What is the management for a patient at 30 weeks and 5 days gestation with an open cervix 1-2cm and active bleeding?

Management of Active Vaginal Bleeding with Cervical Dilation at 30+5 Weeks Gestation

This patient requires immediate hospitalization with urgent assessment for hemodynamic stability, followed by determination of bleeding source (placental abruption, placenta previa, or preterm labor with cervical change), and preparation for potential emergency delivery if maternal or fetal compromise develops. 1, 2

Immediate Stabilization and Assessment

Assess hemodynamic status immediately by checking vital signs, signs of hypovolemia (tachycardia, hypotension, altered mental status), and quantifying active bleeding severity 1, 2. This patient's presentation with active bleeding and cervical dilation at 30 weeks represents a high-risk obstetric emergency requiring rapid evaluation.

Initial Laboratory and Monitoring

• Obtain baseline complete blood count, coagulation profile (PT, PTT, fibrinogen), and type and crossmatch for at least 2-4 units of packed red blood cells 1, 2
• Establish large-bore IV access (two 18-gauge or larger) and initiate fluid resuscitation if any signs of hemodynamic instability 1, 2
• Continuous fetal heart rate monitoring and tocodynamometry to assess fetal status and contraction pattern 2
• Keep patient warm (temperature >36°C) as clotting factors function poorly with hypothermia 1, 2

Diagnostic Evaluation

Ultrasound Assessment

Perform transvaginal ultrasound immediately to determine placental location and rule out placenta previa before any digital cervical examination 1. A digital examination with undiagnosed placenta previa can precipitate catastrophic hemorrhage.

• Confirm placental location and exclude placenta previa or low-lying placenta 1
• Assess for signs of placental abruption (retroplacental hematoma, increased placental thickness) 2
• Measure cervical length by transvaginal ultrasound - cervical length <15 mm with active bleeding significantly increases risk of imminent delivery 3, 4
• Evaluate amniotic fluid volume and fetal biometry 3

Clinical Differential Diagnosis

The combination of active bleeding and 1-2 cm cervical dilation at 30+5 weeks suggests three primary diagnoses:

1. Placental abruption - Most concerning given potential for rapid maternal-fetal deterioration 2
2. Placenta previa/low-lying placenta - Must be excluded before cervical examination 1
3. Preterm labor with cervical change - Bleeding may be from cervical dilation itself ("bloody show") 3, 4

Management Based on Clinical Scenario

If Hemodynamically Unstable (Suspected Abruption)

Proceed immediately to emergency cesarean section without waiting for complete workup if patient shows signs of hemodynamic compromise (BP <90/60 mmHg, HR >110, altered mental status, heavy ongoing bleeding) 2.

• Activate massive transfusion protocol with 1:1:1 ratio of packed red blood cells, fresh frozen plasma, and platelets 1, 2
• Administer tranexamic acid 1 g IV over 10 minutes if postpartum hemorrhage anticipated 5
• Do not wait for laboratory results - treat based on clinical presentation 1, 2
• Prepare for potential hysterectomy if bleeding uncontrollable after delivery 2
• Arrange ICU bed for postoperative intensive monitoring 2

If Hemodynamically Stable

With Placenta Previa Excluded and Minimal Bleeding

Administer corticosteroids for fetal lung maturity (betamethasone 12 mg IM x 2 doses 24 hours apart) given gestational age of 30+5 weeks 3, 4.

• Cervical length measurement is critical: length <15 mm predicts 47% risk of delivery within 7 days, while length ≥15 mm predicts only 1.8% risk 4
• If cervical length ≥15 mm: This may represent false labor; consider expectant management with close observation 3, 4
• If cervical length <15 mm: High risk of imminent preterm delivery; prepare for delivery within days 4

Tocolysis Considerations

Tocolysis may be considered for 48 hours to allow corticosteroid administration to take effect, but only if:

• Hemodynamically stable 3, 4
• No evidence of placental abruption 2
• No signs of chorioamnionitis 6
• Fetal status reassuring 3

However, tocolysis has NOT been shown to independently predict delivery timing in multivariate analysis 3, 4. The decision should prioritize maternal-fetal safety over prolonging pregnancy.

Progesterone and Cervical Support

• Micronized vaginal progesterone 200 mg daily may be continued if already initiated, though evidence at this advanced gestational age with active labor is limited 7
• Cervical cerclage is contraindicated with active bleeding and cervical dilation 7
• Arabin pessary is not appropriate with active labor and bleeding 7

Monitoring Protocol

Inpatient Observation Required

• Serial hemoglobin/hematocrit every 4-6 hours initially 1
• Continuous fetal monitoring until bleeding stabilizes 2
• Repeat cervical length assessment every 24-48 hours if expectant management pursued 3, 4
• Monitor for signs of infection (fever, leukocytosis, uterine tenderness) 6
• Watch for coagulopathy development, particularly if abruption suspected 2

Delivery Planning

If bleeding stabilizes and delivery not imminent, plan for delivery at 34-37 weeks depending on clinical course 3. However, maintain low threshold for earlier delivery if:

• Recurrent bleeding episodes 2
• Cervical dilation progresses beyond 3 cm 8
• Fetal status becomes non-reassuring 2
• Maternal hemodynamic instability develops 1, 2

Critical Pitfalls to Avoid

• Never perform digital cervical examination before excluding placenta previa by ultrasound - this can cause catastrophic hemorrhage 1
• Do not delay delivery in hemodynamically unstable patients - maternal stabilization takes priority and often requires delivery 1, 2
• Avoid over-reliance on normal fetal heart tracing - fetal status can deteriorate rapidly in placental abruption despite initially reassuring monitoring 2
• Do not assume bleeding is benign "bloody show" without excluding placental causes 1, 2
• Avoid aggressive tocolysis if placental abruption suspected - this can worsen maternal-fetal outcomes 2

Risk Factors Requiring Enhanced Surveillance

This patient's presentation warrants evaluation for underlying risk factors:

• Previous preterm birth or pregnancy loss 7, 6
• Cervical insufficiency 7, 6
• Multiple gestation 6
• Preterm premature rupture of membranes 6
• Hypertensive disorders 6
• Gestational diabetes 6
• Bacterial vaginosis (associated with shorter cervical length in preterm labor) 9

The key decision point is hemodynamic stability and bleeding severity - unstable patients require immediate delivery, while stable patients require urgent diagnostic evaluation followed by individualized management based on bleeding source, cervical length, and fetal status 1, 2, 3, 4.