A 32-year-old primigravida at 28 weeks of gestation presents with painless vaginal bleeding. Ultrasound confirms placenta previa. Regarding the management and clinical features of placenta previa, all of the following are true EXCEPT:

Question

Accepted Answer

C. Transvaginal ultrasound is contraindicated and should not be performed in suspected placenta previa. ## Diagnosis and Investigation in Placenta Previa

**Key Point:** Transvaginal ultrasound is NOT contraindicated in placenta previa — it is actually the gold standard for confirming the diagnosis and measuring the distance from the internal cervical os to the placental edge. The old myth that "any probe near the cervix will cause bleeding" is false and has been thoroughly debunked in modern obstetrics.

### Why Transvaginal Ultrasound is Safe
- Gentle insertion with a covered probe does not mechanically disrupt the placenta
- Provides superior resolution for placental location and cervical assessment
- Transabdominal ultrasound alone may be inconclusive, especially in posterior placentas or maternal obesity
- No increased risk of hemorrhage when performed by trained personnel

## Management Principles in Placenta Previa

### Expectant (Conservative) Management
**High-Yield:** Expectant management is the standard of care for preterm, hemodynamically stable patients with no active bleeding or minimal spotting.
- Hospitalization for monitoring and bed rest
- Corticosteroids for fetal lung maturation (if <34 weeks)
- Transfusion availability and IV access maintained
- Delivery planned at 36–37 weeks (or earlier if bleeding recurs)

### Vaginal Delivery Considerations
**Clinical Pearl:** Vaginal delivery is NOT absolutely contraindicated in all cases:
- **Marginal previa** (placental edge 0–2 cm from os) may allow vaginal delivery if labor progresses normally
- **Complete/central previa** (placenta covers the os) requires cesarean delivery
- Vaginal delivery is contraindicated only when the placenta directly covers the internal cervical os

## Risk Factors for Placenta Previa

| Risk Factor | Relative Risk | Notes |
|---|---|---|
| Maternal age >35 years | ↑↑ | Increased with advancing age |
| Multiparity | ↑ | More pronounced with increasing parity |
| Prior cesarean delivery | ↑↑↑ | Strongest modifiable risk factor |
| Smoking | ↑ | Dose-dependent |
| Cocaine use | ↑ | Vasoconstrictive mechanism |
| IVF conception | ↑ | Possibly related to endometrial factors |
| Uterine abnormalities | ↑ | Septate, bicornuate uterus |

**Warning:** Do NOT confuse "marginal previa" with "complete previa" — the former may allow trial of labor, the latter does not.

## Summary of Correct Statements
- ✓ Expectant management is appropriate for preterm, stable patients
- ✓ Vaginal delivery is possible in marginal previa (not absolutely contraindicated in all cases)
- ✓ Maternal age >35 and multiparity are established risk factors
- ✗ Transvaginal ultrasound IS safe and is the diagnostic gold standard

Answer

A. Vaginal delivery is absolutely contraindicated in all cases of placenta previa

Answer

B. Expectant management with hospitalization is preferred in stable patients with preterm gestation and no active bleeding

Answer

D. Maternal age >35 years and multiparity are significant risk factors for placenta previa

A 32-year-old primigravida at 28 weeks of gestation presents with painless vaginal bleeding. Ultrasound confirms placenta previa. Regarding the management and clinical features of placenta previa, all of the following are true EXCEPT:

Explanation

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