What do I do if a patient with placenta previa (placenta covering the cervix) at 22 weeks gestation is hemorrhaging?

Immediate Management of Hemorrhaging Placenta Previa at 22 Weeks

Hospitalize immediately, avoid digital examination, resuscitate aggressively with IV fluids and blood products as needed, and prepare for potential delivery only for maternal indications such as life-threatening hemorrhage—not for fetal benefit, as cesarean delivery before 22 weeks is appropriate only for maternal indications. 1

Initial Stabilization and Assessment

Immediate Actions

• Avoid digital vaginal examination until placenta previa has been excluded or confirmed by ultrasound, as this can trigger catastrophic hemorrhage 1, 2
• Establish two large-bore (14-16 gauge) intravenous lines immediately 3
• Initiate aggressive fluid resuscitation to maintain maternal hemodynamic stability 3
• Administer oxygen supplementation to maintain maternal oxygen saturation >95% for adequate fetal oxygenation 3
• Position the patient with left lateral tilt or manual uterine displacement to optimize venous return and cardiac output 3

Laboratory Assessment

• Obtain baseline complete blood count, type and crossmatch, coagulation panel including fibrinogen, prothrombin time, and partial thromboplastin time 2, 3
• Notify blood bank immediately given the frequent need for large-volume transfusion in placenta previa 2
• If Rh-negative, prepare to administer anti-D immunoglobulin 3

Diagnostic Evaluation

Ultrasound Assessment

• Perform transabdominal ultrasound initially, followed by transvaginal ultrasound for precise diagnosis—transvaginal approach is both safe and accurate for placenta previa 1, 4
• Confirm placental location relative to internal cervical os 4
• Assess for placenta accreta spectrum disorder, particularly critical given any prior uterine surgery 2, 4
• Evaluate for other causes of bleeding including placental abruption 1

Critical Decision Point: Delivery Considerations at 22 Weeks

At 22 weeks gestation, delivery decisions must prioritize maternal survival exclusively. This is a periviable gestational age where neonatal outcomes are extremely poor, and cesarean delivery carries significant maternal morbidity without proven fetal benefit 1.

Maternal Indications for Delivery

• Life-threatening hemorrhage unresponsive to resuscitation 1
• Hemodynamic instability despite aggressive transfusion support 1
• Signs of maternal decompensation or coagulopathy 2

Management Strategy

• Expectant management is preferred if maternal hemodynamic stability can be maintained 2, 5
• Cesarean delivery at this gestational age should be performed only when maternal life is at immediate risk, not for fetal indications 1
• Routine cesarean delivery is not recommended for periviable delivery alone, as it has not been shown to decrease mortality or improve outcomes and significantly increases maternal morbidity 1

Ongoing Inpatient Management

Hospitalization Protocol

• Admit for continuous monitoring with active bleeding 2, 4
• Maintain strict bed rest during active hemorrhage 5
• Serial hemoglobin monitoring and transfusion to maintain hematocrit ≥30% 5
• Continuous assessment of bleeding volume and maternal vital signs 4

Blood Product Management

• Transfuse packed red blood cells to maintain hemoglobin and prevent maternal decompensation 5
• For massive hemorrhage (≥1,500 mL), use massive transfusion protocol with 1:1:1 to 1:2:4 ratio of packed red blood cells:fresh frozen plasma:platelets 4
• Consider tranexamic acid to reduce blood loss 4
• Keep patient warm (>36°C) as clotting factors function poorly at lower temperatures 2

Rh Status Management

• Administer anti-D immunoglobulin to all Rh-negative patients 3
• Perform Kleihauer-Betke test to quantify maternal-fetal hemorrhage and determine need for additional anti-D immunoglobulin doses 3

Common Pitfalls to Avoid

• Never perform digital vaginal examination before ultrasound confirmation—this is the most critical error that can precipitate massive hemorrhage 1, 2
• Do not delay maternal resuscitation for fetal assessment at this periviable gestational age 1
• Avoid vasopressors until fluid resuscitation is maximized, as they adversely affect uteroplacental perfusion 3
• Do not attempt forced placental removal if delivery becomes necessary, as this causes profuse hemorrhage 2
• Recognize that ultrasound has poor sensitivity for placental abruption; do not delay management awaiting ultrasound confirmation if clinical suspicion is high 3

Multidisciplinary Coordination

• Obtain immediate obstetric consultation 3
• Involve maternal-fetal medicine if available 1
• Ensure anesthesiology is aware and prepared for potential emergency surgery 2
• Coordinate with blood bank for massive transfusion protocol availability 2, 4

Counseling Considerations at Periviable Gestational Age

• Provide accurate information about extremely poor neonatal outcomes at 22 weeks gestation 1
• Explain that maternal safety is the priority and cesarean delivery at this gestational age significantly increases maternal morbidity without proven fetal benefit 1
• Involve neonatology for realistic prognostic counseling if delivery appears imminent 1
• Document discussions about goals of care and maternal preferences 1