What is the best management approach for a 35-week pregnant woman with placenta previa (placenta covering the internal os) and a history of moderate vaginal bleeding, who is now stable after initial treatment for hypotension (low blood pressure) and tachycardia (elevated heart rate), with normal Cardiotocography (CTG) results?

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Management of Stabilized Placenta Previa at 35 Weeks

The optimal management is to observe the patient closely with planned cesarean delivery at 36-37 weeks (Option C), as delivery should not be delayed beyond 36 0/7 weeks for placenta previa. 1

Rationale for Expectant Management with Scheduled Delivery

Immediate cesarean section is not indicated because the patient is now hemodynamically stable, bleeding has stopped, and the CTG is reassuring. 1 The American College of Obstetricians and Gynecologists recommends cesarean delivery be planned at 34 0/7 to 35 6/7 weeks for uncomplicated placenta previa, balancing neonatal complications against increased maternal bleeding risk after 36 weeks. 1 However, delivery should not be delayed beyond 36 0/7 weeks, as approximately 50% of women with placenta accreta spectrum beyond 36 weeks require emergent delivery for hemorrhage. 1

Why Not Emergency Cesarean Section Now?

  • The patient has achieved hemodynamic stability after resuscitation (no longer hypotensive or tachycardic) 1
  • Bleeding has completely stopped 1
  • Fetal status is reassuring with normal CTG 1
  • The patient is at 35 weeks, and gaining even 1-2 more weeks significantly reduces neonatal morbidity while the maternal hemorrhage risk remains manageable with close observation 1

Why Induction of Labor is Contraindicated

Induction of labor is absolutely contraindicated in complete placenta previa covering the internal os, as vaginal delivery would require the fetus to pass through the placenta, causing catastrophic maternal and fetal hemorrhage. 2, 3 Women with complete placenta previa must be delivered by cesarean section. 2

Critical Management Steps During Observation Period

Immediate Actions

  • Administer antenatal corticosteroids (intramuscular dexamethasone) immediately, as delivery is anticipated before 37 0/7 weeks 1
  • Ensure patient remains hospitalized given the history of bleeding requiring resuscitation 1
  • Maintain strict pelvic rest - no digital vaginal examinations, no intercourse 1

Evaluation for Placenta Accreta Spectrum

  • This patient requires urgent evaluation for placenta accreta spectrum disorder, particularly if she has any prior cesarean deliveries, as the risk increases 7-fold after one cesarean to 56-fold after three cesareans 1
  • Doppler ultrasound should assess for bladder invasion and abnormal placental blood flow patterns 1

Optimization Before Delivery

  • Maximize hemoglobin with oral or intravenous iron supplementation to prepare for potential hemorrhage at delivery 1
  • Notify blood bank in advance due to frequent need for large-volume transfusion 1

Delivery Planning

  • Schedule cesarean delivery between 36 0/7 to 37 0/7 weeks - do not delay beyond 36 weeks 1
  • Delivery must occur at a level III or IV maternal care facility with multidisciplinary team including maternal-fetal medicine, pelvic surgeons, urologists, interventional radiologists, obstetric anesthesiologists, and adequate blood banking 1
  • Preoperative coordination with all teams is essential 1

Common Pitfall to Avoid

History of bleeding episodes predicts future bleeding - women who have experienced one bleeding episode are at significantly increased risk for subsequent hemorrhage. 4 Therefore, maintain a low threshold for proceeding to delivery if any recurrent bleeding occurs, even if minor. 1 The patient should remain hospitalized with continuous monitoring until delivery. 1

References

1
Guideline

Management of Placenta Previa

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

2
Research

Placenta previa, placenta accreta, and vasa previa.

Obstetrics and gynecology, 2006

3
Research

Late pregnancy bleeding.

American family physician, 2007

4
Guideline

Travel Safety with Low-Lying Placenta

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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