What is the management for a 32-week pregnant woman with brown discharge, normal fetal heart tones, and normal maternal blood pressure, who is asymptomatic?

Management of Brown Discharge at 32 Weeks with Normal Fetal Heart Tones and Maternal Blood Pressure

This asymptomatic 32-week pregnant woman with brown discharge, normal fetal heart tones, and normal blood pressure requires immediate evaluation to rule out placental abruption or bleeding, followed by close outpatient monitoring if initial assessment is reassuring. 1

Immediate Assessment Required

Brown discharge at 32 weeks represents old blood and warrants urgent evaluation to determine the source and exclude serious complications, even when the patient is asymptomatic:

• Perform speculum examination to identify the source of bleeding (cervical vs. vaginal vs. uterine) and assess for cervical dilation or effacement 1
• Obtain ultrasound evaluation to assess placental location, rule out placenta previa, evaluate for signs of abruption, and confirm fetal well-being 2
• Initiate continuous electronic fetal heart rate monitoring for at least 4-6 hours to detect any concerning patterns that may indicate placental insufficiency 2, 3
• Assess uterine activity to rule out contractions or uterine irritability that could indicate preterm labor or abruption 4

Laboratory and Clinical Evaluation

Complete the following baseline assessments to establish maternal and fetal status:

• Complete blood count to assess hemoglobin and platelet count, establishing baseline in case bleeding worsens 2
• Type and screen for potential blood product needs if bleeding progresses 1
• Kleihauer-Betke test if patient is Rh-negative to assess for fetomaternal hemorrhage and determine RhoGAM dosing 3
• Coagulation studies if clinical suspicion for abruption or if patient has risk factors for coagulopathy 5

Risk Stratification and Monitoring Plan

If Initial Evaluation is Reassuring (No Active Bleeding, Normal Fetal Testing):

• Outpatient management with close follow-up is appropriate if bleeding has resolved, fetal monitoring is reassuring, and no evidence of abruption or preterm labor exists 1
• Fetal kick counts should be performed daily by the patient to monitor fetal well-being 2
• Weekly or twice-weekly non-stress tests starting immediately to ensure continued fetal well-being given the bleeding episode 2
• Ultrasound for fetal growth assessment every 2-4 weeks to monitor for any placental insufficiency 1

If Concerning Features Develop:

• Admit for continuous monitoring if any of the following occur: recurrent bleeding, uterine contractions, non-reassuring fetal heart rate patterns, or maternal symptoms (abdominal pain, cramping) 2, 6
• Consider delivery at 34-37 weeks depending on clinical course, with earlier delivery if fetal compromise or maternal instability develops 6
• Administer corticosteroids if delivery before 34 weeks appears likely to enhance fetal lung maturity 6

Critical Warning Signs Requiring Immediate Intervention

Instruct the patient to return immediately for any of the following:

• Active bright red bleeding or increased volume of discharge 1
• Abdominal pain or cramping suggesting abruption or preterm labor 6
• Decreased fetal movement indicating potential fetal compromise 2, 3
• Regular contractions suggesting preterm labor 1

Common Pitfalls to Avoid

• Do not dismiss brown discharge as benign without thorough evaluation, as it may represent a sentinel bleed preceding more significant hemorrhage 6
• Do not rely solely on maternal symptoms to assess severity, as significant placental pathology can exist with minimal symptoms 5
• Do not delay fetal monitoring even when initial presentation appears reassuring, as fetal heart rate patterns provide critical information about placental function 3, 4
• Avoid assuming cervical source without speculum examination, as uterine bleeding can present as brown discharge 1