A 24 years old woman is known to have a placenta that is implanted over the internal os. She presents at 28 weeks gestation with vaginal bleeding. Justify your management.
Grade four placenta previa can be associated with severe life threatening vaginal bleeding and its management at this stage of pregnancy depends on the severity of bleeding and also fetal condition.
I would admit her to the labour ward in order to assess maternal and fetal conditions and provide appropriate management. I review her obstetric notes to get the information about her parity, previous deliveries and antenatal events and also I ask about the amount of her blood loss. Then I would do an examination which include checking the vital signs, blood pressure and pulse to assess her haemodynamic status, inspection of her pads to assess the amount of blood loss, , an abdominal examination to palpate presenting part and presence of any contractions or tenderness and electronic fetal heart monitoring to assess fetal condition . I would not do a digital or speculum examination as it might cause severe bleeding. This only should be performed when theatre and surgeon are ready to perform an emergency caesarean section in the case of a heavy bleeding.
If my assessment shows that the bleeding is heavy, resuscitation should be started immediately and senior obstetrician and anaesthetist should be informed. Two large bore cannulae should be inserted and intravenous fluids such as normal saline, gelofusin or O negative blood should be transfused. Oxygen should be given by mask and she should be placed in a head down position. Blood should be sent for group and cross-match of 4 to 6 units of blood, Kliehauer test, FBC, U&Es, LFTand clotting profile and blood transfusion should be commenced as soon as possible. Bladder should be catheterised to document urinary output .The situation should be explained to the couple and if bleeding continues an informed consent should be obtained for performing an emergency caesarean section. An experienced surgeon should perform the operation as there is higher risk of complications and mortality and morbidity should operation is performed by junior staff. General anaesthetic may be required due to maternal hypotension and to save time. Paediatrician should be in theatre for immediate resuscitation. All part of the care should be documented.
If the bleeding was mild or moderate, conservative management should be considered. If there was active bleeding, she should be kept on the labour ward for observation. Steroids should be given for prevention of neonatal respiratory distress syndrome in case of preterm labour. The usual dose is two doses of Dexamethasone 12 hours apart. Anti-D injection is necessary if the mother is Rhesus negative to prevent iso immunisation. Fetal heart should be monitored and if there was significant fetal distress baby should be delivered. When bleeding was settled she could be transferred to the antenatal ward where fetal heart can be checked daily and blood loss should be observed. She can be discharged when there was no bleeding with follow-up appointments for antenatal clinic. Repeat scan at 37 weeks should be arranged to confirm placental location. In some cases trans vaginal scan may be considered which is safe and more accurate than transabdominal scan. If placenta previa was confirmed patient should be kept in the hospital for the last 4 weeks of pregnancy, as there might be severe bleeding with onset of labour. An elective caesarean section should be booked at 38-39 weeks. If scan shows that placenta has migrated or it is located 3 cms or more above the os, vaginal delivery may be considered.
