What is the best course of action for a 34-year-old pregnant woman at 31 weeks gestation with abdominal pain, moderate vaginal bleeding, hypotension, and tachycardia, who has a placenta covering the cervical os (placenta previa) on ultrasound?

Immediate Cesarean Section is Required

This patient requires immediate cesarean delivery (Option B) given the confirmed placenta previa with hemodynamic instability from significant hemorrhage, despite post-resuscitation stabilization. 1

Clinical Reasoning

Why Immediate Delivery is Mandatory

• The patient has already demonstrated life-threatening hemorrhage requiring resuscitation (hypotension 80/50, tachycardia) at only 31 weeks gestation, indicating high-grade placenta previa with active bleeding that has temporarily stabilized but carries extreme risk of recurrence 1

• ACOG guidelines explicitly state that approximately 50% of women with placenta accreta spectrum (which must be presumed given the severity of hemorrhage) beyond 36 weeks require emergent delivery for hemorrhage - this patient has already experienced that catastrophic bleeding at 31 weeks, making expectant management untenable 1

• The patient is at dramatically increased risk for recurrent massive hemorrhage, as women with one episode of bleeding are at significantly increased risk for subsequent bleeding episodes, and waiting invites maternal mortality 1

Why Other Options Are Incorrect

Option C (Steroids & observation to 37 weeks) is dangerous and contradicts guidelines:

• While ACOG recommends planned cesarean delivery at 34-35 6/7 weeks for uncomplicated placenta previa, this patient has already experienced hemodynamic compromise requiring resuscitation 1
• Hospitalization is mandated for women with active bleeding, and this patient has demonstrated she cannot safely reach 37 weeks 1
• The guidelines explicitly warn against delaying beyond 36 weeks even in stable patients due to hemorrhage risk - this patient is already unstable at 31 weeks 1

Option D (Intramuscular dexamethasone alone) addresses only fetal lung maturity but ignores the life-threatening maternal hemorrhage that has already occurred 1

Option A (Blood transfusion alone) is insufficient as it addresses the consequence but not the source of ongoing bleeding risk 1

Proper Management Algorithm

Immediate Pre-Operative Steps

1. Administer corticosteroids immediately (betamethasone or dexamethasone) for fetal lung maturation given delivery before 37 weeks, but do not delay surgery for steroid completion 1

2. Mobilize multidisciplinary team urgently: maternal-fetal medicine, anesthesiology, neonatology, expert pelvic surgeons (potentially gynecologic oncology), and blood bank for massive transfusion protocol 1

3. Evaluate for placenta accreta spectrum given the severity of initial hemorrhage - the risk increases 7-fold after one prior cesarean delivery to 56-fold after three cesarean deliveries 1

4. Notify blood bank for large-volume transfusion capability and prepare for transfusion in 1:1:1 ratio (packed RBCs:FFP:platelets) if hemorrhage occurs 1

Intraoperative Considerations

• Plan for potential cesarean hysterectomy if placenta accreta spectrum is encountered - the most accepted approach is leaving the placenta in situ rather than attempting removal, which causes profuse hemorrhage 1

• Optimize surgical approach: inspect uterus after peritoneal entry to determine placental location, make uterine incision away from placenta when possible 1

• If placenta accreta is encountered, do not attempt forced placental removal as this results in catastrophic hemorrhage 1, 2

Critical Pitfall to Avoid

The most dangerous error would be attempting expectant management to reach 34-37 weeks - this patient has already declared herself at extreme risk through hemodynamic compromise at 31 weeks, and recurrent hemorrhage could result in maternal death before reaching the delivery suite 1, 3