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 6 hours. On examination, she is hemodynamically stable (BP 118/76 mmHg, HR 88/min), and the uterus is tender and irritable. Speculum examination shows blood in the vagina but no cervical lesions. Fetal heart rate is 140 bpm. Transabdominal ultrasound reveals a placenta covering the internal cervical os. She is given intramuscular betamethasone and admitted. Which of the following is the most appropriate next step in management?

Explanation

## Clinical Scenario Analysis This patient presents with **placenta previa** (placenta covering the internal cervical os) complicated by **preterm labor** at 32 weeks with vaginal bleeding and uterine contractions. ### Key Management Principles in Preterm Labor with Placenta Previa **Key Point:** In preterm labor with placenta previa, the priority is fetal maturity and maternal safety. Expectant management with tocolysis and corticosteroids is the standard approach unless there is uncontrolled hemorrhage or maternal hemodynamic instability. **High-Yield:** The combination of preterm labor + placenta previa mandates: 1. **Antenatal corticosteroids** (betamethasone already given — correct) to accelerate fetal lung maturity 2. **Tocolytic agents** (nifedipine or atosiban) to suppress contractions and allow time for steroids to act 3. **Hospitalization** for continuous fetal monitoring and maternal observation 4. **Planned delivery** at 34 weeks (when fetal lung maturity is reasonable) or earlier if: - Uncontrolled hemorrhage - Maternal hemodynamic instability - Fetal distress - Spontaneous labor progression ### Why This Option is Correct At 32 weeks with stable maternal hemodynamics and reassuring fetal status: - Expectant management allows 2 additional weeks for fetal maturation - Tocolysis buys time for corticosteroid efficacy (peak effect at 24–48 hours) - Planned delivery at 34 weeks balances neonatal morbidity reduction against maternal bleeding risk - This is the **standard of care** per ACOG and RCOG guidelines for preterm labor with placenta previa ### Contraindications to Tocolysis in This Case **Clinical Pearl:** Tocolysis is NOT contraindicated here because: - Maternal bleeding is mild (patient is hemodynamically stable) - No signs of placental abruption (uterus tender but not board-like; no severe pain) - Fetal heart rate is reassuring - The goal is to suppress contractions and allow steroids to work ### Neonatal Outcome Benefit Each week gained from 32 to 34 weeks significantly reduces: - Respiratory distress syndrome (RDS) - Intraventricular hemorrhage (IVH) - Necrotizing enterocolitis (NEC) - Neonatal mortality [cite:ACOG Practice Bulletin 127 on Preterm Labor; Williams Obstetrics 26e Ch 42] ## Comparison Table: Management by Gestational Age and Clinical Stability | Scenario | Approach | Rationale | |----------|----------|----------| | Preterm labor, <24 weeks, stable | Expectant management ± tocolysis | Periviable zone; individualized counseling | | Preterm labor, 24–34 weeks, stable | Tocolysis + corticosteroids + hospitalization | Maximize fetal maturity; reduce neonatal morbidity | | Preterm labor, >34 weeks, stable | Tocolysis optional; prepare for delivery | Neonatal outcomes generally good | | Preterm labor + uncontrolled hemorrhage | Immediate delivery (vaginal or cesarean) | Maternal safety takes precedence | | Preterm labor + fetal distress | Immediate delivery | Fetal safety |