What is the most appropriate management for a 35-week pregnant patient with complete placenta previa, painless vaginal bleeding that has stopped, and who is hemodynamically stable?

Management of Complete Placenta Previa at 35 Weeks with Resolved Bleeding

Close observation with hospitalization until 34-35 weeks, followed by scheduled cesarean delivery, is the most appropriate management for this hemodynamically stable patient with complete placenta previa at 35 weeks. The correct answer is effectively Option C, though delivery should occur at 34-35 weeks rather than waiting until 37 weeks.

Immediate Management

This patient requires hospitalization given the recent bleeding episode. Women with placenta previa who experience bleeding should be hospitalized, as those with one bleeding episode are at increased risk for subsequent hemorrhage 1, 2. The bleeding has stopped and she is stable, so immediate cesarean delivery is not indicated 2.

Critical Initial Steps

• Avoid any digital vaginal examination, as this can trigger catastrophic hemorrhage in placenta previa 2, 3
• Assess for placenta accreta spectrum disorder immediately, particularly given any history of prior cesarean deliveries—the risk increases 7-fold after one prior cesarean and up to 56-fold after three cesarean deliveries 2, 3
• Optimize hemoglobin levels with oral or intravenous iron supplementation to prepare for potential hemorrhage at delivery 1, 2
• Notify the blood bank and coordinate massive transfusion protocol availability, as large-volume transfusion is frequently needed 1, 2

Optimal Timing of Delivery

Delivery should occur at 34 0/7 to 35 6/7 weeks of gestation for uncomplicated placenta previa. This timing balances neonatal complications from prematurity against the substantially increased maternal bleeding risk after 36 weeks 2, 3.

Why Not Wait Until 37 Weeks

Waiting beyond 36 0/7 weeks is explicitly not advised, as approximately 50% of women with placenta accreta spectrum beyond 36 weeks require emergent delivery for hemorrhage 1, 2. Since this patient is already at 35 weeks and has experienced bleeding, proceeding with delivery planning in the 34-35 week window is appropriate 2, 3.

Antenatal Corticosteroids

Administer antenatal corticosteroids immediately for fetal lung maturation, as delivery is anticipated before 37 0/7 weeks 1, 2.

Delivery Planning Requirements

This patient must be delivered at a level III or IV maternal care facility with the following capabilities 2, 3:

• Maternal-fetal medicine subspecialists
• Experienced pelvic surgeons (gynecologic oncology or urology)
• Interventional radiologists
• Obstetric anesthesiologists
• Neonatologists
• Blood bank with massive transfusion protocol capability
• Intensive care unit for postoperative monitoring

Preoperative coordination must occur with anesthesiology, maternal-fetal medicine, neonatology, and expert pelvic surgeons before the scheduled cesarean 1, 2.

Why Other Options Are Incorrect

Option A (Induce Labor) and Option D (Spontaneous Labor)

Vaginal delivery is absolutely contraindicated in complete placenta previa. The placenta completely covers the cervical os, making vaginal delivery impossible without catastrophic maternal hemorrhage 4, 5. Any attempt at labor would result in placental separation and life-threatening bleeding.

Option B (Immediate Cesarean Section)

Immediate delivery is not indicated in a hemodynamically stable patient at 35 weeks with resolved bleeding 2. Rushing to delivery without proper multidisciplinary coordination and preparation increases maternal morbidity 1, 2. The patient should be stabilized, corticosteroids administered, and delivery planned within the optimal 34-35 week window with full team preparation 2, 3.

Intraoperative Considerations

When cesarean delivery is performed 1, 2, 3:

• Make the uterine incision away from the placenta when possible to minimize bleeding
• Leave the placenta in situ if placenta accreta spectrum is encountered—attempts at forced removal cause profuse hemorrhage 1, 2
• Prepare for cesarean hysterectomy, as this is the most accepted approach for placenta accreta spectrum 1, 2
• Maintain patient temperature >36°C during surgery, as clotting factors function poorly at lower temperatures 2
• Use massive transfusion protocol with 1:1:1 to 1:2:4 ratio of packed red blood cells:fresh frozen plasma:platelets if hemorrhage occurs 2, 3

Common Pitfalls to Avoid

The most critical error is failing to evaluate for placenta accreta spectrum disorder in any patient with placenta previa and prior uterine surgery, as this can lead to catastrophic hemorrhage 2, 3. Attempting vaginal delivery or waiting until 37 weeks are both dangerous management errors that significantly increase maternal morbidity and mortality 2, 4.