A 35-year-old G4P3 woman with two prior cesarean deliveries presents at 32 weeks gestation with sudden painless bright-red vaginal bleeding. She denies abdominal pain or contractions. Fetal heart rate is reassuring. Speculum examination reveals blood at the cervix. Transvaginal ultrasound shows the structure marked **A** completely covering the internal cervical os. Which of the following is the most appropriate next step in management?
A. Administer tocolytic agents and schedule cesarean delivery within 48 hours regardless of bleeding control
B. Perform immediate digital cervical examination to assess cervical dilation and plan for vaginal delivery
C. Discharge home with strict pelvic rest and arrange outpatient ultrasound follow-up at 36 weeks
D. Admit for hospitalization, establish IV access, type and cross blood, initiate antenatal corticosteroids and fetal monitoring
Explanation
Why "Admit for hospitalization, establish IV access, type and cross blood, initiate antenatal corticosteroids and fetal monitoring" is right
The structure marked A — placenta completely covering the internal cervical os — defines complete placenta previa. When a patient with placenta previa presents with active vaginal bleeding in the third trimester, the standard of care per ACOG Practice Bulletin 234 is immediate hospitalization with IV access, blood typing and crossmatching, continuous fetal monitoring, and antenatal corticosteroids (at 24–34 weeks for fetal lung maturity) to optimize outcomes if preterm delivery becomes necessary. This is the sentinel bleed, and while often self-limited, subsequent hemorrhages tend to be heavier; therefore, the patient must be in hospital for close observation and rapid access to cesarean delivery if bleeding recurs or becomes uncontrolled.
Why each distractor is wrong
Perform immediate digital cervical examination to assess cervical dilation and plan for vaginal delivery: Digital cervical examination is absolutely contraindicated in suspected placenta previa because it may provoke massive hemorrhage by disrupting the exposed maternal sinuses. Imaging must always precede any cervical manipulation. Additionally, vaginal delivery is contraindicated when the placenta covers the internal os.
Discharge home with strict pelvic rest and arrange outpatient ultrasound follow-up at 36 weeks: While pelvic rest is appropriate for asymptomatic low-lying placenta, a patient with active bleeding and complete placenta previa requires hospitalization for monitoring and rapid intervention capability. Outpatient management is unsafe in this scenario.
Administer tocolytic agents and schedule cesarean delivery within 48 hours regardless of bleeding control: Although tocolytics may be considered for preterm contractions in stable patients, they are not the immediate priority. Cesarean delivery is typically scheduled at 36–37+6 weeks for stable patients, not within 48 hours unless there is uncontrolled hemorrhage, labor, or fetal distress.
High-YieldNEET PG
Placenta previa + active bleeding = hospitalize immediately; digital exam is contraindicated; transvaginal ultrasound is the diagnostic gold standard and is safe.
ACOG Committee Opinion 764 and Practice Bulletin 234
Practice similar questions
Sign up free to access AI-powered MCQ practice with detailed explanations and adaptive learning.
