What is the most appropriate action for a pregnant woman with prior obstetric complications and placenta previa presenting with vaginal bleeding at a hospital lacking adequate obstetric, anesthetic, and surgical facilities?

Management of Placenta Previa with Vaginal Bleeding at an Inadequate Facility

The most appropriate action is to obtain the patient's agreement for transfer to a higher-level center (Option B). 1

Rationale for Coordinated Transfer with Patient Consent

Placenta previa with vaginal bleeding in a woman with prior obstetric complications requires immediate management at a facility with comprehensive obstetric, surgical, anesthetic, and blood banking capabilities. 1 The American College of Obstetricians and Gynecologists explicitly states that when placenta accreta spectrum is unexpectedly recognized or when a facility lacks expertise to manage potential complications, "stabilization and transfer is appropriate, assuming maternal and fetal stability." 1

Why Patient Agreement is Essential

• Transfer requires informed consent and patient cooperation to ensure safe transport and continuity of care. 1
• The patient must understand the risks of remaining at an inadequate facility versus the benefits of transfer to a center with multidisciplinary expertise. 1
• Obtaining agreement allows for coordination of care between the referring and receiving facilities, which improves outcomes. 1

Critical Assessment Before Transfer

Maternal Stability Evaluation

• Assess hemodynamic stability by monitoring vital signs, ongoing blood loss, and signs of hypovolemic shock. 1
• Establish large-bore intravenous access for fluid resuscitation and potential blood product administration during transport. 2
• Obtain baseline laboratory studies including complete blood count, type and crossmatch, and coagulation panel. 2

Risk Stratification for Placenta Accreta Spectrum

• All women with placenta previa and prior cesarean deliveries must be evaluated for placenta accreta spectrum, as this combination markedly increases morbidity and mortality. 1, 3
• The risk increases 7-fold after one prior cesarean and up to 56-fold after three cesarean deliveries. 1, 3
• Prior obstetric complications further elevate the risk of severe hemorrhage and need for hysterectomy. 1

Stabilization Measures During Transfer Preparation

Immediate Interventions

• Avoid digital pelvic examination, as this can precipitate catastrophic hemorrhage. 1, 3
• Activate massive transfusion protocol early if significant bleeding is present, without waiting for laboratory results. 2
• Maintain maternal temperature above 36°C, as clotting factors function poorly at lower temperatures. 2
• Consider tranexamic acid infusion to reduce blood loss during stabilization. 2

Temporizing Measures if Hemorrhage Occurs

• If severe bleeding develops, consider abdominal packing and transfusion with locally available products while arranging urgent transfer. 1
• Alert the receiving facility's multidisciplinary team including maternal-fetal medicine, anesthesiology, gynecologic oncology or pelvic surgery, interventional radiology, and blood bank. 1

Why Other Options Are Inappropriate

Option A (Discharge with Referral Letter) is Dangerous

• Discharging a bleeding patient with placenta previa creates unacceptable risk of catastrophic hemorrhage during unmonitored transport. 1
• The patient requires continuous monitoring and immediate access to resuscitation during transfer. 1

Option C (Tell Her to Go on Her Own) is Negligent

• Instructing a high-risk obstetric patient to self-transfer violates the standard of care and abandons the physician's duty to ensure safe transfer. 1
• Coordinated transfer with medical escort is essential for maternal safety. 1

Level of Care Requirements

This patient requires transfer to a Level III or IV maternal care facility with the following capabilities: 1

• Maternal-fetal medicine specialists available 24/7 for management of complex obstetric complications. 1
• Experienced pelvic surgeons (gynecologic oncologists or female pelvic medicine specialists) for potential cesarean hysterectomy. 1
• Blood bank with massive transfusion protocol capability, as blood loss can exceed 1,500 mL. 1, 3
• Obstetric anesthesiologists and critical care services for perioperative and postoperative management. 1
• Interventional radiology services for potential uterine artery embolization if conservative management is attempted. 1

Common Pitfalls to Avoid

• Never attempt manual placental removal if placenta accreta is encountered, as this causes profuse hemorrhage. 1, 3
• Do not delay transfer waiting for "optimal" timing—maternal stability takes precedence, and approximately 50% of women with placenta accreta spectrum beyond 36 weeks require emergent delivery for hemorrhage. 3
• Failure to recognize placenta accreta spectrum in women with placenta previa and prior cesarean deliveries can lead to catastrophic hemorrhage, so maintain high clinical suspicion. 1, 3