QuestionSBA
QuestionChoice
Intravaginal metronidazole can be used to treat bacterial vaginosis (BV). There is no indication of BV here as the woman does not complain of any unusual vaginal discharge. BV seldom results in vaginal bleeding.
49961
e
Intravaginal metronidazole
QuestionChoice
Foetal fibronectin testing is used to detect foetal fibronectin in cervical secretions to rule out preterm labour. This woman has no signs of preterm labour. In addition, foetal fibronectin is usually only performed between weeks 22 and 35 weeks.
49960
d
Perform foetal fibronectin testing
QuestionChoice
Since this woman has had a recent normal ultrasound scan, and displays no features of infection, the light bleeding is likely to be as a result of her slight cervical ectropion. This is a normal finding and is not a cause for concern.
49957
a
Reassurance and to return if symptoms worsen
QuestionChoice
This woman would likely have had testing for chlamydia and gonorrhoea at her booking appointment. She has no other symptoms of infection and states she has a regular partner, so sexually transmitted infection is unlikely.
49959
c
Obtain an endocervical swab for chlamydia testing
QuestionChoice
Whilst this woman is overdue for her first cervical smear test, smear tests are generally not performed in pregnancy.
49958
b
Perform a cervical smear test
Concept
Chapter
# Summary


Antepartum haemorrhage refers to vaginal bleeding occurring between the 24th week of pregnancy and birth. Key signs and symptoms may vary depending on the underlying cause but generally include vaginal bleeding, abdominal pain, and, in severe cases, signs of shock. Key investigations include taking a thorough clinical history, abdominal and speculum examination, blood tests, and ultrasound. Management involves assessing the patient's haemodynamic status, resuscitation if necessary, hospital admission for observation, and administration of antenatal corticosteroids if there's a risk of preterm birth.


# Definition



Antepartum haemorrhage is a clinical condition characterised by vaginal bleeding that occurs between the 24th week of pregnancy and birth.


# Differential Diagnosis



The differential diagnosis for Antepartum haemorrhage includes:

- Placental abruption: Symptoms may include vaginal bleeding, abdominal pain, and uterine tenderness or rigidity.
- Placenta praevia: This condition may present with painless, bright red vaginal bleeding.
- Vasa praevia: Signs may include vaginal bleeding and abnormal foetal heart rate patterns.
- Genital tract malignancy or trauma: Symptoms may include vaginal bleeding, pelvic pain, and in cases of trauma, a history of injury.
- Genital tract infection: Symptoms can include vaginal bleeding accompanied by fever, pelvic pain, and abnormal vaginal discharge.
- Uterine rupture: This may present with sudden severe abdominal pain, vaginal bleeding, and signs of shock.
- Inherited bleeding disorder: This condition can present with vaginal bleeding and a personal or family history of bleeding disorders.
- Gestational trophoblastic disease: Symptoms may include vaginal bleeding, elevated hCG levels, and larger than expected uterine size.
- Cervical ectropion: This condition may present with vaginal bleeding, especially post-coital.

# Investigations


In the case of suspected antepartum haemorrhage, investigations should include:

- Thorough clinical history
- Abdominal examination
- Speculum examination
- Blood tests including group and save, crossmatch, full blood count, coagulation screen, urea and electrolytes, LFTs, and Kleihauer test in rhesus negative women.
- Ultrasound to exclude placenta praevia 
- Cardiotocography to assess and monitor the foetus

# Management


Management of antepartum haemorrhage involves:

- Assessing haemodynamic status and initiating resuscitation if necessary
- Admitting the patient to the hospital for observation
- Obtaining intravenous access
- Monitoring for concealed haemorrhage
- Administering antenatal corticosteroids between 24 and 34 weeks of gestation if there is a risk of preterm birth.
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Obstetrics
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Placenta praevia
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Quesmed Tutorial: Obstetric Emergencies
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A 26-year-old primiparous woman attends the maternity triage department with four episodes of vaginal bleeding. She is 21+5 weeks pregnant. She describes the bleeding as bright red and painless. Two episodes occurred immediately after intercourse with her regular partner, and two episodes have occurred unprovoked and have been noticed on wiping after using the toilet.

She has no vaginal discharge or other symptoms. She has no past medical history. She has never had a cervical smear test. She has attended both her booking appointment and her 20-week scan, and the pregnancy has been uncomplicated so far.

On examination, her observations are normal. A speculum examination reveals a normal cervix with a slight ectropion and no evidence of unusual vaginal discharge.

What is the most appropriate next step?
a