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You are an F1 doctor working in Maternity Assessment Unit. A 38-year-old lady, Tia Tropium, who is 23 weeks pregnant has come in with vaginal bleeding.

Please take a thorough obstetric history and undertake the appropriate examination. You will then be asked to discuss the case with the examiner.

You are Tia Tropium, a 38-year-old business executive.

HPC: You’ve experienced some vaginal bleeding for the past 4 hours. You didn’t take notice of it initially as you thought it was going subside but it has now continued for a few hours now. You’ve changed two sets of clothes since the bleeding started and you think you have probably lost around 200ml of bright red blood. There is no associated tummy pain/tenderness and your abdomen doesn’t feel hard or bloated. You can also still feel your baby kicking, which you presume is reassuring. This has never happened previously. You were having sex with your husband half an hour before you noticed the bleeding.

Antenatal care: Your care is being delivered by the midwife. You have attended all your appointments until the 16th week and your 12-week scan and other screening tests were normal. However, you’ve had a busy few weeks at work and so have not attended your 20-week anomaly scan. You are due to have the scan in a couple of days. You had no other difficulties in this pregnancy and your blood pressure and blood sugar have been in the normal range in this pregnancy. You planned this pregnancy and have been taking folic acid 4 months before you found out you were pregnant.

Previous pregnancies: You’ve been pregnant before 3 years ago, and had a daughter, Elisa. The pregnancy was uneventful and you had an elective caesarean section at 38 weeks as you couldn’t cope with the idea of going through labour. You are hoping for a caesarean section this time as well. Elisa was a healthy weight (you can’t remember the weight now) and is developing normally.

Past Gynae history: You’ve had no previous problems with your periods. Your smears are up to date and you have never had an abnormal smear.

PMH: You had chlamydia when you were 18 which was treated, and a broken elbow when you were 22.

DH: Pregnacare. You have no known drug allergies.

FH: Your mum had type 2 diabetes from the age of 56. You wondered whether you would get diabetes in your pregnancy as a result of this, but you reckon the coast is clear on that.

SH: You currently live with your husband who is also a business executive. You do not smoke or drink now. You used to smoke 30 a day from the age of 18 to 34 and stopped when trying for your first baby. You’ve planned to go on maternity leave from 39 weeks because you need to “sort everything out at work” before you can concentrate on the baby.

ICE: Your friend had a miscarriage in her 20th week and you’re worried that this might be what’s happening. You were hoping for an ultrasound to make sure that the baby is ok.

A thorough history should be taken about the bleeding and associated symptoms. Differential diagnosis should include placenta praevia, vaginal trauma and cervical polyps.

Discussion points • What is placenta praevia? • What are the factors that predisposes you to placenta praevia? • How would you examine a patient with placenta praevia? • What would be the precautions taken during delivery in a patient with placenta praevia?