What is the initial management for a pregnant woman at 31 weeks gestation with hypotension and moderate uterine tenderness, but a normal Cardiotocography (CTG) and cephalic presentation?

Initial Management: Placental Abruption

This clinical presentation of hypotension (83/50 mmHg) with moderate uterine tenderness at 31 weeks gestation, despite a normal CTG and cephalic presentation, is highly suspicious for placental abruption and requires immediate resuscitation followed by urgent delivery.

Immediate Resuscitation Protocol

Aggressive fluid resuscitation must be initiated immediately with balanced crystalloid solutions (lactated Ringer's or Plasma-Lyte preferred over normal saline) 1. The initial bolus should be 1-2 liters administered rapidly within 60-90 minutes, with readiness to escalate to 30 mL/kg within 3 hours if hypotension persists 1.

Critical Positioning Intervention

• Left lateral decubitus positioning is mandatory to relieve inferior vena cava compression and improve venous return, particularly critical at 31 weeks gestation when the gravid uterus significantly compresses the vena cava 2
• Manual left lateral uterine displacement should be performed immediately while pursuing other interventions 2
• Do not delay positional interventions while waiting for IV access or other treatments 2

Hemodynamic Monitoring and Support

• Target mean arterial pressure (MAP) should be maintained at ≥65 mmHg 1
• If hypotension persists after initial fluid bolus (2 sequential BPs with SBP <90 mmHg or MAP <65 mmHg), vasopressor support with norepinephrine should be initiated at 0.02 µg/kg/min 1
• Diastolic blood pressure should not fall below 80 mmHg to ensure adequate uteroplacental perfusion 3, 2

Corticosteroid Administration

One dose of dexamethasone (or betamethasone) should be administered immediately for fetal lung maturity given the gestational age of 31 weeks and the likelihood of imminent delivery 4. Steroids are highly effective in reducing neonatal mortality and morbidity when given between 24-34 weeks gestation 4.

Delivery Decision

Immediate cesarean section is indicated after initial maternal stabilization 4. The combination of hypotension with uterine tenderness at 31 weeks represents a maternal emergency that will not resolve without delivery, as placental abruption compromises both maternal hemodynamic stability and uteroplacental perfusion 4.

Why Not Induction of Labor?

• Induction of labor (IOL) is contraindicated in suspected placental abruption with maternal hemodynamic compromise 4
• The time required for IOL would delay definitive treatment while maternal condition deteriorates
• Cesarean section allows immediate delivery and surgical control of hemorrhage

Blood Product Preparation

• Type and crossmatch for at least 4 units of packed red blood cells should be ordered immediately 1
• Massive transfusion protocol should be activated if ongoing hemorrhage is evident
• Blood transfusion itself is not the initial management but should be readily available 1

Key Clinical Pitfalls

The normal CTG does not exclude placental abruption - fetal distress may not be immediately apparent, and maternal stabilization takes priority 1. The combination of hypotension with uterine tenderness is the critical diagnostic clue that supersedes the reassuring fetal monitoring 4.

Answer: B - One dose Dexamethasone and immediate Cesarean Section (after initial resuscitation with IV fluids and left lateral positioning)