What is the most appropriate management for a pregnant patient at 33 weeks gestation with severe abdominal pain, moderate vaginal bleeding, and hypotension?

Management of Hemodynamically Unstable Pregnant Patient at 33 Weeks

This patient requires immediate cesarean section after a single dose of dexamethasone (Option D), as hypotension with ongoing bleeding indicates maternal hemodynamic compromise that takes priority over all other considerations. 1

Rationale for Immediate Delivery

Maternal hemodynamic instability with ongoing bleeding is an absolute indication for emergency delivery regardless of reassuring fetal heart rate monitoring. 1 The combination of severe abdominal pain, moderate vaginal bleeding, and hypotension at 33 weeks suggests a life-threatening obstetric emergency, most likely placental abruption or uterine rupture, requiring immediate intervention to prevent maternal mortality. 1

• The European Society of Cardiology explicitly states that hypotension with ongoing bleeding takes priority over all other considerations, including reassuring CTG findings. 1
• Cesarean section is indicated for patients in acute intractable heart failure or hemodynamic instability, which this patient clearly demonstrates. 1

Corticosteroid Administration Protocol

A single dose of dexamethasone (12 mg IM) should be administered immediately for fetal lung maturation, but delivery should NOT be delayed waiting for the second dose. 1

• Corticosteroids are recommended between 24+0 and 34+0 weeks gestation to reduce neonatal respiratory morbidity. 2
• Maternal stability takes precedence over completing the full steroid course. 1
• Even a single dose provides significant fetal benefit, and the 24-48 hour wait for optimal effect cannot be justified when the mother is hemodynamically unstable. 1

Why Other Options Are Inappropriate

Blood transfusion alone (Option A) addresses the consequence but not the source of bleeding. While massive transfusion protocols with 1:1 ratio of RBC:FFP should be prepared, transfusion without definitive surgical intervention will not stop ongoing hemorrhage from placental abruption or uterine rupture. 1

Induction of labor (Option B) is contraindicated in hemodynamically unstable patients. Vaginal delivery takes too long and is only appropriate when the patient is stable. 2 The guideline explicitly states that vaginal delivery should be considered for hypertensive disorders unless cesarean is required for obstetric indications—this patient has a clear obstetric indication. 2

Observation with dexamethasone (Option C) is dangerous and inappropriate. The patient's ongoing bleeding and hypotension indicate active hemorrhage that will not resolve spontaneously. 1 Expectant management is only appropriate when the maternal condition allows for continuation of pregnancy, which is clearly not the case here. 2

Intraoperative Considerations

General anesthesia is preferred over regional anesthesia in this hemodynamically unstable patient. 1

• Regional anesthesia can worsen hypotension and is relatively contraindicated in hypovolemic shock. 1
• Preparation for massive transfusion should be initiated immediately. 1
• Left lateral tilt positioning should be maintained until delivery to avoid aortocaval compression. 2

Post-Delivery Management

Hemodynamic monitoring must continue for at least 24 hours post-delivery, as fluid shifts can precipitate complications. 1

• Systematic measurement of blood loss (not visual estimation) is essential to detect postpartum hemorrhage. 1
• Blood pressure control should be maintained if hypertension develops post-delivery. 1

Critical Pitfall to Avoid

Do not be falsely reassured by a reassuring CTG. 1 The fetal heart rate may remain normal even as the mother deteriorates from hemorrhagic shock. Maternal hemodynamic instability is the primary concern and mandates immediate delivery regardless of fetal monitoring findings. 1