{"id":37090,"date":"2026-06-25T13:05:46","date_gmt":"2026-06-25T07:35:46","guid":{"rendered":"https:\/\/atsixty.com\/?p=37090"},"modified":"2026-06-25T13:06:58","modified_gmt":"2026-06-25T07:36:58","slug":"obs-antepartum-hemorrhage-emergency-consent","status":"publish","type":"post","link":"https:\/\/atsixty.com\/index.php\/obg\/obs-antepartum-hemorrhage-emergency-consent\/","title":{"rendered":"Obs: Antepartum Hemorrhage &amp; Emergency Consent"},"content":{"rendered":"\n\n\n<meta charset=\"UTF-8\">\n<meta name=\"viewport\" content=\"width=device-width, initial-scale=1.0\">\n<title>Morning Rounds \u00b7 Antepartum Hemorrhage &amp; Emergency Consent<\/title>\n<link href=\"https:\/\/fonts.googleapis.com\/css2?family=Playfair+Display:ital,wght@0,400;0,600;0,700;1,400;1,600&#038;family=Source+Serif+4:ital,wght@0,300;0,400;0,600;1,400&#038;display=swap\" rel=\"stylesheet\">\n<style>\n#obs03 *,#obs03 *::before,#obs03 *::after{box-sizing:border-box;margin:0;padding:0}\n#obs03{\n  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.mr-band-s{background:var(--ob-pale);color:var(--ob)}\n#obs03 .mr-retry{display:block;margin:18px auto 4px;background:transparent;border:2px solid var(--ob);color:var(--ob);border-radius:8px;padding:9px 28px;font-family:'Playfair Display',serif;font-size:0.92rem;font-weight:700;cursor:pointer}\n#obs03 .mr-retry:hover{background:var(--ob);color:#F3EFFA}\n@media(max-width:480px){#obs03 .mr-title{font-size:1.4rem}#obs03 .mr-num{font-size:1.7rem}#obs03 .mr-stem{font-size:0.9rem}#obs03 .mr-opt-text{font-size:0.86rem}}\n<\/style>\n\n<!-- SVG Q2: Previa vs Abruption differentiation -->\n<div id=\"obs03-img1\" style=\"display:none\">\n  <figure class=\"mr-img-wrap\">\n    <svg viewBox=\"0 0 560 195\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" style=\"width:100%;max-width:560px;display:block;margin:0 auto\">\n      <rect x=\"0\" y=\"0\" width=\"560\" height=\"195\" rx=\"8\" fill=\"#f2eef8\"\/>\n      <text x=\"14\" y=\"18\" fill=\"#241B36\" font-size=\"9.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Antepartum Hemorrhage \u2014 Quick Differentiation<\/text>\n      <rect x=\"10\" y=\"26\" width=\"130\" height=\"22\" rx=\"3\" fill=\"#4B3A6E\"\/>\n      <text x=\"75\" y=\"41\" text-anchor=\"middle\" fill=\"#F3EFFA\" font-size=\"7.6\" font-family=\"Georgia,serif\" font-weight=\"bold\">Feature<\/text>\n      <rect x=\"144\" y=\"26\" width=\"200\" height=\"22\" rx=\"3\" fill=\"#4B3A6E\"\/>\n      <text x=\"244\" y=\"41\" text-anchor=\"middle\" fill=\"#F3EFFA\" font-size=\"7.6\" font-family=\"Georgia,serif\" font-weight=\"bold\">Placenta Previa<\/text>\n      <rect x=\"348\" y=\"26\" width=\"202\" height=\"22\" rx=\"3\" fill=\"#4B3A6E\"\/>\n      <text x=\"449\" y=\"41\" text-anchor=\"middle\" fill=\"#F3EFFA\" font-size=\"7.6\" font-family=\"Georgia,serif\" font-weight=\"bold\">Abruptio Placentae<\/text>\n      <rect x=\"10\" y=\"50\" width=\"130\" height=\"24\" rx=\"2\" fill=\"#eaf4f0\"\/>\n      <text x=\"75\" y=\"66\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.3\" font-family=\"Georgia,serif\" font-weight=\"bold\">Pain<\/text>\n      <rect x=\"144\" y=\"50\" width=\"200\" height=\"24\" rx=\"2\" fill=\"#eaf4f0\"\/>\n      <text x=\"244\" y=\"66\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.3\" font-family=\"Georgia,serif\">Painless<\/text>\n      <rect x=\"348\" y=\"50\" width=\"202\" height=\"24\" rx=\"2\" fill=\"#fdf0f0\"\/>\n      <text x=\"449\" y=\"66\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7.3\" font-family=\"Georgia,serif\">Severe, tense\/tender uterus<\/text>\n      <rect x=\"10\" y=\"78\" width=\"130\" height=\"24\" rx=\"2\" fill=\"#eaf4f0\"\/>\n      <text x=\"75\" y=\"94\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.3\" font-family=\"Georgia,serif\" font-weight=\"bold\">Bleeding<\/text>\n      <rect x=\"144\" y=\"78\" width=\"200\" height=\"24\" rx=\"2\" fill=\"#eaf4f0\"\/>\n      <text x=\"244\" y=\"94\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.3\" font-family=\"Georgia,serif\">Visible loss &asymp; true loss<\/text>\n      <rect x=\"348\" y=\"78\" width=\"202\" height=\"24\" rx=\"2\" fill=\"#fdf0f0\"\/>\n      <text x=\"449\" y=\"94\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7.3\" font-family=\"Georgia,serif\">May be concealed &mdash; underestimated<\/text>\n      <rect x=\"10\" y=\"106\" width=\"130\" height=\"24\" rx=\"2\" fill=\"#eaf4f0\"\/>\n      <text x=\"75\" y=\"122\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.3\" font-family=\"Georgia,serif\" font-weight=\"bold\">Uterus<\/text>\n      <rect x=\"144\" y=\"106\" width=\"200\" height=\"24\" rx=\"2\" fill=\"#eaf4f0\"\/>\n      <text x=\"244\" y=\"122\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.3\" font-family=\"Georgia,serif\">Soft, non-tender<\/text>\n      <rect x=\"348\" y=\"106\" width=\"202\" height=\"24\" rx=\"2\" fill=\"#fdf0f0\"\/>\n      <text x=\"449\" y=\"122\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7.3\" font-family=\"Georgia,serif\">Tense, tender, &plusmn; woody-hard<\/text>\n      <rect x=\"10\" y=\"134\" width=\"130\" height=\"24\" rx=\"2\" fill=\"#eaf4f0\"\/>\n      <text x=\"75\" y=\"150\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.3\" font-family=\"Georgia,serif\" font-weight=\"bold\">Key risk<\/text>\n      <rect x=\"144\" y=\"134\" width=\"200\" height=\"24\" rx=\"2\" fill=\"#eaf4f0\"\/>\n      <text x=\"244\" y=\"150\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.3\" font-family=\"Georgia,serif\">Recurrent\/massive hemorrhage<\/text>\n      <rect x=\"348\" y=\"134\" width=\"202\" height=\"24\" rx=\"2\" fill=\"#fdf0f0\"\/>\n      <text x=\"449\" y=\"150\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7.3\" font-family=\"Georgia,serif\">DIC, fetal hypoxia, hidden loss<\/text>\n      <text x=\"14\" y=\"174\" fill=\"#4A3D63\" font-size=\"7.3\" font-family=\"Georgia,serif\" font-style=\"italic\">Vaginal examination is avoided in suspected previa until placental location is confirmed sonographically.<\/text>\n    <\/svg>\n  <\/figure>\n<\/div>\n\n<div id=\"obs03\">\n\n  <div class=\"mr-header\">\n    <div class=\"mr-eyebrow\">Morning Rounds &middot; Obstetrics Series &middot; Round 03<\/div>\n    <div class=\"mr-title\">\n      Antepartum Hemorrhage &amp;<br><em>Emergency Consent<\/em>\n    <\/div>\n    <div class=\"mr-subtitle\">Five cases &middot; Previa, abruption, vasa previa &amp; the limits of consent &middot; Trust your instinct<\/div>\n    <div class=\"mr-chips\">\n      <span class=\"mr-chip\">5 Cases<\/span>\n      <span class=\"mr-chip\">+4 \/ &minus;1 scoring<\/span>\n      <span class=\"mr-chip\">Options reshuffled<\/span>\n    <\/div>\n  <\/div>\n\n  <div class=\"mr-sentinel\" id=\"obs03-sentinel\"><\/div>\n\n  <div class=\"mr-progress\" id=\"obs03-progress\">\n    <div class=\"mr-prog-inner\">\n      <div class=\"mr-pips\" id=\"obs03-pips\"><\/div>\n    <\/div>\n  <\/div>\n\n  <div class=\"mr-body\">\n    <div id=\"obs03-cases\"><\/div>\n    <div class=\"mr-submit-wrap\">\n      <button class=\"mr-btn\" id=\"obs03-submit\">Submit for Debrief<\/button>\n    <\/div>\n    <div class=\"mr-score\" id=\"obs03-score\">\n      <div class=\"mr-score-in\">\n        <div class=\"mr-score-ey\">Round Complete<\/div>\n        <div class=\"mr-ring\" id=\"obs03-ring\">\n          <div class=\"mr-ring-in\">\n            <span class=\"mr-ring-pct\" id=\"obs03-pct\">0%<\/span>\n            <span class=\"mr-ring-sub\">net<\/span>\n          <\/div>\n        <\/div>\n        <div class=\"mr-score-title\">Your Debrief<\/div>\n        <div class=\"mr-score-net\" id=\"obs03-net\"><\/div>\n        <div class=\"mr-verdict\" id=\"obs03-verdict\"><\/div>\n        <div class=\"mr-bands\">\n          <span class=\"mr-band mr-band-c\" id=\"obs03-ct-c\"><\/span>\n          <span class=\"mr-band mr-band-w\" id=\"obs03-ct-w\"><\/span>\n          <span class=\"mr-band mr-band-s\" id=\"obs03-ct-s\"><\/span>\n        <\/div>\n        <button class=\"mr-retry\" id=\"obs03-retry\">&#8635; New Round<\/button>\n      <\/div>\n    <\/div>\n  <\/div>\n\n<\/div><!-- end #obs03 -->\n\n<script>\n(function () {\n  'use strict';\n\n  var NS    = 'obs03';\n  var TOTAL = 5;\n  var MAX   = 20;\n  var LTRS  = ['A','B','C','D'];\n\n  var QS = [\n\n    {\n      id:      1,\n      tag:     'Antepartum Hemorrhage &mdash; Placenta Previa',\n      stem:    'A woman at <strong>34 weeks<\/strong> with known <strong>complete (type IV) placenta previa<\/strong> on previous ultrasound presents with painless vaginal bleeding of approximately <strong>150 mL<\/strong>. There are no contractions, the fetal heart rate is normal, and the bleeding has settled with the mother haemodynamically stable. What is the correct management?',\n      correct: 'Admit for inpatient observation, give corticosteroids for fetal lung maturity given the preterm gestation, cross-match blood, and plan expectant management with elective cesarean around 36&ndash;37 weeks (earlier if bleeding recurs or another indication arises)',\n      opts: [\n        'Discharge home with bed rest advice and outpatient follow-up, since the bleeding has stopped, the fetal heart rate is normal, and the mother is haemodynamically stable, so hospital admission is not required',\n        'Admit for inpatient observation, give corticosteroids for fetal lung maturity given the preterm gestation, cross-match blood, and plan expectant management with elective cesarean around 36&ndash;37 weeks (earlier if bleeding recurs or another indication arises)',\n        'Proceed with emergency cesarean section immediately regardless of current stability, since any episode of bleeding in a woman with known complete placenta previa is an absolute indication for delivery at the time it occurs',\n        'Plan for a trial of vaginal delivery once the current bleeding episode resolves, since complete placenta previa managed expectantly until bleeding settles can subsequently be allowed to labor provided fetal heart rate monitoring remains reassuring'\n      ],\n      exp:     'A settled bleed in <strong>complete placenta previa<\/strong> still warrants <strong>inpatient admission<\/strong> &mdash; the risk is recurrent, potentially much larger haemorrhage, not just the episode already seen. With a preterm, stable mother and reassuring fetal heart rate, the priority is <strong>expectant management to gain gestational age<\/strong>: corticosteroids, cross-matched blood on standby, and a planned cesarean around 36&ndash;37 weeks (or earlier if bleeding recurs or other indications arise) &mdash; not immediate delivery on the strength of a single resolved episode. <br><br><strong>Discharging home<\/strong> after a bleeding episode in complete previa under-estimates the risk of a sudden, large recurrent bleed without warning; this is precisely the population kept in hospital once symptomatic, even if the current episode has settled. <br><br><strong>Vaginal delivery is an absolute contraindication<\/strong> in complete (type IV) previa regardless of whether bleeding has stopped &mdash; the placenta itself physically occludes the os, so \"bleeding has resolved\" never converts this into a vaginal-delivery candidate.',\n      imgId:   null\n    },\n\n    {\n      id:      2,\n      tag:     'Antepartum Hemorrhage &mdash; Abruptio Placentae',\n      stem:    'A woman at <strong>32 weeks<\/strong> develops sudden severe abdominal pain with dark vaginal bleeding of approximately <strong>300 mL<\/strong>. The uterus is tense and tender on examination, and the fetal heart rate shows <strong>bradycardia<\/strong>. What is the correct immediate management priority?',\n      correct: 'This is placental abruption with fetal compromise; immediate resuscitation (IV access, cross-match, blood products), continuous monitoring, and expedited delivery (often emergency cesarean) are indicated, with vigilance for DIC, since visible bleeding may significantly underestimate true blood loss when a component is concealed',\n      opts: [\n        'Manage expectantly with bed rest and tocolysis to delay delivery and prolong gestation, since the reported bleeding volume of 300 mL is not large enough to mandate immediate delivery, and tocolysis would help reduce uterine irritability',\n        'This is placental abruption with fetal compromise; immediate resuscitation (IV access, cross-match, blood products), continuous monitoring, and expedited delivery (often emergency cesarean) are indicated, with vigilance for DIC, since visible bleeding may significantly underestimate true blood loss when a component is concealed',\n        'Reassure that the visible blood loss of 300 mL accurately reflects total maternal blood loss in this presentation, and base the resuscitation volume strictly on this visible measurement going forward',\n        'Await spontaneous improvement in the fetal heart rate over the next hour before deciding on mode of delivery, since fetal bradycardia in the setting of abruption commonly resolves once the acute pain and uterine tension settle'\n      ],\n      exp:     'A <strong>tense, tender uterus with dark bleeding and fetal bradycardia<\/strong> is the classic presentation of placental abruption with fetal compromise &mdash; this calls for <strong>immediate resuscitation and expedited delivery<\/strong>, not watchful waiting. <strong>Tocolysis is contraindicated<\/strong> in abruption: attempting to suppress uterine activity in a setting that often requires urgent delivery, and where uterine irritability is part of the pathology itself, risks worsening the clinical picture rather than helping it. <br><br>The critical safety point here is that abruption can be <strong>concealed<\/strong> &mdash; blood may collect retroplacentally rather than escape vaginally, so the visible 300 mL can substantially <strong>underestimate<\/strong> true maternal blood loss. Resuscitating strictly to the visible volume risks under-resuscitating a patient who is losing far more blood than what is seen, and is a recurring, dangerous misjudgement in abruption cases. <br><br><strong>Fetal bradycardia in this setting is not something to wait out<\/strong> &mdash; it signals ongoing compromise that needs urgent action, not an hour\\'s observation on the assumption that it will self-resolve as pain settles.',\n      imgId:   'obs03-img1'\n    },\n\n    {\n      id:      3,\n      tag:     'Antepartum Hemorrhage &mdash; Vasa Previa',\n      stem:    'A routine 20-week anomaly scan with colour Doppler identifies fetal vessels coursing through the membranes near the internal cervical os, unsupported by placental tissue or the umbilical cord &mdash; consistent with vasa previa. There is no bleeding currently. What is the correct management plan?',\n      correct: 'Confirm the diagnosis on follow-up scans, plan third-trimester hospitalisation (around 30&ndash;32 weeks) for closer monitoring, and schedule elective cesarean before the onset of labor or membrane rupture (typically around 34&ndash;36 weeks), since rupture of membranes in vasa previa risks fetal exsanguination from torn fetal vessels',\n      opts: [\n        'Manage as a routine low-risk pregnancy with no specific change to antenatal care, since an asymptomatic finding of vessels near the os without current bleeding does not require any alteration to standard delivery planning',\n        'Confirm the diagnosis on follow-up scans, plan third-trimester hospitalisation (around 30&ndash;32 weeks) for closer monitoring, and schedule elective cesarean before the onset of labor or membrane rupture (typically around 34&ndash;36 weeks), since rupture of membranes in vasa previa risks fetal exsanguination from torn fetal vessels',\n        'Plan for vaginal delivery at term as usual, since vasa previa diagnosed antenatally without bleeding poses minimal additional risk once the fetus reaches term and labor can be allowed to proceed under close fetal heart rate monitoring',\n        'Schedule amniotomy at the onset of labor specifically to assess for vessel rupture directly, since early artificial rupture of membranes allows prompt identification of bleeding and timely intervention if the fetal vessels are damaged'\n      ],\n      exp:     'The entire value of <strong>antenatal diagnosis<\/strong> of vasa previa is that it changes management even when the patient is currently asymptomatic &mdash; treating an asymptomatic finding as requiring no change defeats the purpose of having found it on the anomaly scan. The standard approach is heightened surveillance, often inpatient observation in the <strong>third trimester<\/strong>, and a <strong>planned elective cesarean before labor or membrane rupture<\/strong>, because either event can tear the unsupported fetal vessels and cause rapid fetal exsanguination. <br><br><strong>Vaginal delivery is not an acceptable plan<\/strong> here regardless of reassuring fetal heart rate monitoring at term &mdash; the risk is a sudden vessel rupture with labor or membrane rupture, against which FHR monitoring offers no real protection once it happens, since exsanguination can be catastrophic within minutes. <br><br><strong>Amniotomy is specifically contraindicated<\/strong> in vasa previa &mdash; artificially rupturing membranes is itself the dangerous act that can directly lacerate the vessel, which is the exact harm the whole management plan is designed to prevent, not a way of detecting it safely.',\n      imgId:   null\n    },\n\n    {\n      id:      4,\n      tag:     'Emergency Consent Doctrine',\n      stem:    'A woman arrives in <strong>hemorrhagic shock<\/strong> from suspected abruption, unconscious, with no immediately available next-of-kin and no advance directive. The on-call team needs to proceed urgently with cesarean delivery and blood transfusion to save her life. What is the correct legal basis for proceeding?',\n      correct: 'Under the doctrine of necessity (the emergency-treatment exception), care can proceed without explicit consent when the patient is incapacitated, the intervention is necessary to preserve life or prevent serious harm, and there is no time to obtain consent from the patient or a substitute decision-maker; the reasoning for proceeding should still be documented carefully',\n      opts: [\n        'Treatment must be delayed until a next-of-kin or legal guardian can be located and gives consent, since no medical intervention can lawfully proceed on an incapacitated adult patient without some form of substituted consent obtained first, regardless of the urgency involved',\n        'Under the doctrine of necessity (the emergency-treatment exception), care can proceed without explicit consent when the patient is incapacitated, the intervention is necessary to preserve life or prevent serious harm, and there is no time to obtain consent from the patient or a substitute decision-maker; the reasoning for proceeding should still be documented carefully',\n        'Formal authorisation from a hospital ethics committee must be obtained before life-saving treatment can be administered to an unconscious patient without consent, since individual clinicians lack independent legal authority to proceed in such circumstances',\n        'Since the patient cannot consent, the team should proceed only with the minimum intervention necessary to stabilise her temporarily, deferring more extensive but clearly necessary procedures such as cesarean delivery until consent can eventually be obtained, even if delay carries clinical risk'\n      ],\n      exp:     'The <strong>doctrine of necessity<\/strong> (sometimes called the emergency-treatment exception) exists precisely for this scenario: an incapacitated patient, a genuinely necessary intervention to preserve life or prevent serious harm, and no realistic time to obtain consent from the patient or any substitute decision-maker. It permits clinicians to proceed with the <strong>full treatment that is actually necessary<\/strong>, not a minimal holding measure, and good practice is to document the clinical reasoning and the absence of available consent pathways clearly afterward. <br><br><strong>Waiting to locate a next-of-kin<\/strong> before acting defeats the purpose of the doctrine &mdash; if the situation is genuinely time-critical, the law does not require this delay, since the harm of waiting (death or serious injury) is exactly what the exception is designed to prevent. <br><br>An <strong>ethics committee review<\/strong> is not a precondition for emergency treatment &mdash; that kind of process-bound delay is incompatible with situations where minutes matter, and treating clinicians already hold the authority to act under the necessity doctrine without needing prior committee sign-off. <br><br>Limiting care to <strong>\"minimum stabilisation only\"<\/strong> while deferring the actually necessary procedure (cesarean delivery, in this case) misapplies the doctrine &mdash; it covers the necessary treatment itself, not a watered-down placeholder version of it.',\n      imgId:   null\n    },\n\n    {\n      id:      5,\n      tag:     'Competent Refusal of Blood Transfusion',\n      stem:    'A <strong>conscious, competent adult<\/strong> woman with postpartum hemorrhage explicitly refuses blood transfusion on religious grounds, having been clearly informed of the risk of death without it. She remains alert and oriented throughout the discussion. What is the correct legal and ethical approach?',\n      correct: 'Her informed refusal must be respected even though it may result in her death, since a competent adult has the right to refuse treatment including life-saving blood transfusion; the team should pursue all available non-blood alternatives and document the refusal and discussion thoroughly, while continuing to offer all other appropriate care',\n      opts: [\n        'Blood transfusion should be administered regardless of her refusal once her life is at clear risk, since the duty to preserve life overrides a patient\\'s stated wishes whenever death is the likely alternative to a clearly available and effective treatment',\n        'Her informed refusal must be respected even though it may result in her death, since a competent adult has the right to refuse treatment including life-saving blood transfusion; the team should pursue all available non-blood alternatives and document the refusal and discussion thoroughly, while continuing to offer all other appropriate care',\n        'Her refusal should be treated as presumptively invalid in this acute setting, since the pain and distress of postpartum hemorrhage are assumed to impair decision-making capacity enough that a refusal of life-saving treatment cannot be considered truly informed or competent',\n        'Family members\\' consent for transfusion can override the patient\\'s own explicit refusal in this situation, since decisions of this magnitude during active hemorrhage should default to the next-of-kin\\'s judgement rather than solely to the patient\\'s stated wishes'\n      ],\n      exp:     'A <strong>competent adult\\'s informed refusal<\/strong> of treatment, including a life-saving blood transfusion, must be respected &mdash; the right to refuse treatment does not disappear simply because the consequence of refusal is severe or fatal. The correct response is to pursue every reasonable <strong>non-blood alternative<\/strong> (volume expanders, cell salvage where available, surgical haemostasis, iron\/erythropoietin as appropriate) and to <strong>document<\/strong> the refusal, the information given, and the discussion thoroughly, while continuing all other care she will accept. <br><br><strong>Overriding her refusal<\/strong> because death is the likely alternative directly violates patient autonomy &mdash; \"the treatment would clearly save her life\" is not, on its own, a legal basis to act against a competent, informed refusal. <br><br><strong>Presuming incapacity from the pain or stress of hemorrhage<\/strong>, without an actual capacity assessment supporting that conclusion, is also incorrect &mdash; she is specifically documented as alert and oriented; distress alone is not evidence of impaired decision-making capacity. <br><br><strong>Family override<\/strong> of a competent patient\\'s own explicit, informed refusal has no legal basis here &mdash; her own stated wishes, while she retains capacity, take precedence over what next-of-kin might prefer.',\n      imgId:   null\n    }\n\n  ];\n\n  var answers  = {};\n  var answered = 0;\n  var shuffled = {};\n  var done     = false;\n\n  function byId(id) { return document.getElementById(id); }\n  function gid(suffix) { return byId(NS + '-' + suffix); }\n\n  function shuffleArr(arr) {\n    var a = arr.slice(), i, j, tmp;\n    for (i = a.length - 1; i > 0; i--) {\n      j = Math.floor(Math.random() * (i + 1));\n      tmp = a[i]; a[i] = a[j]; a[j] = tmp;\n    }\n    return a;\n  }\n\n  function countVal(val) {\n    var k, n = 0;\n    for (k in answers) {\n      if (answers.hasOwnProperty(k) && answers[k] === val) n++;\n    }\n    return n;\n  }\n\n  function buildPips() {\n    var cont = gid('pips'), i, q, wLine, wPip, line, pip;\n    cont.innerHTML = '';\n    for (i = 0; i < QS.length; i++) {\n      q = QS[i];\n      if (i > 0) {\n        wLine = document.createElement('div');\n        wLine.className = 'mr-pip-wrap';\n        line = document.createElement('div');\n        line.className = 'mr-pip-line';\n        line.id = NS + '-pl' + q.id;\n        wLine.appendChild(line);\n        cont.appendChild(wLine);\n      }\n      wPip = document.createElement('div');\n      wPip.className = 'mr-pip-wrap';\n      pip = document.createElement('div');\n      pip.className = 'mr-pip';\n      pip.id = NS + '-pip' + q.id;\n      pip.textContent = String(q.id);\n      wPip.appendChild(pip);\n      cont.appendChild(wPip);\n    }\n  }\n\n  function build() {\n    var cont, i, q, opts, card, top, numDiv, meta, tag, stem,\n        rule, optsDiv, expDiv, lbl, txt, imgDiv, imgSrc, j,\n        optEl, ltrSpan, txtSpan;\n\n    cont = gid('cases');\n    cont.innerHTML = '';\n    answers = {}; answered = 0; shuffled = {}; done = false;\n    gid('score').style.display = 'none';\n    buildPips();\n\n    for (i = 0; i < QS.length; i++) {\n      q = QS[i];\n      opts = shuffleArr(q.opts);\n      shuffled[q.id] = opts;\n\n      card = document.createElement('div');\n      card.className = 'mr-case';\n\n      top = document.createElement('div');\n      top.className = 'mr-case-top';\n\n      numDiv = document.createElement('div');\n      numDiv.className = 'mr-num';\n      numDiv.textContent = q.id < 10 ? 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Both the ward and the courtroom would clear you.'],\n      [4, 'Strong round \\u2014 one threshold or doctrine to revisit.'],\n      [3, 'Solid base \\u2014 the debrief will sharpen the distinctions.'],\n      [2, 'Halfway there \\u2014 review the missed cases carefully.'],\n      [0, 'Antepartum hemorrhage and consent law both reward close re-reading \\u2014 the stakes in both are high.']\n    ];\n    gid('verdict').textContent = verdicts[4][1];\n    for (vi = 0; vi < verdicts.length; vi++) {\n      if (c >= verdicts[vi][0]) {\n        gid('verdict').innerHTML = verdicts[vi][1];\n        break;\n      }\n    }\n\n    gid('ct-c').textContent = '\\u2705 ' + c + ' Correct';\n    gid('ct-w').textContent = '\\u274C ' + w + ' Wrong';\n    gid('ct-s').textContent = '\\u23ED ' + s + ' Skipped';\n\n    sc = gid('score');\n    sc.style.display = 'block';\n    sc.scrollIntoView({ behavior: 'smooth', block: 'center' });\n  }\n\n  function tryInit() {\n    var sentinel = document.getElementById(NS + '-sentinel');\n    var submit   = document.getElementById(NS + '-submit');\n    var retry    = document.getElementById(NS + '-retry');\n    if (!sentinel || !submit || !retry) {\n      setTimeout(tryInit, 80);\n      return;\n    }\n    submit.addEventListener('click', showScore);\n    retry.addEventListener('click', function () {\n      build();\n      window.scrollTo(0, 0);\n    });\n    var bar = document.getElementById(NS + '-progress');\n    if (bar && window.IntersectionObserver) {\n      new IntersectionObserver(function (entries) {\n        bar.className = entries[0].isIntersecting ? 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