What is the most appropriate management for a pregnant woman at 33 weeks gestation presenting with severe abdominal pain, moderate vaginal bleeding, and hypotension, with a reassuring cardiotocography (CTG) tracing?

Management of Pregnant Woman at 33 Weeks with Severe Abdominal Pain, Moderate Vaginal Bleeding, and Hypotension

This patient requires immediate cesarean section after one dose of dexamethasone (Option D), as the combination of hypotension with ongoing vaginal bleeding indicates likely placental abruption with maternal hemodynamic instability, which is an absolute indication for emergency delivery regardless of reassuring fetal heart rate monitoring.

Clinical Reasoning for Immediate Cesarean Section

The clinical presentation strongly suggests placental abruption with maternal shock:

• Hypotension with ongoing bleeding indicates maternal hemodynamic compromise that takes priority over all other considerations 1
• Severe abdominal pain with vaginal bleeding at 33 weeks is the classic triad for placental abruption 2
• The reassuring CTG is misleading in this context—placental abruption can present with normal fetal heart tracings initially, but maternal instability mandates immediate delivery 2

Cesarean section should be considered for patients in acute intractable heart failure or hemodynamic instability, and hypotension with ongoing bleeding meets this threshold 1

Why Other Options Are Inappropriate

Blood Transfusion Alone (Option A) - Inadequate

• Blood transfusion addresses the consequence but not the source of bleeding 3
• Ongoing bleeding that "did not stop since admission" indicates active hemorrhage requiring source control through delivery 3
• Transfusion without delivery allows continued maternal deterioration and fetal compromise 2

Induction of Labor (Option B) - Too Slow

• Labor induction takes hours to days, which is unacceptable in a hemodynamically unstable patient 1
• Hypotension with ongoing bleeding requires immediate delivery, not a prolonged induction process 1
• The patient's unstable condition precludes the time required for cervical ripening and labor progression 2

Dexamethasone and Observation (Option C) - Dangerous Delay

• Observation is contraindicated when maternal hemodynamic stability is compromised 2
• Continued bleeding with hypotension will lead to maternal shock, DIC, and fetal death if delivery is delayed 2
• At 33 weeks, the fetus is viable and maternal life takes absolute priority 1

Immediate Pre-Delivery Management Protocol

Resuscitation Measures (Simultaneous with Delivery Preparation)

• Establish two large-bore (14-16 gauge) IV lines for aggressive fluid resuscitation 2
• Administer oxygen to maintain saturation >95% to ensure adequate fetal oxygenation 2
• Position patient in left lateral tilt to relieve aortocaval compression and improve venous return 2
• Transfuse O-negative blood immediately if cross-matched blood is unavailable, to prevent Rh alloimmunization and restore circulating volume 2

Critical Medication Administration

• Give single dose of dexamethasone (12 mg IM) for fetal lung maturation, as recommended between 24+0 and 34+0 weeks gestation 1
• Do not delay delivery waiting for the second dose of steroids—maternal stability takes precedence 1
• Avoid vasopressors until after aggressive fluid resuscitation, as they adversely affect uteroplacental perfusion 2

Laboratory Assessment

• Obtain coagulation panel including fibrinogen immediately, as placental abruption commonly causes consumptive coagulopathy 2
• Type and cross-match for at least 4 units of packed red blood cells 3
• Monitor for DIC with serial fibrinogen levels (normal pregnancy: 4-6 g/L) 3

Intraoperative Considerations

Anesthesia Selection

• General anesthesia is preferred in hemodynamically unstable patients requiring immediate delivery 1
• Regional anesthesia (epidural/spinal) can worsen hypotension and is relatively contraindicated in hypovolemic shock 1

Surgical Technique

• Prepare for potential massive transfusion with 1:1 ratio of RBC:FFP after 4 units if coagulopathy develops 3
• Maintain maternal temperature >36°C as hypothermia impairs coagulation factor function 3
• Administer slow IV oxytocin (<2 U/min) after placental delivery to prevent uterine atony without causing hypotension 1

Critical Pitfalls to Avoid

• Do not wait for laboratory confirmation of placental abruption—ultrasound is insensitive for this diagnosis and clinical suspicion mandates action 2
• Do not use methylergonovine for uterine atony, as it causes vasoconstriction and worsening hypotension 1
• Do not delay delivery for complete steroid course—one dose provides significant benefit and maternal life takes priority 1
• Do not rely on reassuring CTG as the sole indicator of fetal well-being when maternal instability is present 2
• Do not attempt vaginal delivery in a hemodynamically unstable patient with ongoing hemorrhage 1

Post-Delivery Monitoring

• Continue hemodynamic monitoring for at least 24 hours post-delivery, as fluid shifts can precipitate complications 1
• Maintain blood pressure control if hypertension develops post-delivery 3
• Monitor for postpartum hemorrhage with systematic measurement of blood loss, not visual estimation 3