Management of Placenta Previa After First Episode of Bleeding
After the first episode of bleeding in placenta previa, patients should be hospitalized for monitoring, and if bleeding stabilizes with reassuring fetal status, expectant management with bed rest, activity restriction, and close surveillance should continue until 36-37 weeks of gestation, unless complications arise. 1
Initial Management
Hospitalization Decision
- Women with placenta previa and one episode of bleeding are at increased risk of subsequent bleeding episodes 1
- Factors influencing hospitalization decision:
- Distance from hospital/referral center
- Logistical considerations for emergency access to care
- Individual patient preferences 1
Monitoring Protocol
- Continuous fetal monitoring during active bleeding
- Regular assessment of maternal vital signs
- Quantification of blood loss
- Laboratory evaluation:
- Complete blood count
- Type and cross-match
- Coagulation studies
Expectant Management Components
Activity Restriction
- While bed rest is of unproven benefit, it remains a common recommendation for placenta previa patients after bleeding 1
- Low-intensity physical activity (walking) may be maintained 1
- Avoid moderate-to-vigorous physical activity (MVPA) after 28 weeks of gestation with confirmed placenta previa 1
Surveillance Requirements
- Regular ultrasound assessment of:
- Placental location
- Cervical length
- Signs of placental separation
- Transabdominal ultrasound is the mainstay of evaluation 1
- Transvaginal ultrasound may be needed for accurate assessment of placental edge-to-cervical os distance 1
- Doppler studies to rule out vasa previa 1
Preparation for Potential Complications
- Notification and collaboration with blood bank 1
- Multidisciplinary team involvement:
- Maternal-fetal medicine
- Anesthesiology
- Neonatology
- Experienced pelvic surgeons 1
- Optimization of hemoglobin values during pregnancy 1
Delivery Planning
Timing of Delivery
- Planned delivery at 36-37 weeks if no complications arise
- Earlier delivery may be necessary for:
- Recurrent bleeding episodes
- Hemodynamic instability
- Non-reassuring fetal status
- Preterm labor
Mode of Delivery
- Cesarean delivery is the standard approach for complete placenta previa
- Cesarean hysterectomy may be necessary if placenta accreta spectrum is present 1
Special Considerations
Risk of Placenta Accreta Spectrum
- Higher risk with prior cesarean deliveries
- Preoperative planning should include:
Management of Recurrent Bleeding
- Recurrent bleeding episodes may necessitate earlier delivery
- Tocolytics may be considered to allow for corticosteroid administration for fetal lung maturity 2
- Blood product preparation and massive transfusion protocol readiness
Pitfalls and Caveats
- Digital pelvic examination should be avoided until placenta previa has been excluded by imaging 1
- Attempts at forced placental removal during cesarean delivery can result in profuse hemorrhage 1
- Underestimation of blood loss is common in placenta previa cases
- Delayed recognition of placenta accreta spectrum can lead to catastrophic hemorrhage
- Failure to prepare for massive transfusion can lead to increased morbidity and mortality
The management of placenta previa requires careful balance between prolonging pregnancy for fetal maturity and preventing life-threatening maternal hemorrhage. While hospitalization after the first bleeding episode is generally recommended, the specific management plan should consider individual risk factors, available resources, and patient preferences.