What is the most appropriate management for a pregnant patient at 33 gestational weeks, presenting with severe abdominal pain, moderate vaginal bleeding, and hypotension, with a reassuring cardiotocography (CTG) and ongoing bleeding since admission?

Management of Suspected Placental Abruption with Hemodynamic Instability at 33 Weeks

Proceed with immediate cesarean section after administering one dose of dexamethasone (12 mg IM)—maternal hemodynamic instability with ongoing bleeding is an absolute indication for emergency delivery regardless of reassuring CTG findings. 1, 2

Clinical Rationale

The combination of severe abdominal pain, moderate vaginal bleeding, hypotension, and ongoing hemorrhage at 33 weeks strongly suggests placental abruption with maternal hemodynamic compromise, which is a life-threatening emergency requiring immediate delivery. 1

• Hypotension with ongoing bleeding indicates maternal hemodynamic compromise and takes priority over all other considerations, including reassuring fetal monitoring. 2
• A normal CTG can be falsely reassuring in placental abruption, as fetal status deteriorates rapidly due to shunting of oxygenated blood away from the uterus. 1
• The decision-to-delivery interval should be within 25 minutes for optimal maternal and neonatal outcomes. 1

Pre-Operative Management

Corticosteroid Administration

• Administer a single dose of dexamethasone (12 mg IM) immediately for fetal lung maturation at 33 weeks gestation (between 24+0 and 34+0 weeks). 2
• Do not delay delivery waiting for the second dose of steroids—maternal stability takes precedence. 2

Resuscitation Protocol

• Establish large-bore IV access (14-16 gauge) and begin aggressive fluid resuscitation immediately. 3
• Activate massive transfusion protocol and prepare blood products in 1:1:1 ratio (packed red blood cells:fresh frozen plasma:platelets). 1
• Administer tranexamic acid 1 g IV immediately, as it reduces total blood loss in severe hemorrhage. 1
• Maintain oxygen supplementation to keep maternal saturation >95% for adequate fetal oxygenation. 3

Positioning

• Position the patient in left lateral tilt or manually displace the uterus off the inferior vena cava to optimize venous return and cardiac output. 3

Why Other Options Are Inappropriate

Blood Transfusion Alone

• Blood transfusion is a supportive measure but does not address the underlying cause of ongoing hemorrhage from placental abruption. 1
• Transfusion should occur simultaneously with preparation for emergency delivery, not as isolated management. 1

Induction of Labor

• Induction of labor is absolutely contraindicated in hemodynamically unstable patients. 2
• The time required for labor progression would result in continued maternal blood loss and deterioration, with high risk of maternal death and fetal demise. 1

Observation with Dexamethasone

• Expectant management is only appropriate for hemodynamically stable patients with mild preeclampsia or mild bleeding, not for ongoing hemorrhage with hypotension. 4
• Over 80% of severe abruption cases develop disseminated intravascular coagulation (DIC), making observation dangerous. 1

Intraoperative Considerations

• General anesthesia is preferred in hemodynamically unstable patients, as regional anesthesia can worsen hypotension and is relatively contraindicated in hypovolemic shock. 2
• Keep the patient warm (temperature >36°C) during surgery, as hypothermia severely impairs clotting factor function. 1
• Prepare for potential hysterectomy if bleeding is uncontrollable after delivery. 1

Post-Operative Management

• Continue intensive monitoring in ICU for at least 24 hours postoperatively due to potential hemodynamic changes and fluid shifts. 1, 2
• Monitor for ongoing coagulopathy and DIC, which commonly complicates severe abruption. 1
• Maintain a low threshold for re-exploration if bleeding continues. 1

Critical Pitfalls to Avoid

• Never delay surgical intervention in hemodynamically unstable patients while pursuing conservative measures or waiting for complete steroid courses. 1
• Avoid using vasopressors except for intractable hypotension unresponsive to fluid resuscitation, as they adversely affect uteroplacental perfusion. 3
• Do not rely on CTG reassurance alone—maternal hemodynamic status determines urgency of delivery in suspected abruption. 1