What is the most appropriate management for a patient at 28-32 weeks gestation with a history of 1-2 previous cesarean sections (C-sections), presenting with mild, painless vaginal bleeding and a diagnosis of partial placenta previa, with a reactive cardiotocogram (CTG)?

Management of Partial Placenta Previa at 28-32 Weeks with Mild Bleeding

Expectant management with hospitalization is the most appropriate approach for this patient with partial placenta previa at 28-32 weeks gestation presenting with mild painless bleeding and a reactive cardiotocogram. 1, 2

Rationale for Expectant Management

The clinical scenario describes a hemodynamically stable patient with:

• Mild bleeding that has stopped (described as "few hours ago")
• Reactive CTG confirming fetal well-being
• Preterm gestation (28-32 weeks) where delivery would result in significant prematurity-related morbidity
• No signs of active hemorrhage or fetal compromise

1, 2

Specific Management Protocol

Immediate Actions

• Admit for inpatient observation and bed rest with minimal ambulation 1, 2
• Avoid digital vaginal examination absolutely, as this can precipitate catastrophic hemorrhage in placenta previa 3, 4
• Maintain maternal hematocrit ≥30% with transfusion support if needed 1
• Serial ultrasonography at 2-week intervals to assess fetal growth and placental location 1, 2

Corticosteroid Administration

• Administer corticosteroids weekly until 32 weeks' gestation to accelerate fetal lung maturity 1, 2
• This is critical given the 62-67% risk of recurrent bleeding requiring expeditious delivery 2, 5

Tocolytic Therapy

• Consider tocolytics if uterine contractions develop, as bleeding with placenta previa is usually associated with contractions 1, 5
• Tocolysis was initiated in 53% of cases in one series 5

Monitoring Strategy

• Antepartum fetal heart rate monitoring to detect fetal compromise 1
• Serial hemoglobin/hematocrit monitoring 1, 5
• Continuous assessment for recurrent bleeding 2

Why Other Options Are Inappropriate

Option B (Fetal Biophysical Profile)

• The reactive CTG already confirms fetal well-being 1
• BPP adds no additional management value in this stable scenario
• Does not address the primary issue of placenta previa management

Option C (Immediate Cesarean Section)

• Delivery at 28-32 weeks carries 4-8% perinatal mortality primarily from prematurity complications 1
• Immediate delivery is only indicated for:
  • Uncontrolled maternal hemorrhage
  • Non-reassuring fetal status
  • Maternal hemodynamic instability
• None of these conditions are present 1, 2

Option D (Amniocentesis for Lung Maturity)

• Amniocentesis is reserved for 36 weeks' gestation when elective delivery is planned 1, 2
• At 28-32 weeks, fetal lungs are definitively immature
• The risk of amniocentesis precipitating bleeding outweighs any benefit
• Corticosteroids should be given regardless at this gestational age 1, 2

Target Delivery Timing

Goal is to reach 36 weeks' gestation with documented fetal lung maturity via amniocentesis, followed by elective cesarean delivery 1, 2

The mean gestational age at delivery in expectant management studies was 34.5-34.6 weeks, with acceptable neonatal outcomes and no neonatal deaths 2

Critical Safety Considerations

High-Risk Features in This Patient

• History of 1-2 prior cesarean sections significantly increases risk of placenta accreta 1, 6
• Placenta accreta is common when placenta previa occurs with prior cesarean delivery 1, 6
• Delivery should occur at an institution with adequate blood banking facilities and multidisciplinary team available 6

Recurrent Bleeding Risk

• 62% of patients experience recurrent bleeding episodes 2
• 26 of 33 patients (79%) with recurrent bleeding required expeditious cesarean delivery 2
• Patients must be counseled about this risk and the need for immediate return if bleeding recurs

Outpatient vs Inpatient Management

While one randomized trial showed outpatient management after initial stabilization (≥72 hours) was safe and cost-effective (saving $15,080 per patient), initial hospitalization for stabilization, corticosteroid administration, and assessment is mandatory 2. Given this patient just presented "few hours ago," they are in the initial stabilization phase requiring inpatient care 2.