What is the management for a 29-year-old woman, gravida (number of times pregnant) 1, para (number of viable births) 0, at 33 weeks gestation with known vasa previa, who experienced rupture of membranes with blood-tinged fluid, no contractions, and no heavy vaginal bleeding, with a fetal heart rate of bradycardia?

From the Guidelines

This patient with vasa previa who has ruptured membranes and blood-tinged fluid with fetal bradycardia requires immediate emergency cesarean delivery. The fetal heart rate of 100/min indicates fetal distress, likely due to bleeding from the ruptured vasa previa vessels. Preparation should include immediate notification of the operating room team, anesthesia, and neonatology for an emergency cesarean delivery. Two large-bore IVs should be placed, and blood products should be made available as significant hemorrhage may occur. The patient should receive nothing by mouth and be prepared for general anesthesia if needed for rapid delivery. Vasa previa is a condition where fetal blood vessels traverse the membranes over the cervical os, unprotected by placental tissue or umbilical cord. When membranes rupture, these vessels can tear, causing fetal hemorrhage and exsanguination. The blood-tinged fluid likely represents fetal blood, and the bradycardia indicates the fetus is already compromised. Even without heavy vaginal bleeding, fetal blood loss can be significant and rapidly fatal. Every minute counts in this scenario, as fetal mortality approaches 100% if delivery is delayed after vessel rupture. The prior diagnosis of vasa previa and current presentation with rupture of membranes, blood-tinged fluid, and fetal bradycardia constitute an obstetrical emergency requiring immediate intervention, as highlighted in the context of managing complications in pregnancy 1.

Key considerations in this case include:

• The risk of fetal exsanguination and death if delivery is delayed
• The need for immediate cesarean delivery to prevent further fetal blood loss
• Preparation for potential maternal hemorrhage and the need for blood products
• The importance of a multidisciplinary approach, including anesthesia and neonatology, for optimal outcomes

Given the high risk of fetal mortality associated with delayed delivery in the context of vasa previa with ruptured membranes and fetal distress, immediate emergency cesarean delivery is the most appropriate course of action. This approach prioritizes the reduction of morbidity and mortality, and improvement of quality of life for both the mother and the fetus, as the primary outcome in managing this obstetrical emergency.

From the Research

Patient Management

• The patient is a 29-year-old woman, gravida 1 para 0, at 33 weeks gestation with a known vasa previa, and has just experienced rupture of membranes with leakage of blood-tinged fluid 2.
• She has no contractions or heavy vaginal bleeding, and the pregnancy was the result of in vitro fertilization with an otherwise uncomplicated course.
• A fetal growth ultrasound performed yesterday revealed a cephalic fetus with an estimated fetal weight at the 50th percentile and a normal amniotic fluid index.

Cesarean Delivery Considerations

• An emergent cesarean delivery may be necessary to immediately intervene and improve maternal or fetal outcome, especially in cases of fetal distress, prolapsed cord, maternal hemorrhage from previa or trauma, uterine rupture, and complete placental abruption 2.
• Preoperative preparation for cesarean delivery is crucial and should include protocols guided by the findings of recent reviews, with the goal of decreasing maternal and neonatal morbidity and mortality related to cesarean delivery 3.
• The preoperative period should include skin cleansing, possibly with showering with either soap or an antiseptic solution at least the night before the procedure, and weight-based intravenous cefazolin 60 minutes before skin incision 3.

Surgical Management

• Modified cesarean hysterectomy may be considered in cases of placenta previa percreta with bladder invasion, as it can prevent hemorrhage and the need for blood salvage, transfusion, or component therapy 4.
• The use of a Rapid Response Team (RRT) in emergency cesarean section can improve delivery intervals and be conducive to maternal and infant safety, with shorter operation time indexes and higher neonatal Apgar scores 5.

Maternal and Fetal Outcomes

• Maternal demographics and prenatal history may impact the efficacy of betamethasone therapy for threatened preterm labor, with cesarean births associated with higher rates of neonatal respiratory distress syndrome (RDS) compared to vaginal births 6.
• Preterm premature rupture of membranes (PPROM) may be associated with lower RDS rates in neonates delivered within 14 days of betamethasone dosing, highlighting the importance of individualized care and consideration of maternal and fetal factors in treatment decisions 6.