Placenta Previa Management at Term
A 39-year-old woman at 37 weeks of gestation with known placenta previa totalis reports a small fresh vaginal bleed this morning that has stopped. She had two similar episodes at 30 and 34 weeks. Blood pressure is 118/70 mm Hg, pulse 88 beats/min, hemoglobin 108 g/L, and cardiotocography is reactive. Which of the following is the most appropriate timing of hospital admission?
- A.Admit her if bleeding recurs
- B.Admit once the cesarean date is booked
- C.Admit her immediately for inpatient monitoringCorrect
- D.No admission; review in one week
Explanation
A major placenta previa that has already bled repeatedly is one of the highest-risk situations in obstetrics because the next bleed can be torrential and unheralded, and exsanguination can occur within minutes as uterine blood flow at term approaches 700 mL per minute. The fact that this episode was small and has stopped is not reassuring, since recurrent antepartum hemorrhage predicts further and usually heavier bleeding. She should be admitted immediately for inpatient observation with intravenous access, a full blood count, a group and save with cross-matched blood available, anti-D if she is rhesus negative, and continuous availability of an operating theatre and neonatal team. Admission also allows fetal monitoring and immediate recourse to cesarean section if heavy bleeding or fetal compromise occurs. At 37 weeks she is term, so delivery by elective cesarean section at 36 to 37 weeks is planned, and any bleeding at this gestation is an indication to consider expediting it rather than sending her home. Digital vaginal examination is absolutely contraindicated because it can provoke catastrophic hemorrhage. Waiting for another bleed or reviewing in a week gambles with maternal and fetal life, and outpatient management is only ever considered for asymptomatic women who live close to hospital with immediate transport and constant companionship.
Why each option
- A.
- Waiting for the next bleed is dangerous because hemorrhage from a total previa can be sudden and massive with no time to reach hospital.
- B.
- Scheduling first and admitting later leaves her unmonitored during the period of highest risk; the cesarean can be planned while she is an inpatient.
- C.
- Correct. Recurrent bleeding from placenta previa totalis at term requires immediate admission with cross-matched blood and readiness for urgent cesarean section.
- D.
- Outpatient review in a week is unsafe for a symptomatic major previa at term and ignores the risk of catastrophic hemorrhage.
Reference: RCOG Green-top Guideline No. 27a, Placenta Praevia and Placenta Accreta, 2018
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