Management of PV Spotting at 37 Weeks in a Primigravida

Step 1 - Immediate Assessment (First 15-30 minutes)

• Onset, amount, colour of bleeding (painless vs painful)
• Associated uterine contractions or pain (abruption is painful; previa is painless)
• Fetal movements
• Known placental location from previous scans
• Trauma, coitus, or recent VE (can cause cervical ectropion bleed)
• History of show (blood-streaked mucus plug at term - physiological, not APH)

• BP, pulse, respiratory rate, SpO2
• CTG (cardiotocography) - start immediately for fetal wellbeing
• Urine output

• CBC / Hb
• Blood group and crossmatch (2 units)
• Coagulation profile (PT, aPTT, fibrinogen) - especially if abruption suspected
• Serum electrolytes, renal function
• Kleihauer-Betke test if Rh-negative mother

Step 2 - IV Access and Resuscitation

• Two large-bore IV cannulae (14-16G)
• IV fluid (Ringer's lactate or 0.9% NaCl) if hemodynamically compromised
• Oxygen if needed
• Foley's catheter if significant bleeding
• Cross-match and keep blood ready

Step 3 - Bedside Ultrasound (Urgent)

Step 4 - Classify the APH

• Spotting - blood on underwear/pad, <50 mL
• Minor - <500 mL, no hemodynamic compromise
• Major - 500 mL to 1 L
• Massive - >1 L or signs of shock

Step 5 - Cause-Based Management

A. Placenta Previa (most dangerous cause to exclude)

• No VE at any cost
• Admit to hospital
• At 37 weeks: elective cesarean section is indicated (JOGC Guideline 402 recommends CS at 37+0 to 37+6 weeks for placenta previa without risk factors; 36+0 to 36+6 with risk factors)
• If active bleeding: emergency CS regardless of gestation
• Have neonatologist present for delivery

B. Placental Abruption

• Usually presents with painful bleeding + uterine tenderness + hypertonic uterus
• At 37 weeks with abruption: expedite delivery
  • If fetal heart normal + no maternal compromise: induction of labour (IOL) may be attempted
  • If fetal distress or maternal compromise: emergency cesarean section
• Monitor for DIC (consume clotting factors - watch fibrinogen <2 g/L as warning sign)
• Watch for Couvelaire uterus, renal failure, PPH

C. Show (Physiological at Term)

• Blood-streaked mucus; not true APH
• Assess for labour (cervical dilatation, contractions)
• If labour is beginning, monitor and manage accordingly
• If not in labour: reassure, observe, monitor CTG

D. Cervical Ectropion / Cervicitis

• Diagnosed by speculum exam (only after previa excluded)
• Painless, small amount of bleeding from cervical os
• Usually not significant - reassure, follow up
• Can do cervical swab if infection suspected

E. Unexplained APH

• After excluding all above causes
• At 37 weeks: induction of labour should be considered - the WISDOM/NHS Wales APH guideline supports IOL to avoid risks of abruption progression
• Reclassify as high-risk; consultant-led care

Step 6 - Fetal Monitoring

• CTG for minimum 4 hours (even if bleeding settles)
• If CTG reassuring + bleeding settled + no previa: may consider outpatient monitoring with close follow-up
• If any concern: admit and monitor continuously

Step 7 - Rh Status

• If Rh-negative: administer anti-D immunoglobulin (300 mcg IM) within 72 hours of any bleeding episode

Step 8 - Delivery Decision at 37 Weeks

Special Considerations for Primigravida

• Primis have no previous uterine scar, so IOL with oxytocin is generally safe if route allows
• Cervical favourability (Bishop's score) guides IOL approach - ripen cervix if needed (PGE2 / misoprostol with caution)
• Lower threshold for CS due to unpredictability of labour and potential for rapid deterioration
• Continuous CTG in labour is mandatory once APH has occurred

Summary Flowchart

PV Spotting at 37 weeks
        |
        ├── Stabilize: IV access, bloods, CTG, Vitals
        |
        ├── Urgent USG → Placental location
        |         |
        |     Previa? → YES → No VE → Plan Cesarean
        |         |
        |        NO → Abruption? → YES → Expedite delivery (IOL or CS)
        |                  |
        |                 NO → Speculum exam
        |                        |
        |                  Show / Ectropion → Reassure / observe
        |                        |
        |                  Unexplained → IOL at 37 weeks
        |
        └── All cases: Check Rh status → Anti-D if Rh-negative