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 ongoing bleeding since admission?

Immediate Cesarean Section After One Dose of Dexamethasone

The most appropriate management is immediate cesarean section after administering one dose of dexamethasone (Option D). This patient at 33 weeks gestation with severe abdominal pain, moderate vaginal bleeding, hypotension, and ongoing hemorrhage despite admission represents hemodynamic instability that constitutes an absolute indication for emergency delivery, regardless of reassuring fetal monitoring. 1

Clinical Rationale for Immediate Delivery

Hypotension with ongoing bleeding indicates maternal hemodynamic compromise that takes priority over all other considerations. 1 This clinical presentation—likely representing placental abruption or another obstetric hemorrhage—requires urgent intervention to prevent maternal mortality, as the combination of severe abdominal pain, vaginal bleeding, and hypotension represents life-threatening hemorrhage. 2

• The European Society of Cardiology explicitly states that hemodynamic instability with ongoing bleeding is an absolute indication for emergency delivery regardless of reassuring fetal heart rate monitoring. 1
• Cesarean section should be performed for patients in acute intractable heart failure or hemodynamic instability, and this patient's hypotension with ongoing bleeding meets this threshold. 1
• Induction of labor is contraindicated in hemodynamically unstable patients—vaginal delivery would prolong the time to definitive management and increase maternal risk. 1

Corticosteroid Administration Protocol

Administer a single dose of dexamethasone (12 mg IM) for fetal lung maturation immediately, but do not delay delivery waiting for the second dose. 1 At 33 weeks gestation, this falls within the 24+0 to 34+0 week window where corticosteroids reduce neonatal respiratory morbidity. 1

• Maternal stability takes absolute precedence over completing the full corticosteroid course. 1
• The benefit of one dose is substantial, and delaying delivery for the second dose would unacceptably increase maternal mortality risk. 1

Why Other Options Are Inappropriate

Blood transfusion alone (Option A) is insufficient because it addresses the consequence of hemorrhage without treating the source—ongoing bleeding will continue until delivery occurs. 2 While massive transfusion protocol should be activated simultaneously with surgical preparation, transfusion is a supportive measure, not definitive management. 2

Induction of labor (Option B) is contraindicated in hemodynamically unstable patients as it prolongs time to delivery and increases maternal risk. 1 The patient's hypotension and ongoing bleeding require immediate delivery, not a prolonged labor process.

Dexamethasone with observation (Option C) is dangerous because continued observation in a hemodynamically unstable patient with ongoing hemorrhage will lead to maternal death. 1, 2 The reassuring fetal heart tracing is falsely reassuring—fetal status deteriorates rapidly in placental abruption as oxygenated blood is shunted away from the uterus. 2

Immediate Preoperative Management

Activate massive transfusion protocol immediately with packed red blood cells, fresh frozen plasma, and platelets in a 1:1:1 ratio for hemostatic resuscitation. 2

• Establish large-bore IV access (two sites minimum) and begin aggressive fluid resuscitation while preparing for surgery. 2
• Order blood products immediately without waiting for laboratory results—treat based on clinical presentation. 2
• Anticipate disseminated intravascular coagulation (DIC), which complicates over 80% of severe abruption cases. 2

Anesthetic Considerations

General anesthesia is preferred over regional anesthesia in this hemodynamically unstable patient, as regional anesthesia can worsen hypotension and is relatively contraindicated in hypovolemic shock. 1

Intraoperative Priorities

Proceed directly to cesarean section with decision-to-delivery interval within 25 minutes for optimal maternal and neonatal outcomes. 2

• Keep the patient warm (temperature >36°C) during surgery, as clotting factors function poorly with hypothermia. 2
• Avoid acidosis, which impairs coagulation. 2
• Prepare for potential hysterectomy if bleeding is uncontrollable after delivery. 2
• Use slow IV oxytocin (<2 U/min) after placental delivery to prevent postpartum hemorrhage while avoiding systemic hypotension. 2
• Avoid methylergonovine due to vasoconstrictive effects and risk of hypertension. 2

Postoperative Management

Continue intensive monitoring in an ICU setting for at least 24 hours postoperatively due to potential hemodynamic changes and fluid shifts that commonly occur after delivery. 1, 2

• Monitor for ongoing coagulopathy and have a low threshold for re-exploration if bleeding continues. 2
• Maintain vigilance for postpartum hemorrhage with systematic measurement of blood loss. 1

Critical Pitfall to Avoid

The most dangerous error is being falsely reassured by the normal fetal heart tracing. 2 A normal CTG at the moment of placental abruption does not indicate maternal or fetal stability—fetal status can deteriorate within minutes, and maternal hemorrhage can progress to irreversible shock. The combination of severe abdominal pain, vaginal bleeding, and hypotension demands immediate action regardless of fetal monitoring. 2