Anna's Vaginal Bleeding

By Samanta Zahir (Foundation Year 1 Doctor)

Name	Anna White
DOB	10/18/1991 (29 years)
Gestation	32+5 weeks
History	I noticed some blood passing from down below this morning, its not continuous but it has been 8 hours now. I'm quite worried about this bleeding. If asked: Fresh blood No clots No trigger Roughly 2 cups of blood Haven't felt the baby kick in the last couple of hours
Current Pregnancy History	All scans and tests Was told that my placenta was "low-lying" but they said it would move No other abnormalities found with tests/scans No hospital admissions
Previous Obstetric History	1 previous pregnancy: 5-year-old - Emergency c-section 2015 - foetal distress - No other complications before/after delivery No miscarriages/terminations
Past Medical History	-
Past Surgical History	C-section as above in 2015
Systems Review	-
Drug History	None No known allergies
Family History	Father had a heart attack earlier this year - aged 62
Social History (Occupation/ Smoking/ Alcohol/ Recreational drugs)	Smoking - Never smoked Alcohol - rare, not during pregnancy Recreational drugs - no Occupation - Accountant Living situation - House, with husband and 5-year-old child
Ideas, concerns, expectations	I really don't know, I'm very worried about my baby. Is my baby going to be okay?

0	1	2	Markscheme
			Introduces self, washes hands
			Confirms patient's name & date of birth, establishes gestation
			Gain's consent & builds rapport
			History of presenting complaint
			Onset, duration, progression
			Bleeding: amount, colour, clots
			Any other bleeding episodes
			Associated symptoms: abdominal pain, headache, discharge
			Fetal movements
			Current obstetric history
			Ultrasound scan – placental location
			Complications – previous bleeding, Hospital admissions, pre-eclampsia
			Rhesus status
			Past Obstetric History
			Previous deliveries – year, gestation, mode of delivery, birth weight, complications
			Previous pregnancy losses – miscarriage, termination
			Previous pregnancy histories: GDM, pre-eclampsia, APH
			Cervical smears - previous abnormal results when last smear was taken
			General Medical History
			Past medical history / Past Surgical History
			Drug history & allergies
			Family history – bleeding disorders, obstetric conditions e.g. GDM
			Social history: Smoking, Alcohol, Living situation/support
			Systems enquiry
			Ideas, concerns, and expectations
			Communication
			Summarises back to patient
			Avoids medical jargon
			Thank patient and close consultation
			Examiner Questions
			Gives reasonable differential diagnoses: Placenta praevia, Placental abruption, Bloody show, Ectropion, Vasa praevia
			Investigations & management plan
			Suggests appropriate investigations (Ultrasound, CTG, relevant blood tests [see below])
			Gives appropriate management plan (A-E assessment, senior review, anti-D, corticosteroids)

Q1. What are your differential diagnoses?

Q2. What is the difference between major and minor placenta praevia?

Major placenta praevia is when the placenta covers the internal cervical os
Minor placenta praevia is when the leading edge of the palcenta is in the lower segment but not covering the internal cervical os

Q3. How would you manage this patient?

Admit for observation and monitoring
ABCDE approach to resuscitaton, which may include the following if indicated:
- Two large bore cannulas
- Bloods to include FBC, clotting profile, group & save, Kleihauer test, U&E, Liver function tests
Obstetric Examination
Ultrasound abdomen
CTG
Anti-D given within 72 hours of onset of bleeding if Rh-ve
Antenatal corticosteroids if immediate delivery not indicated
Senior review - emergency/elective c-secton

OSCE Stations