A 28-year-old primigravida at 32 weeks of gestation presents to the emergency department with complaints of vaginal bleeding and lower abdominal pain for the past 4 hours. On examination, her blood pressure is 130/85 mmHg, pulse 102/min, and temperature 37.2°C. The uterus is tender on palpation with frequent uterine contractions (6 contractions in 10 minutes). Speculum examination shows blood in the vagina but no cervical lesions. Fetal heart rate is 145 bpm. Ultrasound shows a normally positioned placenta with no evidence of placental abruption. Cervical length on transvaginal ultrasound is 2.8 cm. What is the most appropriate immediate management?

## Clinical Assessment This patient presents with **preterm labor at 32 weeks** with vaginal bleeding, uterine contractions (6 in 10 minutes = 1 contraction per 90 seconds, meeting the frequency criterion), and cervical change (shortened cervix on ultrasound). The fetal heart rate is reassuring, and there is no evidence of placental abruption or fetal distress. ## Management Priorities at 32 Weeks **Key Point:** Between 28–34 weeks, the primary goals are: 1. Fetal neuroprotection with **antenatal corticosteroids** 2. Tocolysis to delay delivery and allow steroid action 3. Antibiotics if indicated (not routine in preterm labor without rupture of membranes) ## Antenatal Corticosteroids **High-Yield:** Betamethasone (12 mg IM × 2 doses, 24 hours apart) or dexamethasone reduces: - Neonatal respiratory distress syndrome by ~30% - Intraventricular hemorrhage - Neonatal mortality - Most effective between 24–34 weeks [cite:ACOG 2016 Preterm Labor] ## Tocolytic Choice at 32 Weeks | Agent | Mechanism | Efficacy | Adverse Effects | Use at 32 wks | | --- | --- | --- | --- | --- | | **Nifedipine (calcium channel blocker)** | Reduces uterine smooth muscle contractility | Delays delivery 48 hrs–7 days | Hypotension, flushing, headache | **First-line** | | Indomethacin (NSAID) | Inhibits prostaglandin synthesis | Effective | Oligohydramnios, PDA closure (avoid >32 wks) | Avoid after 32 weeks | | Magnesium sulfate | Stabilizes myofilaments | Modest delay | Hypermagnesemia, respiratory depression | Neuroprotection if <30 wks | | Atosiban (oxytocin antagonist) | Blocks oxytocin receptors | Comparable to nifedipine | Fewer systemic effects | Not available in India | **Clinical Pearl:** At 32 weeks, **nifedipine is preferred** because indomethacin risks fetal ductus arteriosus closure and oligohydramnios at this gestational age. ## Why NOT the Other Options - **Antibiotics alone:** Indicated only if rupture of membranes is confirmed (positive fern test, pooling, nitrazine). This patient has no evidence of ROM. - **Cesarean section:** Reserved for fetal distress (non-reassuring FHR pattern), placental abruption, or failed tocolysis. Current FHR is normal. - **Discharge home:** Preterm labor at 32 weeks requires hospitalization for monitoring, corticosteroid administration, and tocolysis. ## Summary Algorithm ```mermaid flowchart TD A[Preterm labor 32 weeks]:::outcome --> B{Fetal heart rate reassuring?}:::decision B -->|Yes| C[Administer betamethasone IM]:::action C --> D[Start IV nifedipine tocolysis]:::action D --> E[Admit for monitoring]:::action B -->|No| F[Cesarean section]:::urgent E --> G[Reassess in 24-48 hours]:::decision ```