A 32-year-old primigravida at 34 weeks gestation presents to the emergency department with painless vaginal bleeding. She reports soaking 2–3 pads over the last 4 hours. Vital signs: BP 128/76 mmHg, HR 92 bpm, RR 18/min. Abdominal examination reveals a soft, non-tender uterus. Fetal heart rate is 148 bpm. Transabdominal ultrasound shows the placenta covering the internal cervical os completely. What is the most appropriate next step in management?

Explanation

## Diagnosis and Classification **Key Point:** This patient has **complete placenta previa** (placenta covers the entire internal cervical os) with painless vaginal bleeding at 34 weeks gestation—the classic presentation. ## Management Principles for Placenta Previa ### Expectant Management (Inpatient) For stable patients with complete placenta previa before 37 weeks: - Hospitalization is mandatory to enable rapid intervention if bleeding recurs - Strict pelvic rest (no intercourse, no strenuous activity) - Corticosteroids for fetal lung maturity (betamethasone 12 mg IM × 2 doses, 24 hours apart) - Transvaginal ultrasound is safe and preferred for confirmation - **Avoid digital cervical examination** — risk of massive hemorrhage ### Delivery Timing - **Elective cesarean at 37 weeks** if no further bleeding and fetal maturity confirmed - **Earlier delivery** if recurrent heavy bleeding, maternal hemodynamic compromise, or fetal distress **Clinical Pearl:** Expectant management reduces neonatal morbidity from prematurity while maintaining maternal safety. Approximately 10–15% of patients with placenta previa will have no further bleeding after the first episode. **High-Yield:** Complete placenta previa **always** requires cesarean delivery; vaginal delivery is contraindicated. ## Why Hospitalization Is Essential - Rapid access to blood products and OR - Continuous fetal monitoring - Early detection of recurrent hemorrhage [cite:Williams Obstetrics 26e Ch 35]