From the Guidelines
Management of a patient at 21 weeks gestation with placenta previa covering the os and bleeding requires immediate hospitalization for stabilization and monitoring, with a focus on maternal stabilization while maintaining the pregnancy if possible. The primary goal is to prevent morbidity and mortality, while also considering the quality of life for both the mother and the fetus. Initial management includes:
- Bed rest
- IV access with two large-bore catheters
- Fluid resuscitation
- Continuous fetal and maternal monitoring
- Laboratory tests, including complete blood count, coagulation studies, and type and cross-match for potential blood transfusion 1 Tocolytics may be administered if contractions are present, with options including nifedipine or indomethacin for 48 hours. Antenatal corticosteroids should be considered if approaching viability. Magnesium sulfate for neuroprotection may be given if delivery seems imminent near viability. Expectant management is preferred unless bleeding is severe or there is maternal hemodynamic instability. Cesarean delivery is indicated for severe, uncontrolled bleeding despite the poor fetal prognosis at this gestational age. The patient should be counseled about the risks of preterm delivery, recurrent bleeding, and the need for cesarean delivery at the time of eventual delivery due to placenta previa. In cases of severe bleeding, consideration should be given to the use of blood products, such as packed red blood cells, fresh frozen plasma, and platelets, with a potential ratio of 1:1:1 to 1:2:4 1. Additionally, antifibrinolytic therapy with tranexamic acid may be useful in reducing bleeding complications and mortality 1. It is essential to have a multidisciplinary team, including surgical, anesthesia, and intraoperative nursing staff, to ensure all are continuously apprised of the current status, ongoing blood loss, and expectations about future blood loss 1.
From the Research
Management of Placenta Previa
- The management of a patient at 21 weeks gestation with placenta previa covering the os and bleeding involves several considerations, including the use of tocolytic agents to extend the duration of pregnancy 2.
- Tocolytic agents such as beta mimetics, atosiban, and indomethacin may be used to reduce the rate of delivery at 24 hours, 48 hours, and at 7 days 2, 3.
- However, there is no proof of their beneficial effect on perinatal or neonatal outcomes 2, 3.
- In cases of moderate hemorrhage due to placenta previa, tocolysis may be considered 2.
- The choice of tocolytic agent depends on various factors, including the gestational age and the presence of maternal or fetal complications 4, 5.
Tocolytic Agents
- Nifedipine, magnesium sulfate, and indomethacin are commonly used tocolytic agents, but their efficacy and safety profiles vary 3, 4.
- A randomized clinical trial comparing the efficacy and maternal side effects of nifedipine, magnesium sulfate, and indomethacin found no significant differences in gestational age at delivery or arrest of labor 4.
- Atosiban and nifedipine have been shown to have no direct fetal adverse effects on fetal movement, heart rate, and blood flow 5.
Corticosteroids and Magnesium Sulfate
- Antenatal corticosteroids and magnesium sulfate may be administered to improve preterm neonatal outcomes, including fetal lung maturation and neuroprotection 6.
- Guidelines from leading medical societies recommend the use of corticosteroids and magnesium sulfate in cases of anticipated preterm delivery, but there is variation in the recommended timing and administration of these agents 6.