 108/min and blood pressure is 112/70 mmHg. Her uterus is tense and tender between contractions. Ultrasonography shows a fundal placenta but no visible retroplacental haematoma. Fetal monitoring shows a heart rate of 85/min, persisting for 12 minutes. She is not in labour. Maternal assessment and resuscitation have begun, and the obstetric, anaesthetic and neonatal teams are present. What is the most appropriate birth plan?

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Correct answer: C — Arrange category 1 caesarean birth with concurrent maternal resuscitation.

The combination of antepartum bleeding, continuous pain and a tense, tender uterus strongly suggests placental abruption. A scan showing no retroplacental haematoma does not exclude it: abruption is a clinical diagnosis, and ultrasound has limited sensitivity for retroplacental bleeding. The sustained fetal bradycardia establishes an immediate fetal threat. Because she is not in labour, the birth plan is category 1 caesarean birth while maternal resuscitation continues. NICE identifies both major abruption and persistent fetal bradycardia as examples of category 1 urgency; RCOG recommends caesarean birth with concurrent maternal resuscitation when antepartum haemorrhage is accompanied by fetal compromise. ([nice.org.uk](https://www.nice.org.uk/guidance/ng192/chapter/recommendations)) A would delay birth for an investigation that cannot rule out abruption. B would also delay birth: induction is not a sufficiently rapid route for this fetus when labour has not begun. D may appear attractive because birth is preterm, but a course of corticosteroids must not delay delivery for immediate fetal compromise. E selects the appropriate mode of birth but the wrong urgency category: category 2 describes compromise that is not immediately life-threatening. ([nice.org.uk](https://www.nice.org.uk/guidance/ng192/chapter/recommendations))

Reference: NICE NG192: Caesarean birth — classification of urgency (10 June 2025) — https://www.nice.org.uk/guidance/ng192/chapter/recommendations RCOG Green-top Guideline No. 63: Antepartum Haemorrhage (2011) — https://www.rcog.org.uk/media/pwdi1tef/gtg_63.pdf