What is the management plan for a gravida 3, para 2 (G3P2) woman at 35 weeks gestation presenting with vaginal spotting, a category 1 Cardiotocography (CTG) and no active bleeding on pelvic (PV) examination?

Management of G3P2 at 35 Weeks with Vaginal Spotting

For a G3P2 at 35 weeks with vaginal spotting, reassuring CTG (category 1), and no active bleeding on examination with closed cervical os, expectant management with close outpatient monitoring is appropriate, with instructions to return immediately for increased bleeding, contractions, decreased fetal movement, or signs of labor. 1, 2

Immediate Assessment and Safety Considerations

Critical Initial Steps

• Confirm placental location has been documented earlier in pregnancy - if placenta previa or low-lying placenta was never excluded by prior ultrasound, perform ultrasound imaging now before any further digital examination 1, 2
• Document fetal heart rate pattern and confirm Category 1 CTG (normal baseline, moderate variability, no decelerations) 3
• Assess maternal vital signs and hemodynamic stability 3

Physical Examination Findings

• Closed cervical os with no active bleeding suggests a stable clinical scenario 1, 2
• The absence of active bleeding on speculum examination reduces concern for placental abruption, placenta previa, or vasa previa 3, 1

Differential Diagnosis at 35 Weeks

Most Likely Causes

• Cervical changes or irritation - common benign cause of spotting in late third trimester 3
• Bloody show from early cervical changes - can occur even with closed os 4
• Subchorionic hemorrhage or marginal placental separation - may present with minimal bleeding 5, 6
• Placental abruption - must be considered even with minimal bleeding, though less likely with reassuring fetal status 2

Important Caveat

• Ultrasound misses up to 50% of placental abruptions, so clinical suspicion must remain high even with normal imaging 2
• Category 1 CTG makes significant abruption less likely but does not completely exclude it 3

Management Plan

Expectant Management Criteria

Since this patient meets stability criteria (hemodynamically stable, reassuring fetal status, no active bleeding, closed os), expectant management is appropriate 3, 4

Outpatient Monitoring Instructions

• Daily temperature monitoring to screen for infection 3
• Monitor for warning signs: increased bleeding, regular contractions, abdominal pain, decreased fetal movement, fever, or rupture of membranes 3
• Frequent outpatient follow-up (typically weekly) with assessment of maternal vital signs, fetal heart rate, and physical examination 3

Indications for Immediate Return to Hospital

• Heavy vaginal bleeding or passage of clots 4, 6
• Regular painful contractions suggesting labor onset 3
• Decreased fetal movement 3
• Abdominal pain that could indicate abruption 3, 2
• Rupture of membranes 3
• Maternal fever suggesting infection 3

Antenatal Surveillance

Fetal Monitoring

• Continue routine antenatal surveillance with non-stress tests or biophysical profiles as clinically indicated 3
• At 35 weeks, fetal well-being assessment is standard practice 3

Corticosteroid Consideration

• Corticosteroids are indicated up to 35+6 weeks for fetal lung maturity if delivery becomes imminent 3
• Given this patient is at 35 weeks with spotting, consider administration if not previously given and delivery risk increases 3

Delivery Planning

Timing Considerations

• At 35 weeks gestation, if bleeding worsens or fetal status becomes non-reassuring, delivery is appropriate 3
• With stable spotting and reassuring fetal status, expectant management can continue toward term 3

Mode of Delivery

• Mode of delivery depends on placental location (if previa excluded), fetal presentation, and obstetric history 3
• No automatic indication for cesarean delivery based solely on spotting with these reassuring findings 3

Common Pitfalls to Avoid

• Never perform digital cervical examination before confirming placental location - this can precipitate catastrophic hemorrhage with undiagnosed placenta previa 1, 2
• Do not dismiss minimal bleeding - placental abruption can present with minimal external bleeding but significant concealed hemorrhage 2
• Avoid false reassurance from normal ultrasound - up to 50% of abruptions are not visible on imaging 2
• Do not delay corticosteroids if delivery risk increases, as benefit extends through 35+6 weeks 3