Second-trimester bleeding in a woman with two prior caesareans
A 34-year-old G4P2 (both lower-segment caesareans, last 3 years ago) presents at 30+2 weeks with painless bright-red vaginal bleeding of about 150 mL over 2 hours. She has had two earlier episodes of small painless bleeds at 26 and 28 weeks, each settling with observation. She is haemodynamically stable: BP 118/70, pulse 92, Hb 104 g/L, platelets 210. Ultrasound shows a fundal anterior placenta with its lower edge covering the internal os; the myometrium under the previous scar is 2 mm thick and there is a single viable fetus with normal Dopplers and estimated weight on the 40th centile. She is contracting irregularly on CTG but the trace is otherwise normal. She lives 90 minutes from the hospital and asks to go home.
1. Outline your immediate management and disposition, justifying your decision against her request for discharge.
Read the worked answer
This is a major placenta praevia with a previous caesarean scar and a thin lower uterine segment, so the two dominant risks are antepartum haemorrhage and placenta accreta spectrum at delivery.
Immediate steps:
- Admit to a unit with 24-hour theatre, blood bank and neonatal intensive care. Do not discharge: painless bleeding is unpredictable, she has had three episodes, and she is 90 minutes from care.
- Two large-bore cannulae, group and hold with antibody screen, full blood count, coagulation, and crossmatch 2-4 units given the accreta risk.
- Antenatal corticosteroids (betamethasone 11.5 mg IM twice, 24 hours apart) because delivery may become urgent; consider magnesium sulphate for neuroprotection only if delivery before 32 weeks becomes likely.
- Anti-D if she is RhD-negative and unsensitised.
- Correct iron deficiency; transfuse if symptomatic or Hb falls below about 70-80 g/L depending on ongoing loss.
- Keep on a labour ward or high-dependency setting with continuous or regular CTG, intravenous access maintained, and a clear plan for immediate caesarean if bleeding becomes heavy or fetal compromise develops.
She needs an agreed threshold for delivery (e.g. ongoing bleeding, maternal instability, or fetal compromise) rather than a fixed date, and a documented discussion that she may need a caesarean hysterectomy.
2. How does the imaging change your delivery planning, and what should be arranged before theatre?
Read the worked answer
A lower-edge-covering placenta with a 2 mm myometrial thickness over a prior scar is highly suggestive of placenta accreta spectrum. Ultrasound markers of accreta include loss of the clear zone, myometrial thinning under the placenta, placental lacunae, bladder-wall interruption and bridging vessels; MRI may be used for posterior placenta or equivocal findings but is not mandatory.
Planning:
- Deliver by planned caesarean at 36-37 weeks if she remains stable, in a centre with a multidisciplinary accreta team (obstetrician with accreta experience, anaesthetist, urologist, interventional radiology, blood bank, neonatology). Earlier delivery only for bleeding or fetal compromise.
- Preoperative consent must cover caesarean hysterectomy, bladder injury, ureteric injury, massive transfusion and intensive care. Document this explicitly.
- Crossmatch adequate blood products; consider cell salvage and tranexamic acid availability; ureteric stents if bladder involvement is suspected.
- Place the incision to allow access above the placenta; avoid transecting the placenta. A fundal or classical approach may be needed.
- Leave the placenta in situ and proceed to hysterectomy if accreta is confirmed, rather than attempting piecemeal removal, which causes catastrophic haemorrhage.
- If she declines hysterectomy, this must be an antenatal, documented discussion with contingency planning, not an intraoperative surprise.
3. She asks about future pregnancies. What counselling do you give?
Read the worked answer
Counsel that this pregnancy carries a high chance of caesarean hysterectomy, which would end her fertility, and that even if the uterus is preserved she will have a scarred, thin lower segment with a high risk of recurrence of praevia and accreta in any future pregnancy.
Key points:
- Recurrence of placenta praevia after caesarean rises with each caesarean; accreta risk rises steeply with praevia plus multiple prior caesareans.
- Any future pregnancy requires early ultrasound to locate the placenta and a plan for delivery in a tertiary centre.
- If the uterus is preserved, advise a minimum interpregnancy interval and preconception review; discuss effective contraception and the option of permanent sterilisation at the time of caesarean, which should be consented antenatally.
- Acknowledge uncertainty: outcomes depend on intraoperative findings, and she should be given written information and the chance to revisit decisions with her partner.
- Screen for and treat anaemia before any future pregnancy, and address modifiable risks.
Frame the discussion around her priorities, and record that she understands the possible loss of fertility.