A 32-year-old primigravida at 28 weeks of gestation presents to the emergency department with painless vaginal bleeding of 200 mL. Vital signs are stable (BP 128/82 mmHg, HR 88/min). Obstetric examination reveals a soft, non-tender uterus. Speculum examination shows blood pooling in the vagina. Transabdominal ultrasound confirms placenta previa (complete type, covering the internal cervical os). What is the most appropriate next step in management?

Explanation

## Management of Placenta Previa with Antepartum Hemorrhage ### Clinical Context This patient presents with painless vaginal bleeding at 28 weeks with confirmed complete placenta previa on ultrasound. Hemodynamic stability and moderate bleeding volume allow for conservative management. ### Rationale for Admission and Expectant Management **Key Point:** In stable patients with placenta previa and antepartum hemorrhage before 34–36 weeks, expectant (conservative) management is the standard of care, provided the patient can access emergency care. **High-Yield:** The goals of expectant management are: 1. Maximize fetal maturity (administer corticosteroids for fetal lung maturity) 2. Avoid precipitating labor or further hemorrhage 3. Allow time for fetal hemoglobin recovery if fetal anemia develops 4. Plan for elective cesarean delivery at 36–37 weeks (or earlier if recurrent heavy bleeding or labor onset) ### Management Algorithm ```mermaid flowchart TD A[Placenta Previa + APH]:::outcome --> B{Hemodynamically stable?}:::decision B -->|Yes| C{Gestational age < 34 weeks?}:::decision B -->|No| D[Immediate resuscitation + emergency LSCS]:::urgent C -->|Yes| E[Admit for expectant management]:::action C -->|No| F[Plan elective LSCS at 36-37 weeks]:::action E --> G[Corticosteroids for fetal maturity]:::action E --> H[Strict pelvic rest, NPO precautions]:::action E --> I[Transfuse if Hb < 7 g/dL or ongoing bleeding]:::action G --> J[Deliver at 36-37 weeks or if recurrent bleeding]:::outcome ``` ### Supportive Measures During Admission - **Corticosteroids:** Betamethasone 12 mg IM × 2 doses (24 h apart) for fetal lung maturity [cite:RCOG Green-top Guideline 63] - **Blood products:** Keep 2 units PRBC cross-matched; transfuse if Hb < 7 g/dL or active bleeding - **Tocolytics:** Consider if preterm labor develops (e.g., nifedipine or terbutaline) - **Pelvic rest:** No sexual intercourse, no digital cervical examination, no vaginal delivery ### Delivery Plan - **Timing:** Elective cesarean section at 36–37 weeks (or earlier if recurrent heavy bleeding, labor, or rupture of membranes) - **Route:** Cesarean delivery is mandatory for complete or partial placenta previa **Clinical Pearl:** Expectant management is safe and reduces neonatal morbidity from prematurity. Most patients do not have recurrent bleeding; ~50% remain stable until planned delivery. **Warning:** Digital cervical examination is contraindicated in placenta previa — it can trigger massive hemorrhage by disrupting the placental edge.