What is the most appropriate management for a patient at 35 weeks of gestation with complete placenta previa and painless vaginal bleeding who is hemodynamically stable?

Management of Complete Placenta Previa at 35 Weeks with Resolved Bleeding

The most appropriate management is to wait until 37 weeks, then perform cesarean section (Option C). 1, 2

Rationale for Delayed Delivery

The American College of Obstetricians and Gynecologists recommends planned cesarean delivery at 34 0/7 to 35 6/7 weeks for uncomplicated placenta previa when balancing maternal hemorrhage risk against neonatal complications. 1, 2 However, this patient is hemodynamically stable with resolved bleeding at 35 weeks, which allows for expectant management to reach 37 weeks for optimal neonatal outcomes while minimizing prematurity-related morbidity. 1

Waiting beyond 36 0/7 weeks carries significant risk, as approximately 50% of women with placenta accreta spectrum (which must be evaluated in this patient) require emergent delivery for hemorrhage after this gestational age. 1, 2 Therefore, delivery should be planned between 36-37 weeks, not awaiting spontaneous labor beyond this window. 3

Why Other Options Are Incorrect

• Option A (Induce labor): Vaginal delivery is contraindicated in complete placenta previa covering the cervical os, as this would result in catastrophic maternal hemorrhage. 4, 5 Cesarean delivery is mandatory for complete previa. 4

• Option B (Immediate cesarean section): This patient is hemodynamically stable with resolved bleeding at 35 weeks. Immediate delivery would subject the neonate to unnecessary prematurity-related complications without maternal indication. 1, 2

• Option D (Wait for spontaneous labor): Awaiting spontaneous labor is dangerous because labor onset with complete placenta previa causes severe hemorrhage as the cervix dilates against the placenta. 4, 5 Additionally, approximately 50% of women require emergent delivery for hemorrhage beyond 36 weeks. 1, 2

Critical Preoperative Planning Required

Evaluation for Placenta Accreta Spectrum

• This patient MUST be evaluated for placenta accreta spectrum disorder given complete placenta previa, as the risk increases 7-fold after one prior cesarean delivery and up to 56-fold after three cesarean deliveries. 1, 2
• MRI may be helpful if ultrasound findings are concerning for accreta, particularly for posterior placenta or suspected bladder invasion. 1, 2

Multidisciplinary Coordination

• Delivery must occur at a level III or IV maternal care facility with maternal-fetal medicine subspecialists, pelvic surgeons (gynecologic oncology or urology), interventional radiologists, obstetric anesthesiologists, and neonatologists. 1, 2
• Notify the blood bank in advance due to frequent need for large-volume transfusion, particularly if accreta is suspected. 3, 1, 2
• Preoperative coordination should include discussion of potential cesarean hysterectomy if accreta is confirmed. 3

Anemia Optimization

• Maximize hemoglobin values before delivery by treating any anemia with oral or intravenous iron to prepare for potential hemorrhage. 3, 1, 2

Antenatal Corticosteroids

• Administer antenatal corticosteroids if delivery is planned before 37 0/7 weeks to promote fetal lung maturity. 3, 1

Intraoperative Management Principles

Surgical Approach

• Make the uterine incision away from the placenta when possible after inspecting the uterus following peritoneal entry. 1
• If placenta accreta is encountered, leave the placenta in situ and proceed to cesarean hysterectomy, as attempts at manual placental removal cause profuse hemorrhage. 3, 1, 4

Hemorrhage Protocol

• Activate massive transfusion protocol early with transfusion of packed red blood cells, fresh frozen plasma, and platelets in a 1:1:1 ratio. 1, 2
• Maintain maternal temperature >36°C during surgery, as clotting factors function poorly at lower temperatures. 1, 6
• Consider tranexamic acid to reduce blood loss. 2

Common Pitfalls to Avoid

• Failure to diagnose placenta accreta spectrum in women with placenta previa and prior cesarean deliveries can lead to catastrophic hemorrhage. 1
• Digital pelvic examination must be avoided until placenta previa has been excluded, as it can trigger life-threatening hemorrhage. 1, 2, 4
• Attempting vaginal delivery with complete placenta previa is absolutely contraindicated and will result in severe maternal hemorrhage. 4
• Delaying delivery beyond 36-37 weeks significantly increases the risk of emergent delivery for hemorrhage. 1, 2

Postoperative Monitoring

• Intensive care unit monitoring is recommended given risks of ongoing bleeding, with close monitoring of volume status, urine output, and hemodynamics. 1, 2
• Maintain low threshold for reoperation if ongoing bleeding is suspected. 1, 2