What is the best course of action for a patient with severe placental abruption (abruptio placenta), intrauterine fetal death, and disseminated intravascular coagulopathy (DIC)?

Management of Severe Placental Abruption with IUFD and DIC

Augmentation of labor (Option C) is the recommended management approach for this patient with severe placental abruption, intrauterine fetal death, and DIC, as vaginal delivery is preferable when fetal demise has occurred, minimizing surgical risks in the setting of severe coagulopathy. 1, 2

Rationale for Vaginal Delivery

• In cases where fetal demise has occurred, vaginal delivery is preferable to avoid the hemorrhagic complications of cesarean section in a patient with established DIC 2
• The maternal effect of abruption depends primarily on its severity, and surgical intervention increases bleeding risk when coagulopathy is present 2
• Cesarean section in the setting of DIC dramatically increases the risk of uncontrollable hemorrhage, potential hysterectomy, and multi-organ failure 3

Immediate Stabilization Protocol

• Establish large-bore intravenous access immediately and activate massive transfusion protocol early given the presence of DIC 1
• Obtain baseline laboratory studies including complete blood count, type and crossmatch for at least 4 units, coagulation panel, fibrinogen level, and platelet count 1
• Maintain maternal temperature above 36°C, as clotting factors function poorly below this threshold 1
• Transfuse blood products in a fixed 1:1:1 ratio (red cells:platelets:plasma), with cryoprecipitate preferred over fresh frozen plasma to minimize volume overload risk 4

Labor Augmentation Strategy

• Administer oxytocin infusion to enhance uterine contractions and expedite delivery, as prompt delivery is essential to prevent progression of DIC 1, 3
• Consider tranexamic acid administration to reduce blood loss during the delivery process 4, 1
• Continuous monitoring of fibrinogen levels is indispensable, as even initially normal levels can rapidly decrease in placental abruption with IUFD 5
• Monitor JSOG DIC score, fibrinogen level, platelet count, D-dimer, FDP, and heart rate as indicators for escalating transfusion needs 5

Critical Management Principles

• Aggressive DIC management is mandatory, as DIC accompanies the majority of severe abruption cases and more easily causes critical bleeding necessitating hysterectomy 4, 3
• Prepare uterotonic agents (oxytocin, methylergonovine) for immediate postpartum use to prevent uterine atony 4
• Have the most experienced obstetric team available, as uncontrollable bleeding may still necessitate emergency hysterectomy despite optimal medical management 3, 6

When Cesarean Section Becomes Necessary

• Cesarean section is only indicated if maternal hemodynamic instability or uncontrolled hemorrhage develops despite resuscitation efforts 1
• If surgical delivery becomes unavoidable, do not attempt forced placental removal if placenta accreta spectrum is encountered, as this triggers profuse hemorrhage 1
• Have cell salvage technology available if cesarean delivery is required 1

Common Pitfalls to Avoid

• Never proceed directly to cesarean section with a dead fetus and DIC unless maternal hemodynamic collapse occurs, as this dramatically increases hemorrhagic morbidity 3, 2
• Do not delay delivery attempting prolonged expectant management, as this allows DIC progression and worsens maternal outcomes 3
• Avoid underestimating transfusion requirements—patients with PA-IUFD often require massive transfusion even with initially normal coagulation parameters 5

Postpartum Monitoring

• ICU monitoring is recommended for severe cases with ongoing assessment for complications including renal failure, liver failure, infection, and pulmonary edema 1
• Maintain low threshold for reoperation if ongoing bleeding is suspected despite medical management 1
• Serial hemoglobin checks and coagulation studies should continue for 24-48 hours postpartum 5