Immediate Emergency Management: Placental Abruption at 37 Weeks
This patient requires immediate delivery via emergency cesarean section due to placental abruption with maternal hemodynamic compromise. The clinical triad of vaginal bleeding, sudden abdominal pain, and a firm tender uterus in late pregnancy is pathognomonic for placental abruption, and maternal tachycardia indicates significant blood loss requiring urgent intervention 1, 2.
Immediate Stabilization and Assessment
Activate obstetric emergency protocol immediately with multidisciplinary team including obstetrics, anesthesia, and neonatology 2.
Establish large-bore IV access (two lines minimum) and begin aggressive fluid resuscitation with crystalloid while preparing for blood product transfusion 2.
Obtain stat laboratory studies: complete blood count, type and crossmatch for at least 4 units packed red blood cells, coagulation panel (PT, PTT, fibrinogen), and basic metabolic panel to assess for disseminated intravascular coagulopathy 3, 2.
Initiate continuous fetal heart rate monitoring to assess fetal status, though abnormal tracings are common with abruption and should not delay delivery if maternal instability is present 1, 2.
Monitor maternal vital signs continuously including blood pressure, heart rate, oxygen saturation, and urine output as indicators of ongoing hemorrhage 2.
Diagnostic Confirmation
Ultrasound should NOT delay delivery in this hemodynamically unstable patient, as the diagnosis is clinical and ultrasound misses up to 50% of abruptions 4, 1.
The classic clinical presentation (vaginal bleeding, abdominal pain, firm tender uterus, maternal tachycardia) is sufficient for diagnosis without imaging 1, 5, 2.
If ultrasound is performed while preparing for delivery, look for retroplacental hematoma, though its absence does not exclude abruption 1.
Delivery Decision
Proceed immediately to cesarean delivery given:
- Gestational age of 37 weeks (term pregnancy) 2
- Maternal tachycardia indicating significant hemorrhage 2
- Firm, tender uterus suggesting concealed bleeding 1, 5
- High risk of maternal disseminated intravascular coagulopathy and fetal compromise 4, 2
Vaginal delivery is contraindicated in this scenario due to maternal hemodynamic instability and the need for rapid delivery 6, 2.
Blood Product Management
Activate massive transfusion protocol if ongoing hemorrhage or signs of coagulopathy develop 2.
Transfuse packed red blood cells to maintain hemoglobin >7 g/dL, with higher targets if ongoing bleeding 2.
Monitor for disseminated intravascular coagulopathy with serial fibrinogen levels (target >200 mg/dL), platelet counts (transfuse if <50,000/μL), and coagulation studies 2.
Consider viscoelastic point-of-care testing (if available) to guide component therapy in real-time 2.
Administer fresh frozen plasma and cryoprecipitate as needed based on coagulation parameters and clinical bleeding 2.
Critical Pitfalls to Avoid
Never delay delivery for imaging in a hemodynamically unstable patient with clinical signs of abruption 1, 2.
Do not perform digital cervical examination until placenta previa is excluded by ultrasound, though in this case the clinical presentation strongly suggests abruption rather than previa 6, 3.
Avoid underestimating blood loss, as concealed hemorrhage behind the placenta can be massive despite modest external bleeding 1, 5, 2.
Do not wait for laboratory confirmation of coagulopathy before initiating blood product therapy if clinical bleeding is severe 2.