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Antepartum haemorrhage with possible placenta praevia — MRCEM SBA MCQ

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EasyObstetric and gynaecological emergenciesAntepartum haemorrhage with possible placenta praeviaMRCEM SBA

A woman at 30+5 weeks’ gestation attends the emergency department after an episode of painless, bright-red vaginal bleeding. Her 20-week scan showed a low-lying placenta, but its position has not been reassessed. The bleeding has slowed. Her pulse is 88/min, blood pressure 120/74 mmHg, abdomen is soft and non-tender, and cardiotocography is reassuring. An obstetric review has been requested. What is the most appropriate next assessment plan?

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Correct answer: D — Arrange ultrasound placental localisation and avoid digital examination.

This is antepartum haemorrhage with features that make placenta praevia possible: painless bleeding and a previously low-lying placenta whose current position is unknown. Maternal stability and a reassuring cardiotocograph do not establish where the placenta lies. Ultrasound placental localisation is therefore the appropriate next assessment, alongside obstetric review. Digital vaginal examination should be avoided until placenta praevia has been excluded by ultrasound. ([rcog.org.uk](https://www.rcog.org.uk/media/pwdi1tef/gtg_63.pdf)) A is inappropriate because digital examination may provoke haemorrhage when placenta praevia remains possible. B is a closer alternative: speculum examination can help identify a cervical source of bleeding, but it cannot replace placental localisation. C mistakes reassuring fetal monitoring for an adequate assessment of the bleeding; discharge is premature. E may become appropriate if observation is warranted after obstetric assessment, but observation alone leaves the key placental uncertainty unresolved. Ultrasound identifies placental position; it does not, by itself, exclude placental abruption, so ongoing clinical assessment remains necessary. ([rcog.org.uk](https://www.rcog.org.uk/media/pwdi1tef/gtg_63.pdf))

Reference: RCOG Green-top Guideline No. 63: Antepartum Haemorrhage, sections 7.3 and 8.1.2 (2011; current edition pending revision) — https://www.rcog.org.uk/media/pwdi1tef/gtg_63.pdf NICE NG201: Antenatal care, recommendations 1.4.17–1.4.19 (2021) — https://www.nice.org.uk/guidance/ng201/chapter/recommendations