Antepartum Hemorrhage Resuscitation
A 30-year-old woman at 33 weeks' gestation arrives in the emergency department with severe lower abdominal pain and vaginal bleeding that has soaked her clothing. Blood pressure is 92/58 mm Hg and pulse is 122 beats/min. The uterus is tense and tender. Fetal heart rate is 140 beats/min. Which of the following is the most appropriate immediate next step?
- A.Insert two large-bore intravenous cannulasCorrect
- B.Perform a digital vaginal examination
- C.Send her to radiology for ultrasound
- D.Proceed to emergency caesarean section
Explanation
Third-trimester bleeding with tachycardia and a falling blood pressure is an obstetric emergency, and the first action is maternal resuscitation. Two large-bore intravenous cannulas allow rapid crystalloid and blood transfusion, and blood is drawn at the same time for complete blood count, crossmatch, coagulation profile, and renal function. Maternal circulation is the fetus's only oxygen supply, so stabilizing the mother is also the best immediate fetal resuscitation. The tense, tender uterus with pain points to placental abruption, where revealed bleeding badly underestimates concealed retroplacental loss and disseminated intravascular coagulation can develop quickly. Digital vaginal examination is forbidden until placenta previa has been excluded, because it can provoke catastrophic hemorrhage. Transferring an unstable woman to the radiology department is unsafe; ultrasound is done at the bedside once resuscitation is under way, and a normal scan never excludes abruption, which remains a clinical diagnosis. Caesarean section is indeed likely to be needed, but it follows intravenous access, blood products, and continuous fetal monitoring rather than preceding them. Give corticosteroids if delivery can be safely delayed and anti-D immunoglobulin if she is RhD-negative.
Why each option
- A.
- Correct. Two large-bore cannulas with crossmatch and fluid resuscitation come first in any obstetric hemorrhage.
- B.
- Digital examination is contraindicated until placenta previa is excluded because it can provoke torrential bleeding.
- C.
- Moving an unstable bleeding woman to radiology is unsafe; bedside ultrasound follows resuscitation.
- D.
- Delivery is often required but must be preceded by intravenous access, blood availability, and monitoring.
Reference: RCOG Green-top Guideline No. 63: Antepartum Haemorrhage, 2011 (reaffirmed 2022)
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