What is the best course of action for a pregnant woman at 31 weeks of gestation with hypotension and moderate uterine tenderness?

Immediate Cesarean Section with Concurrent Resuscitation

This patient requires immediate cesarean delivery while simultaneously initiating aggressive IV fluid resuscitation and blood product transfusion—this clinical picture of hypotension (83/50 mmHg) with moderate uterine tenderness at 31 weeks strongly suggests placental abruption, which is a life-threatening emergency for both mother and fetus. 1

Critical Clinical Recognition

This presentation is not hypertensive disease of pregnancy—the hypotension with uterine tenderness indicates hemorrhagic shock from concealed bleeding:

• Placental abruption presents with uterine tenderness and maternal hypotension from blood loss, even when external bleeding is minimal 1
• The normal fetal parameters and cephalic presentation do not rule out abruption, as maternal decompensation often precedes fetal compromise 1
• Hypotension in pregnancy at this gestational age is pathological and suggests significant blood loss (>1000-1500 mL) 2

Immediate Management Algorithm

Step 1: Simultaneous Resuscitation and Delivery Preparation (Within Minutes)

• Establish two large-bore IV lines immediately and begin aggressive crystalloid resuscitation 2
• Activate massive transfusion protocol and cross-match for at least 4 units packed red blood cells 2
• Position patient in left lateral tilt to prevent aortocaval compression and maintain placental perfusion 1
• Continuous fetal monitoring while preparing for immediate delivery 1
• Alert anesthesia, neonatology, and OR team for emergency cesarean section 1

Step 2: Proceed Directly to Cesarean Delivery

• Do not attempt induction of labor (IOL) in this unstable patient—IOL is contraindicated with maternal hemodynamic instability and suspected abruption 1
• Cesarean section is the only appropriate delivery method given maternal instability and gestational age of 31 weeks with suspected abruption 1
• Administer betamethasone (single dose of dexamethasone acceptable if immediate delivery) during preparation, but do not delay surgery 3

Step 3: Intraoperative Considerations

• Avoid magnesium sulfate unless there are clear signs of preeclampsia/eclampsia (which this case does not suggest)—magnesium can worsen hypotension 4
• General anesthesia may be required given hemodynamic instability, though regional anesthesia can be considered if patient stabilizes rapidly 1
• Prepare for postpartum hemorrhage management including uterotonic agents and potential surgical interventions 2

Why the Other Options Are Wrong

Option 1 (IV fluid and blood products alone): While resuscitation is essential, it must occur simultaneously with delivery preparation—delaying delivery in suspected abruption increases maternal mortality risk from DIC, renal failure, and hemorrhagic shock 1

Option 3 (Induction of labor): IOL is absolutely contraindicated in this scenario because:

• Maternal hemodynamic instability requires immediate delivery 1
• IOL takes hours and this patient needs delivery within minutes 1
• Progressive abruption during labor will worsen maternal and fetal outcomes 1
• At 31 weeks with suspected abruption, vaginal delivery attempts increase risk of complete abruption and fetal death 1

Critical Pitfalls to Avoid

• Do not assume this is hypertensive disease because the patient is hypotensive—uterine tenderness with hypotension = abruption until proven otherwise 1, 2
• Do not wait for laboratory confirmation of coagulopathy or fetal distress—these are late findings and delay increases mortality 1
• Do not use antihypertensive medications—this patient needs volume and blood products, not BP reduction 2
• Do not delay for complete fetal lung maturity—maternal life takes precedence, and a single dose of steroids provides some benefit even with immediate delivery 3

Post-Delivery Monitoring

• Monitor for DIC with serial coagulation studies, platelet counts, and fibrinogen levels 2
• Assess for postpartum hemorrhage and uterine atony given the abruption 2
• Renal function monitoring as abruption-related hypotension can cause acute tubular necrosis 1
• Avoid NSAIDs which can worsen renal function in this setting 2