A 28-year-old primigravida at 32 weeks 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 128/82 mmHg, HR 92/min), and the abdomen is tender with mild rigidity. Speculum examination shows active vaginal bleeding. Fetal heart rate is 142/min and reactive. Ultrasound confirms placenta previa with no evidence of placental abruption. She has no prior history of preterm labor. What is the most appropriate immediate management?

Explanation

## Clinical Scenario Analysis This patient presents with **symptomatic placenta previa at 32 weeks** — a condition that threatens preterm delivery and maternal hemorrhage. ### Why Option B is Correct **Key Point:** In placenta previa with active but controlled bleeding before 34 weeks in a hemodynamically stable patient, the standard management is **in-hospital expectant management**: admission for bed rest and pelvic rest, administration of antenatal corticosteroids (betamethasone 12 mg IM × 2 doses, 24 hours apart) to accelerate fetal lung maturity, and planning for elective cesarean section at 36–38 weeks (or earlier if bleeding recurs or becomes uncontrolled). **High-Yield (Williams Obstetrics, 25th ed.):** The management of placenta previa with bleeding at <34 weeks in a stable patient includes: 1. **Admission** — inpatient monitoring is mandatory; outpatient management (option C) is inappropriate with active bleeding 2. **Corticosteroids** — to promote fetal lung maturity given gestational age <34 weeks 3. **Pelvic rest** — strict avoidance of intercourse and vaginal examination 4. **Planned cesarean delivery** — elective cesarean at 36–38 weeks (or 37 weeks per ACOG) once fetal maturity is adequate ### Why Option D (Tocolytics + Transfer) is NOT the Best Answer **Clinical Pearl:** The stem does **not** describe active preterm labor (no mention of regular uterine contractions or cervical change). The primary diagnosis is placenta previa with bleeding, not preterm labor. Tocolytics are used in placenta previa **only when there is concurrent preterm labor** (documented uterine contractions). Administering tocolytics without evidence of active labor is not standard first-line management. Furthermore, the question asks for "most appropriate immediate management" — admission with corticosteroids and bed rest (option B) is the universally accepted first step. Transfer to tertiary care is situationally appropriate but is not the defining element of the answer, and option D omits corticosteroids entirely. ### Why Other Options Are Wrong - **Option A (Emergency cesarean):** Not indicated in a hemodynamically stable patient with a reactive fetal heart rate at 32 weeks — delivery at this gestation carries significant neonatal morbidity. - **Option C (Discharge home):** Absolutely contraindicated with active vaginal bleeding from placenta previa; inpatient monitoring is mandatory. ### Table: Management by Gestational Age and Bleeding Severity | Gestational Age | Bleeding Severity | Management | |---|---|---| | < 34 weeks | Mild–moderate, stable | Admit; corticosteroids; pelvic rest; plan elective CS | | < 34 weeks | Severe, unstable | Urgent cesarean delivery | | ≥ 34–36 weeks | Any | Delivery (cesarean) | **High-Yield:** Per ACOG Practice Bulletin No. 234, antenatal corticosteroids are recommended for all patients with placenta previa at risk of preterm delivery before 34 weeks. Tocolytics are reserved for cases with concurrent preterm labor, not routine bleeding episodes.