A 28-year-old primigravida at 32 weeks of gestation presents to the labor ward 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 with mild contractions. Speculum examination reveals a small amount of blood in the vagina with no cervical lesions. Transvaginal ultrasound shows a placenta covering the internal cervical os. Fetal heart rate is 142 bpm with normal variability. What is the most appropriate immediate management?

Explanation

## Clinical Context This patient presents with **placenta previa** (confirmed on transvaginal ultrasound) at 32 weeks with vaginal bleeding and uterine tenderness. The key clinical challenge is distinguishing between preterm labor and antepartum hemorrhage from placental pathology. ## Management Principles **Key Point:** In placenta previa with vaginal bleeding, digital cervical examination is **contraindicated** because it may precipitate massive hemorrhage by disrupting the placental edge. **High-Yield:** The standard of care for stable patients with placenta previa and preterm labor symptoms is: 1. **Avoid digital cervical examination** — use transvaginal ultrasound instead 2. **Administer corticosteroids** (betamethasone 12 mg IM × 2 doses, 24 hours apart) for fetal lung maturity 3. **Admit for observation** and continuous fetal monitoring 4. **Tocolytics** (nifedipine or terbutaline) may be considered if true preterm labor is confirmed by ultrasound cervical assessment ## Why This Answer Betamethasone administration + admission achieves: - Fetal lung maturity improvement (reduces respiratory distress syndrome by ~50%) - Continuous monitoring for progression of bleeding or labor - Safe assessment of cervical status via transvaginal ultrasound (not digital) - Readiness for delivery if hemorrhage becomes uncontrolled At 32 weeks with stable hemodynamics and no evidence of fetal distress, expectant management with corticosteroids is standard unless bleeding becomes life-threatening. **Clinical Pearl:** Transvaginal ultrasound is safe in placenta previa and provides accurate cervical length and dilation assessment without mechanical disruption. ## Why Other Options Fail | Option | Why Wrong | |--------|----------| | Digital cervical examination | **Contraindicated in placenta previa** — risks catastrophic hemorrhage; transvaginal ultrasound is the diagnostic gold standard | | Emergency cesarean delivery | Premature at 32 weeks with stable bleeding and reassuring fetal status; reserved for uncontrolled hemorrhage or fetal distress | | Discharge home | Placenta previa with active bleeding requires inpatient monitoring; risk of rapid decompensation is high | [cite:Williams Obstetrics 26e Ch 34]