What is the next management step for a pregnant patient at 31 weeks gestation in the delivery room with moderate vaginal bleeding, no uterine contractions, and hypotension (blood pressure 80/50)?

Immediate Resuscitation and Stabilization

This patient requires immediate aggressive fluid resuscitation with blood products via massive transfusion protocol, followed by urgent delivery—the priority is maternal hemodynamic stabilization while simultaneously preparing for emergency cesarean section. 1

Critical Initial Actions (First 5 Minutes)

• Activate massive transfusion protocol immediately and establish large-bore IV access (two 16-gauge or larger lines) for aggressive volume resuscitation 1
• Begin blood product transfusion using packed red blood cells, fresh frozen plasma, and platelets in a 1:1:1 ratio (hemostatic resuscitation) without waiting for laboratory results—this approach improves outcomes in obstetric hemorrhage with hemodynamic compromise 2, 1
• Prepare for emergency cesarean section while resuscitating—do not delay delivery for complete stabilization as the source of bleeding must be addressed surgically 1
• Place patient in left lateral decubitus position to optimize venous return and cardiac output 2

Differential Diagnosis Considerations

The presentation of moderate vaginal bleeding at 31 weeks with hypotension (BP 80/50) and absent uterine contractions most likely represents:

• Placental abruption with concealed hemorrhage—the hypotension is disproportionate to visible bleeding, suggesting significant retroplacental blood loss 1, 3
• Placenta previa with significant bleeding—though typically presents with painless bleeding 4
• Uterine rupture—less likely without prior cesarean or labor 5

Why Blood Transfusion Takes Priority Over Dexamethasone

Blood transfusion for hemodynamic stabilization must precede any consideration of corticosteroids for the following reasons:

• Maternal mortality from hemorrhagic shock is immediate and preventable—hypotension with BP 80/50 indicates severe hypovolemia requiring urgent correction 5
• Dexamethasone for fetal lung maturity requires 24-48 hours to be effective and is irrelevant if the mother dies from hypovolemic shock 1
• Delivery must occur urgently regardless of gestational age when maternal hemodynamic instability is present—there is no time to wait for steroid benefit 1

Intraoperative Management Priorities

• Anticipate disseminated intravascular coagulation (DIC)—occurs in over 80% of severe abruption cases and requires early assessment of clotting status 2
• Consider tranexamic acid administration if hyperfibrinolysis is suspected (bedside thromboelastography can guide this decision if available) 2
• Maintain maternal temperature >36°C as hypothermia impairs clotting factor function 1
• Avoid acidosis which further impairs coagulation 1
• Prepare for potential hysterectomy if bleeding is uncontrollable after delivery 1

Critical Pitfalls to Avoid

• Do not delay delivery to "stabilize" the patient first—the source of bleeding (placenta) must be removed to control hemorrhage 1
• Do not use crystalloid alone for resuscitation—use blood products for volume replacement to avoid dilutional coagulopathy and volume overload 2
• Do not administer methylergonovine for uterine atony if it occurs—it causes vasoconstriction and hypertension (>10% risk) which is dangerous in this hemodynamically unstable patient 2
• Use slow IV oxytocin (<2 U/min) instead to prevent postpartum hemorrhage while avoiding systemic hypotension 2

Post-Delivery Monitoring

• Continue intensive monitoring in ICU for at least 24 hours postoperatively as hemodynamic changes and fluid shifts can precipitate complications 2, 1
• Monitor for ongoing coagulopathy and have low threshold for re-exploration if bleeding continues 1
• Watch for development of acute respiratory distress or cardiovascular collapse which could indicate amniotic fluid embolism (though less likely given the clinical presentation) 2

Answer: Option A (Blood transfusion) is correct—but this is only the first step in a coordinated resuscitation that must include simultaneous preparation for emergency delivery.