MANAGEMENT OF THE SYMPTOMATIC PLACENTA PREVIA - A RANDOMIZED, CONTROLLED TRIAL OF INPATIENT VERSUS OUTPATIENT EXPECTANT MANAGEMENT

OBJECTIVE: Our purpose was to determine the safety efficacy, and costs of inpatient and outpatient management of symptomatic placenta previa . STUDY DESIGN: Fifty-three women with the initial diagnosis oi placen ta previa at 24 to 36 weeks' gestation who required hospitalization fo r vaginal bleeding were stabilized and then randomized to receive eith er inpatient or outpatient expectant management. Twenty-seven inpatien ts were placed at bed rest with minimal ambulation, received weekly co rticosteroids until 32 weeks of gestation, and underwent ultrasonograp hic examination at 2-week intervals to assess fetal growth and placent al location. Twenty-six outpatients were discharged home after greater than or equal to 72 hours of hospitalization. Each week they also rec eived corticosteroids, until 32 weeks' gestation, and ultrasonographic evaluations. Outpatients with recurrent bleeding were readmitted for evaluation. All subjects who reached 36 weeks' gestation with persiste nt placenta previa underwent amniocentesis. When fetal lung maturity w as present, cesarean delivery was electively performed. RESULTS: There were insignificant differences between inpatients and outpatients for mean age, parity, race, type of previa (complete or partial), number of prior vaginal bleeding episodes, and initial hemoglobin value. The mean estimated gestational age at enrollment was 29.1 +/- 3.1 (SD) wee ks for inpatients and 29.9 +/- 3.1 weeks for outpatients. In eight pat ients the placenta was found to no longer cover the internal os by 36 weeks' gestation. There were seven patients in each group who did not complete the protocol for initial treatment assignment. The average es timated gestational age at delivery for the inpatients was 34.5 +/- 2. 4 weeks and 34.6 +/- 2.3 weeks for the outpatients (p = 0.90), whereas the mean birth weights were 2413.7 +/- 642.7 gm and 2607.8 +/- 587.1 gm, respectively (p = 0.28). Thirty-three patients (62.3%) had recurre nt episodes of bleeding, with 26 requiring expeditious cesarean delive ry. Four (14.8%) inpatients and one (3.7%) outpatient required blood t ransfusion (p = 0.67). There was no difference in neonatal morbidity ( defined as the presence of respiratory distress syndrome, intracranial hemorrhage, or culture-proved sepsis) between the two groups (relativ e risk 1.16, 95% confidence interval 0.66 to 2.02). There were no neon atal deaths. The mean number of maternal hospital days differed signif icantly between the two groups: inpatients required an average of 28.6 +/- 20.3 days and outpatients remained hospitalized for an average of 10.1 +/- 8.5 days (p < 0.0001). Cost analysis based on maternal hospi tal days reveals a net savings of $15,080 per patient if women with sy mptomatic placenta previa initially diagnosed before 37 weeks' gestati on are treated as outpatients. CONCLUSIONS: For selected patients, out patient management of symptomatic placenta previa appears to be an acc eptable alternative to traditional conservative expectant inpatient ma nagement.