What is the best course of action for a pregnant patient at 31 weeks gestation with placenta previa, who presented with abdominal pain, moderate vaginal bleeding, hypotension, and tachycardia, but is now vitally stable after resuscitation?

Management of Stabilized Placenta Previa at 31 Weeks with Prior Hemorrhage

After achieving hemodynamic stability following resuscitation in a patient with placenta previa at 31 weeks gestation, the correct management is administration of corticosteroids (intramuscular dexamethasone) with close observation until 34-37 weeks, not immediate cesarean section. 1

Immediate Post-Resuscitation Management

Once the patient is vitally stable after the initial hemorrhagic episode, the priority shifts from emergency intervention to optimizing fetal maturity while maintaining maternal safety:

• Administer antenatal corticosteroids immediately when delivery is anticipated before 37 weeks gestation, as this patient is only 31 weeks 1
• Intramuscular dexamethasone is the appropriate steroid preparation for fetal lung maturation 1
• Continue intensive monitoring with serial hemoglobin checks, coagulation studies, and continuous fetal heart rate monitoring 2, 1

Why Not Immediate Cesarean Section?

The key clinical detail is that the patient is now vitally stable after resuscitation. This fundamentally changes the management approach:

• Immediate cesarean delivery is indicated only when maternal hemodynamic instability persists or cannot be corrected 2
• At 31 weeks gestation, delaying delivery by even 3-6 weeks dramatically reduces neonatal morbidity from prematurity 1, 3
• The optimal delivery timing for uncomplicated placenta previa is 34 0/7 to 35 6/7 weeks gestation 1
• Approximately 50% of women with placenta previa will have recurrent bleeding episodes, but most can be managed expectantly if hemodynamically stable 4

Expectant Management Protocol

Close observation means:

• Hospitalization with bed rest and minimal ambulation 4
• Weekly corticosteroid administration until 32 weeks gestation 4
• Serial ultrasound examinations every 2 weeks to assess fetal growth and confirm persistent placenta previa 4
• Continuous availability of blood products and operating room access 1
• Multidisciplinary team coordination including maternal-fetal medicine, anesthesiology, and neonatology 1

Critical Assessment for Placenta Accreta Spectrum

This patient's presentation with moderate bleeding, hypotension, and tachycardia raises concern for possible placenta accreta spectrum, especially if she has prior cesarean deliveries:

• Evaluate immediately for placenta accreta spectrum given the severity of initial hemorrhage 1
• The risk increases 7-fold after one prior cesarean and up to 56-fold after three cesarean deliveries 1
• MRI may be helpful if ultrasound findings suggest abnormal placental invasion 1
• If placenta accreta is confirmed, plan for cesarean hysterectomy with the placenta left in situ at time of delivery 1, 5

Delivery Planning Timeline

Target delivery window: 34 0/7 to 35 6/7 weeks gestation 1

• Do not delay beyond 36 0/7 weeks, as approximately 50% of women with placenta accreta spectrum beyond 36 weeks require emergent delivery for hemorrhage 1
• Earlier delivery is required if: persistent bleeding recurs, preeclampsia develops, labor begins, membranes rupture, or fetal compromise occurs 1
• Perform amniocentesis at 36 weeks if still undelivered to confirm fetal lung maturity before elective cesarean 4

Preparation for Delivery

• Optimize hemoglobin with oral or intravenous iron supplementation during the expectant period 1
• Notify blood bank in advance given high likelihood of massive transfusion requirement 1
• Ensure delivery occurs at a facility with level III/IV maternal care capabilities 1
• Assemble multidisciplinary team including pelvic surgeons and interventional radiology 1

Common Pitfalls to Avoid

• Do not perform digital vaginal examination as this can trigger catastrophic hemorrhage 1, 6
• Do not attempt vaginal delivery with complete placenta previa covering the cervical os 6, 3
• Do not attempt manual placental removal at cesarean if placenta accreta is encountered, as this causes profuse hemorrhage 1, 5
• Do not delay corticosteroid administration while waiting for delivery planning 1

Why Blood Transfusion Alone is Insufficient

While this patient may have required blood transfusion during initial resuscitation, transfusion alone does not address the underlying management strategy:

• Transfusion is a supportive measure, not definitive management 2
• The question asks for the best course of action after stabilization, which requires a comprehensive plan including corticosteroids and timing of delivery 1
• Maintaining hemoglobin >30% is part of expectant management but not the primary intervention 3

The answer is D (Intramuscular dexamethasone) as part of a comprehensive expectant management strategy with close observation until 34-37 weeks, or C if interpreted as the complete management approach including both steroids and observation. 1, 4