A 32-year-old primigravida at 34 weeks of gestation presents to the emergency department with painless vaginal bleeding of 200 mL. She denies abdominal pain, contractions, or leakage of fluid. Vital signs are stable (BP 128/82, HR 88, RR 18). On speculum examination, blood is seen pooling in the vagina with no cervical source identified. Transabdominal ultrasound confirms a placenta covering the internal cervical os. What is the most appropriate immediate management?

Explanation

## Diagnosis & Classification **Key Point:** This patient has placenta previa (placenta covering the internal cervical os) with first episode of bleeding at 34 weeks — a classic presentation of major (complete) previa. ## Management Algorithm for Stable Placenta Previa ```mermaid flowchart TD A[Placenta previa diagnosed]:::outcome --> B{Patient stable?}:::decision B -->|Yes, < 37 weeks| C[Admit for observation]:::action C --> D[Restrict activity/bed rest]:::action D --> E[Administer corticosteroids]:::action E --> F[Plan elective CS at 37 weeks]:::action B -->|Massive hemorrhage/shock| G[Emergency CS]:::urgent B -->|Yes, ≥ 37 weeks| H[Elective CS within 48-72 hrs]:::action ``` ## Rationale for Correct Answer **High-Yield:** At 34 weeks with stable hemodynamics and first bleeding episode, expectant management is the standard of care: 1. **Admission & Activity Restriction** — Reduces risk of recurrent bleeding and allows fetal maturation. 2. **Corticosteroids (Betamethasone 12 mg IM × 2 doses, 24 hrs apart)** — Reduces neonatal respiratory distress, intraventricular hemorrhage, and mortality if preterm delivery occurs. 3. **Elective Cesarean at 37 weeks** — Balances fetal maturity against bleeding risk; most guidelines recommend 37 weeks for uncomplicated major previa. 4. **Avoid Digital Cervical Exam** — Risks catastrophic hemorrhage by disrupting placental edge. **Clinical Pearl:** Expectant management succeeds in ~50% of cases; many patients do not bleed again and deliver at term. Each bleeding episode is managed conservatively unless hemodynamically unstable or at ≥37 weeks. ## Why Other Options Are Wrong | Option | Why Incorrect | |--------|---------------| | Digital cervical exam | Contraindicated in previa; can precipitate life-threatening hemorrhage | | Magnesium sulfate + emergency CS | Magnesium is for neuroprotection in preterm labor/PROM, not previa; emergency CS only if unstable or massive bleed | | Amniocentesis for lung maturity | Unnecessary at 34 weeks with stable previa; planned delivery at 37 weeks, not based on lung maturity | [cite:Park 26e Ch 16]