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OG10.1-2,OG11.1 | Late Pregnancy Complications — Practice Quiz
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Antepartum haemorrhage (APH) is defined as bleeding from the genital tract after which gestational age (as per the most widely used Indian definition)?
Correct. APH is defined as bleeding from or into the genital tract after 20 weeks of gestation and before delivery of the fetus. (Some UK authorities use 24 weeks — the threshold of viability — but 20 weeks is the standard in Indian practice per DC Dutta.)
The gestational threshold for APH is 20 weeks in Indian obstetric practice; UK practice sometimes uses 24 weeks (threshold of viability). State the threshold when defining APH.
APH is bleeding after 20 weeks of gestation (the Indian/DC Dutta standard). 24 weeks is sometimes used in UK practice; 16 and 28 weeks are incorrect thresholds.
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A 30-year-old primigravida at 34 weeks presents with painless, bright-red vaginal bleeding. Her abdomen is soft, the uterus is non-tender, and the fetal head is high and not engaged. The most likely diagnosis is:
Correct. Placenta praevia classically presents with painless, bright-red vaginal bleeding; the uterus is soft and non-tender, and the presenting part is high (unengaged) because the low-lying placenta obstructs the pelvis.
Painless, bright-red bleeding + soft/non-tender uterus + high presenting part = placenta praevia until proven otherwise. Never do a digital vaginal exam until the placenta has been localised by USS.
Painless bleeding with a soft, non-tender uterus and an unengaged presenting part is the hallmark of placenta praevia. Abruption is typically painful with a tense, tender uterus. Vasa praevia causes fetal (not maternal) blood loss and is associated with rupture of membranes.
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In placental abruption, the finding most strongly associated with fetal death is:
Correct. Fetal mortality in abruption correlates with the area of placenta separated. Separation of more than one-third of the placental surface severely compromises uteroplacental perfusion and is strongly associated with fetal death (as per DC Dutta's grading criteria).
In placental abruption, fetal death correlates with area of separation (>1/3 of placental surface), not with visible external blood loss — concealed haemorrhage can be enormous while external bleeding is minimal.
The extent of placental separation — not the volume of external blood loss — determines fetal outcome, because concealed abruption can be massive with minimal external bleeding. Separation of >1/3 of the placental area is the threshold associated with fetal death.
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The single most important absolute contraindication before performing a digital vaginal examination in a patient presenting with APH is:
Correct. A digital vaginal examination must NEVER be performed in APH until the placenta has been localised by ultrasonography. If the placenta is praevia, a digital exam can precipitate torrential haemorrhage by disrupting the placental sinuses.
NEVER perform a digital vaginal examination in APH until USS has excluded placenta praevia. This is one of the most important safety rules in obstetrics.
The absolute rule in APH is: no digital vaginal examination until the placenta has been localised by USS. This is independent of haemoglobin, fetal heart rate, or gestational age.
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A 28-year-old woman with placenta praevia develops massive haemorrhage during caesarean section. Laboratory results: Hb 7 g/dL, platelets 45,000/µL, fibrinogen 0.8 g/L, PT and aPTT markedly prolonged. The blood product MOST appropriate to correct the fibrinogen deficit is:
Correct. Cryoprecipitate is the product of choice for fibrinogen replacement in obstetric DIC. Each unit raises fibrinogen by approximately 0.15–0.25 g/L. FFP contains fibrinogen but at too low a concentration to efficiently correct severe hypofibrinogenaemia; the volume required would cause fluid overload.
Cryoprecipitate — NOT FFP — is the product of choice for fibrinogen replacement in obstetric DIC. FFP cannot deliver enough fibrinogen without causing volume overload.
Cryoprecipitate is concentrated fibrinogen (plus factor VIII, vWF, and factor XIII) — it is the product of choice for fibrinogen deficit in obstetric DIC. FFP does contain fibrinogen but at too low a concentration to efficiently replete severe deficits without volume overload.
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Massive transfusion is defined as replacement of how many units of packed red blood cells within 24 hours?
Correct. Massive transfusion is defined as the replacement of 10 or more units of packed red blood cells (approximately one entire blood volume) within 24 hours. In obstetric practice, this most commonly occurs with placenta praevia/accreta or massive PPH.
Massive transfusion threshold: 10 units PRBCs/24 hours (or one whole blood volume/24 hours). Triggers MTP activation with damage-control haemostasis ratios (1:1:1 PRBCs:FFP:platelets).
Massive transfusion = replacement of 10 units of PRBCs within 24 hours (or replacement of the entire blood volume within 24 hours). 4-6 units is a significant transfusion but does not reach the threshold for a massive transfusion protocol.
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Which of the following transfusion reactions is characterised by fever, chills, and rigors occurring within the first 15 minutes of blood transfusion, WITHOUT evidence of haemolysis?
Correct. Febrile non-haemolytic transfusion reaction (FNHTR) is the most common transfusion reaction, caused by cytokines in stored blood or recipient antibodies against donor leukocytes. It presents with fever and rigors without haemolysis. Management: slow/stop transfusion, give paracetamol, verify no AHTR, resume cautiously.
FNHTR is the most common transfusion reaction. Distinguish it from AHTR (haemolysis) by absence of haemoglobinuria and normal direct Coombs test. Always stop and verify before restarting.
FNHTR = fever + chills with NO haemolysis — the most common transfusion reaction. AHTR involves haemolysis (haemoglobinuria, flank pain, renal failure). TRALI is pulmonary oedema within 6 hours. Anaphylaxis involves urticaria, bronchospasm, and cardiovascular collapse.
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A 26-year-old woman at 12 weeks gestation has an ultrasound showing twin pregnancy. The dividing membrane is seen originating at the placenta as a thick, triangular wedge of placental tissue (lambda/twin-peak sign). This finding confirms:
Correct. The lambda (twin-peak) sign — a triangular projection of placental tissue into the base of the inter-twin membrane — is the first-trimester ultrasonographic marker of dichorionic diamniotic (DCDA) placentation. Monochorionic twins show the T-sign (thin membrane meets the placenta at a right angle).
Lambda sign = dichorionic (DCDA). T-sign = monochorionic diamniotic (MCDA). First-trimester USS (11-14 weeks) is the most accurate time to determine chorionicity — it becomes progressively more difficult as pregnancy advances.
Lambda/twin-peak sign = DCDA (dichorionic diamniotic). T-sign (thin membrane meets placenta perpendicularly) = MCDA (monochorionic diamniotic). These signs are most reliably distinguished in the first trimester (11-14 weeks).
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Twin-to-twin transfusion syndrome (TTTS) is a complication unique to which type of twin pregnancy?
Correct. TTTS occurs exclusively in monochorionic (MC) twin pregnancies because it requires arterio-venous anastomoses within a shared placenta. MCDA twins are the most common MC type; MCMA twins are also at risk. Dichorionic twins (whether DZ or MZ) do not share placental circulation and cannot develop TTTS.
TTTS is exclusive to monochorionic twins (shared placenta with arterio-venous anastomoses). It does NOT occur in dichorionic twins regardless of zygosity. This is why chorionicity — not zygosity — determines risk.
TTTS requires intraplacental arterio-venous anastomoses, which only exist in monochorionic pregnancies (shared placenta). Dichorionic twins, even if monozygotic, have separate placentas and cannot develop TTTS.
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At 14 weeks of gestation, an ultrasound identifies triplets with a single placental mass and two dividing membranes. What is the most likely chorionicity/amnionicity classification?
Correct. Triplets with a single fused placental mass and two inter-twin membranes are most consistent with either dichorionic triamniotic (one pair of MCDA + one singleton with separate chorion — fused placenta) or monochorionic triamniotic. Definitive classification requires careful first-trimester assessment of membrane thickness and insertion signs. Trichorionic triamniotic would be expected to show three distinct placentas (though fusion is possible).
In higher-order multiple pregnancies, placentas may fuse and appear as a single mass; chorionicity is determined by membrane insertion signs (lambda vs T), membrane thickness, and sex discordance — ideally in the first trimester.
In triplet pregnancy, placental fusion is common and can mimic a single mass even with dichorionic or trichorionic placentas. Definitive chorionicity in triplets requires careful first-trimester USS including membrane insertion signs; a single fused mass alone does not confirm monochorionicity.
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