A 28-year-old primigravida at 32 weeks of gestation presents to the emergency department with vaginal bleeding and lower abdominal pain for the past 6 hours. On examination, she is hemodynamically stable with a blood pressure of 118/76 mmHg and heart rate of 88 bpm. The abdomen is tender but soft, and the uterus is irritable. Speculum examination shows blood in the vagina but no cervical lesions. Fetal heart rate is 142 bpm with normal variability. Ultrasound confirms a placenta previa. She is having uterine contractions every 5–7 minutes. What is the most appropriate immediate management?

Explanation

## Clinical Context This patient presents with **preterm labor (PTL) complicated by placenta previa** at 32 weeks. The key clinical features are: - Vaginal bleeding + uterine irritability + regular contractions - Hemodynamically stable - Viable fetus with reassuring FHR - Confirmed placenta previa on ultrasound ## Management Principles for Preterm Labor with Placenta Previa **Key Point:** In preterm labor with placenta previa, **expectant management with corticosteroids is the standard approach** if bleeding is mild-to-moderate and the patient is hemodynamically stable. Vaginal delivery is contraindicated in placenta previa. **High-Yield:** The goals at 32 weeks are: 1. Administer antenatal corticosteroids (betamethasone or dexamethasone) to accelerate fetal lung maturity 2. Achieve fetal maturity if possible (target ≥34 weeks) 3. Avoid precipitating labor or performing vaginal delivery 4. Monitor for massive hemorrhage or fetal compromise ## Why Expectant Management? | Aspect | Rationale | |--------|----------| | **Corticosteroids** | Reduce respiratory distress syndrome, intraventricular hemorrhage, and neonatal mortality by ~30% when given 24 hours to 7 days before delivery | | **Admission** | Allows continuous fetal monitoring, tocolysis if needed, and rapid intervention if bleeding worsens | | **Avoid vaginal delivery** | Placenta previa is an absolute contraindication to vaginal delivery; cesarean section is mandatory | | **Expectant vs. immediate delivery** | At 32 weeks, the neonatal morbidity/mortality is high; delaying delivery by even 1–2 weeks significantly improves outcomes | **Clinical Pearl:** Magnesium sulfate is used for **neuroprotection** in preterm labor <32 weeks (reduces cerebral palsy risk) and for seizure prophylaxis in preeclampsia—not as a first-line tocolytic. In this case, magnesium may be given, but it is NOT the primary intervention; corticosteroids and expectant management are. ## Indications for Urgent Cesarean Section **Warning:** Cesarean delivery is indicated immediately if: - Massive hemorrhage (>500 mL) or hemodynamic instability - Fetal distress (late decelerations, bradycardia) - Placental abruption suspected - Maternal compromise This patient is stable and bleeding is controlled, so urgent cesarean is NOT indicated now. [cite:Williams Obstetrics 26e Ch 42]