In a 40-year-old woman at 32 weeks gestation with two prior cesarean deliveries, presenting with a brief episode of mild painless vaginal bleeding, ultrasound showing partial placenta previa, and a reactive cardiotocogram, what is the most appropriate management?

Management of Partial Placenta Previa at 32 Weeks with Mild Bleeding

Expectant management with hospitalization is the most appropriate approach for this stable patient with partial placenta previa at 32 weeks gestation, mild bleeding that has resolved, and a reactive cardiotocogram. 1

Rationale for Expectant Management

The clinical scenario describes a hemodynamically stable patient with:

• Mild bleeding that occurred "few hours ago" (implying it has stopped)
• Reactive cardiotocogram (indicating fetal well-being)
• 32 weeks gestation (preterm but approaching viability threshold where outcomes are favorable) 2

Expectant management involves hospitalization with bed rest, corticosteroid administration for fetal lung maturity, serial ultrasound monitoring, and delaying delivery until 36 weeks or documented fetal lung maturity. 1, 3

Why NOT Immediate Cesarean Section

Immediate cesarean delivery at 32 weeks would expose the neonate to unnecessary prematurity risks when the mother is stable and bleeding has ceased. 1 The survival rate for neonates at 32 weeks is 95% with low neurological sequelae risk, but delaying delivery closer to term further improves outcomes. 2

Cesarean section is indicated only for:

• Active, uncontrolled hemorrhage
• Maternal hemodynamic instability
• Non-reassuring fetal status
• Reaching 36 weeks gestation with persistent placenta previa 1, 3

Why NOT Amniocentesis for Fetal Lung Maturity

Amniocentesis is premature at this point because the patient is stable with no indication for immediate delivery. 1 Amniocentesis for fetal lung maturity assessment is performed when delivery is being considered at 36 weeks gestation in patients with persistent placenta previa. 4

Why NOT Fetal Biophysical Profile

A reactive cardiotocogram already confirms fetal well-being, making biophysical profile redundant in this acute setting. 2 The biophysical profile does not change immediate management decisions when the NST is already reactive.

Critical Management Components

The expectant management protocol includes:

• Strict avoidance of digital vaginal examination (can precipitate catastrophic hemorrhage) 2, 5, 6
• Hospitalization with bed rest and minimal ambulation 1, 4
• Corticosteroid administration (betamethasone for fetal lung maturity given delivery before 34 weeks is possible) 2, 1
• Maintenance of maternal hematocrit ≥30% with transfusion support if needed 1
• Serial ultrasound examinations at 2-week intervals to assess placental location and fetal growth 4
• Continuous fetal heart rate monitoring during hospitalization 1
• Tocolytic therapy if uterine contractions develop (bleeding with placenta previa is usually associated with contractions) 1

High-Risk Considerations

This patient has TWO prior cesarean deliveries, which dramatically increases her risk for placenta accreta spectrum. 2, 3 The incidence of placenta accreta increases with each prior cesarean, and the combination of prior cesarean delivery with current placenta previa creates exceptional risk. 2

Delivery should be planned at a level III or IV maternal care facility with:

• Multidisciplinary team experienced in placenta accreta management
• Blood bank with massive transfusion protocols
• Immediate access to interventional radiology 2

Timing of Delivery

Target delivery at 36 weeks gestation with documented fetal lung maturity via amniocentesis, or earlier if:

• Recurrent significant bleeding occurs
• Maternal hemodynamic compromise develops
• Fetal status becomes non-reassuring 1, 3, 4

Answer: A. Expectant management