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A 33-year-old woman at 37 weeks gestation with known pre-eclampsia presents with sudden onset severe constant abdominal pain and dark vaginal bleeding. On examination: BP 155/100, pulse 120, uterus is hard, woody, and exquisitely tender. Fetal heart rate is 80 bpm (bradycardia). Blood tests: fibrinogen 1.8 g/L, platelets 48 x10 to the 9 per litre.
Questions
a) What is the diagnosis? (1 mark)
Severe placental abruption with DIC: painful bleeding + hard/woody/tender uterus + fetal bradycardia (distress) + pre-eclampsia (risk factor) + low fibrinogen and platelets (DIC).
b) What distinguishes this from placenta praevia? (2 marks)
Abruption is PAINFUL with a HARD/WOODY/TENDER uterus, dark blood, and fetal distress. Praevia is PAINLESS with a SOFT/NON-TENDER uterus, bright red blood, and normal fetal heart. Abruption is associated with pre-eclampsia; praevia with previous C-section.
c) Outline your immediate management. (4 marks)
- ABC: oxygen, 2 large-bore IV cannulae, crystalloid resuscitation.
- Crossmatch 4 to 6 units. Correct DIC: cryoprecipitate (raise fibrinogen over 2 g/L), platelets, FFP.
- EMERGENCY C-SECTION (fetus alive with distress) after coagulopathy correction.
- Anti-D if Rh negative.
- Postpartum: watch for PPH (Couvelaire uterus → atonic).
d) What is Couvelaire uterus and what complication does it cause? (2 marks)
Couvelaire uterus = blood infiltrating the myometrium to the serosa (uterus appears purple/blue). The muscle damage prevents effective contraction → REFRACTORY ATONIC PPH that may not respond to uterotonics. May require Bakri balloon, B-Lynch suture, or hysterectomy (last resort).
e) How would management differ if the fetus was dead? (1 mark)
VAGINAL DELIVERY would be preferred (avoid C-section in a coagulopathic patient). Induce/augment labour with oxytocin. C-section only for maternal indications (uncontrolled haemorrhage).