A 32-year-old G3P2 woman at 34 weeks of gestation presents with sudden onset painless bright-red vaginal bleeding. She has no uterine contractions and the uterus is soft on palpation. Fetal heart rate is 148 bpm and reactive. She is hemodynamically stable and the bleeding has decreased. The transvaginal ultrasound is shown (Image 1). Which of the following is the most appropriate next step in management?

Question

Accepted Answer

A. Administer a single course of intramuscular betamethasone and manage expectantly with hospitalization. ***A. Administer a single course of intramuscular betamethasone and manage expectantly with hospitalization***
- The patient presents with **painless bright-red vaginal bleeding** and a soft uterus, which is the classic presentation of **placenta previa**; at 34 weeks, the goal is to prolong the pregnancy if hemodynamically stable.
- **Antenatal corticosteroids** like betamethasone are indicated between 24 and 36 weeks of gestation to enhance **fetal lung maturity** and reduce neonatal morbidity.

*B. Proceed to immediate emergency caesarean section under general anaesthesia*
- Emergency delivery is only indicated for **uncontrolled hemorrhage**, maternal hemodynamic instability, or evidence of **fetal compromise** (abnormal heart rate patterns).
- Since the patient is currently stable and the bleeding has decreased, the risks of **preterm delivery** at 34 weeks outweigh the benefits of immediate intervention.

*C. Perform a digital cervical examination to assess Bishop score and consider induction of labour*
- A **digital cervical examination** is strictly **contraindicated** in suspected or confirmed placenta previa as it can cause catastrophic, life-threatening maternal hemorrhage.
- **Induction of labor** is not an option for complete placenta previa, as the placental position physically obstructs the birth canal and necessitates **caesarean delivery**.

*D. Administer tocolysis with nifedipine and discharge with outpatient surveillance*
- **Outpatient management** is generally not recommended immediately after an acute bleeding episode in placenta previa; **hospitalization** is required for close monitoring for at least 48 hours.
- While tocolytics can be used briefly to allow for steroid administration, **nifedipine** and discharge are inappropriate for a patient who has just presented with an active bleeding event. [Practice more Obstetrics and Gynecology questions on OnCourse]

Obstetrics and Gynecology Questions

Topics

Prenatal Care

Labor and Delivery

Postpartum Care

Neonatology and Perinatology

Gynecological Disorders

Menstrual Disorders

Fertility and Infertility

Contraception and Family Planning

Menopause

Gynecologic Oncology

Urogynecology

Endocrinology of Pregnancy

Operative Obstetrics

Maternal-Fetal Medicine

Reproductive Endocrinology

Sexual Dysfunction

Pelvic Pain Syndromes

Gender-Affirming Care

Reproductive Ethics

About Obstetrics and Gynecology Questions