A 28-year-old G3P2 at 29 weeks of gestation presents with sudden-onset painless vaginal bleeding (approximately 500 mL). She is tachycardic (HR 104 bpm), blood pressure is 110/68 mmHg, and she appears anxious. Fetal heart rate is 140 bpm with normal variability. Transabdominal ultrasound shows a placenta completely covering the internal cervical os with a large retroplacental clot. Which of the following is the most appropriate next step in management?

Explanation

## Management of Placenta Previa with Heavy Antepartum Hemorrhage ### Clinical Scenario Analysis This patient presents with **warning signs of hemodynamic compromise**: - **Heavy bleeding (500 mL)** — significant blood loss - **Tachycardia (HR 104)** — compensatory response to hypovolemia - **Retroplacental clot on ultrasound** — indicates ongoing placental separation - **Gestational age 29 weeks** — preterm, but maternal stability takes priority - **Stable fetal heart rate** — reassuring but does not change maternal management ### Correct Management Approach **Key Point:** Heavy bleeding with hemodynamic instability (tachycardia, anxiety) in placenta previa requires **urgent preparation for emergency cesarean delivery**. Expectant management is no longer safe. ### Immediate Management Protocol ```mermaid flowchart TD A["Placenta Previa + Heavy Bleeding"]:::outcome --> B{"Hemodynamically Stable?"}:::decision B -->|"Yes (SBP >100, HR <100)"|C["Expectant Management"]:::action C --> D["Admit, bed rest, corticosteroids"]:::action D --> E["Elective cesarean at 37 weeks"]:::action B -->|"No (Tachycardia, Low BP)"|F["Emergency Cesarean"]:::urgent F --> G["IV access × 2, fluid resuscitation"]:::action G --> H["Cross-match blood, prepare OR"]:::action H --> I["Cesarean delivery"]:::action ``` ### Critical Steps in This Case 1. **Establish two large-bore IV lines** (18G or larger) 2. **Begin rapid IV fluid resuscitation** (normal saline or Ringer's lactate) 3. **Type and cross-match blood** — have 2–4 units PRBC ready 4. **Notify obstetrics, anesthesia, and neonatology** immediately 5. **Prepare for emergency cesarean delivery** 6. **Administer betamethasone** (12 mg IM × 2 doses, 24 hours apart) if time permits — fetal neuroprotection 7. **Do NOT perform transvaginal ultrasound** — delay and risk of further bleeding **High-Yield:** Tachycardia (HR >100) in the setting of antepartum hemorrhage indicates **compensated shock** and is an absolute indication for emergency delivery in placenta previa. ### Differentiation: Stable vs. Unstable Placenta Previa | Feature | Stable (Expectant) | Unstable (Emergency Cesarean) | |---------|-------------------|-------------------------------| | **Blood loss** | <250 mL | >500 mL or ongoing | | **Heart rate** | <100 bpm | >100 bpm | | **Blood pressure** | SBP >110 mmHg | SBP <110 or dropping | | **Fetal HR** | Reassuring | May show decelerations | | **Retroplacental clot** | Absent or small | Large, expanding | | **Management** | Bed rest, steroids, expectant | Emergency cesarean | **Clinical Pearl:** In this case, the **retroplacental clot is a red flag** — it indicates active placental separation and ongoing bleeding risk. Combined with tachycardia, this mandates emergency delivery. **Mnemonic: CRASH for Unstable APH** — **C**ompensated shock (tachycardia), **R**apid bleeding (>500 mL), **A**ctive clot on imaging, **S**evere symptoms (anxiety, pallor), **H**eavy flow → **H**urry to OR.