Placenta Previa: Management of Bleeding at Term
A 27-year-old woman, gravida 4 para 2, at 37 weeks presents with painless vaginal bleeding soaking two pads in an hour. Blood pressure is 106/66 mm Hg, pulse 104 beats/min, the uterus is soft and non-tender, and the fetal tracing is reactive. Ultrasound shows the placenta covering the internal os. Which of the following is the most appropriate management?
- A.Induce labor after amniotomy
- B.Admit for expectant management
- C.Deliver by cesarean sectionCorrect
- D.Perform digital cervical examination
Explanation
Placenta praevia with significant bleeding at 37 weeks requires delivery by caesarean section. Vaginal birth is absolutely contraindicated when the placenta covers the internal os, because cervical dilatation shears the placental attachment and produces torrential haemorrhage from the poorly contractile lower uterine segment. The classic picture is present: painless bright red bleeding in the third trimester with a soft, non-tender uterus and a normal fetal tracing, which contrasts with abruption where pain, uterine tenderness or hypertonus and fetal compromise dominate. For an uncomplicated praevia without bleeding, planned caesarean is scheduled at 36 to 37 weeks, and earlier or immediately when bleeding is significant, as here, since she is already at term equivalent for this condition and is tachycardic. Preparation includes large-bore access, group and cross-match with blood available, senior obstetric and anaesthetic presence, and anticipation of postpartum haemorrhage from the lower segment, for which uterotonics, balloon tamponade and further surgical measures should be ready. Digital vaginal examination must never be performed when praevia is suspected, since the examining finger can provoke catastrophic bleeding; transvaginal ultrasound, by contrast, is safe and is the diagnostic modality of choice. Anti-D is given if she is rhesus negative.
Why each option
- A.
- Labour and amniotomy are contraindicated in placenta praevia because cervical dilatation shears the placenta and causes massive haemorrhage.
- B.
- Expectant management applies to a stable preterm woman with minimal bleeding. At 37 weeks with active bleeding and tachycardia, delivery is indicated.
- C.
- Correct. Placenta praevia with significant bleeding at term is delivered by caesarean section with blood cross-matched and senior support available.
- D.
- Digital examination in suspected praevia can precipitate catastrophic haemorrhage and is contraindicated; transvaginal ultrasound is the safe diagnostic test.
Reference: RCOG Green-top Guideline No. 27a, Placenta Praevia and Placenta Accreta, reaffirmed 2024
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