What is the management plan for a patient with vasa previa presenting with pelvic pressure and back pain?

From the Guidelines

The management plan for a patient with vasa previa presenting with pelvic pressure and back pain requires immediate hospitalization for close monitoring and preparation for emergency cesarean delivery. The patient should be admitted to a tertiary care center with immediate access to blood products, neonatal intensive care, and surgical capabilities. Antenatal corticosteroids should be administered to accelerate fetal lung maturity (betamethasone 12 mg IM, two doses 24 hours apart) as recommended by recent guidelines 1. Continuous electronic fetal monitoring is essential to detect early signs of fetal distress. Tocolytics may be used if preterm contractions develop, with magnesium sulfate (4-6g loading dose followed by 1-2g/hour maintenance) being preferred for its neuroprotective effects if delivery is anticipated before 32 weeks. The patient should maintain strict bed rest with bathroom privileges only. Planned cesarean delivery should be scheduled between 34-36 weeks after confirming fetal lung maturity, or earlier if there are signs of bleeding, labor, or fetal distress. Type and cross-match for at least 4 units of packed red blood cells should be available at all times. This aggressive management approach is necessary because vasa previa carries a high risk of fetal mortality (50-75%) if vessels rupture, as the fetal blood volume is small (80-100 mL/kg) and even minor bleeding can lead to rapid fetal exsanguination and death within minutes, as highlighted in a recent study 1.

Key considerations in the management of vasa previa include:

• Immediate hospitalization for close monitoring
• Preparation for emergency cesarean delivery
• Administration of antenatal corticosteroids to accelerate fetal lung maturity
• Continuous electronic fetal monitoring
• Use of tocolytics if preterm contractions develop
• Strict bed rest with bathroom privileges only
• Planned cesarean delivery between 34-36 weeks after confirming fetal lung maturity

The importance of accurate diagnosis and management of vasa previa is emphasized in a recent review 1, which highlights the significant risks of stillbirth associated with unrecognized vasa previa. Therefore, it is crucial to prioritize the management plan outlined above to minimize the risk of adverse outcomes for both the mother and the fetus.

From the Research

Management Plan for Vasa Previa with Pelvic Pressure and Back Pain

The management plan for a patient with vasa previa presenting with pelvic pressure and back pain involves several key considerations:

• Diagnosis: Prenatal diagnosis of vasa previa is crucial to prevent intrapartum fetal death 2, 3, 4. Transvaginal ultrasound in combination with color Doppler is the most effective tool in the antenatal diagnosis of vasa previa 2.
• Risk Factors: Identification of risk factors such as bilobed, succenturiate-lobed, and low-lying placentas, pregnancies resulting from in vitro fertilization, and multiple pregnancy is essential 2, 3, 4.
• Symptomatic Management: Patients presenting with symptoms such as pelvic pressure and back pain require immediate attention and hospitalization 5.
• Hospitalization vs. Outpatient Management: Asymptomatic women with an antenatal diagnosis of vasa previa, singleton pregnancies, and at low risk for preterm birth may be safely managed as outpatients, as long as they are able to access hospital promptly in the event of antepartum bleeding or early labor 5, 3.
• Cesarean Delivery: Cesarean delivery is the method of delivery of choice for patients with vasa previa 2, 3, 4. Scheduled cesarean section between 34 and 36 weeks' gestation is recommended for asymptomatic women presenting with vasa previa 3.
• Fetal Monitoring: Close fetal monitoring is essential to detect any signs of fetal distress or compromise 2, 4.
• Multidisciplinary Care: Management of vasa previa requires a multidisciplinary approach involving obstetricians, family physicians, nurses, midwives, maternal-fetal medicine specialists, and radiologists 6.

Key Considerations

• Patients with vasa previa are at an increased risk of maternal and fetal or postnatal adverse outcomes, including preterm birth, cesarean delivery, and neonatal morbidity and mortality 5, 6.
• Optimization of diagnostic and management protocols can improve maternal and fetal or postnatal outcomes 6.
• The quality of evidence and strength of recommendations should be evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach 6.