What is the most appropriate management for a 33-week pregnant woman presenting with severe abdominal pain, moderate vaginal bleeding, and hypotension, whose bleeding has not stopped since admission?

Management of Hemodynamically Unstable Pregnant Woman at 33 Weeks with Severe Bleeding

This patient requires immediate cesarean section after one dose of dexamethasone (Option D), as the combination of severe abdominal pain, ongoing moderate vaginal bleeding, and hypotension indicates hemodynamic instability that mandates urgent delivery—maternal stability takes absolute precedence over all other considerations. 1, 2

Clinical Reasoning

Why Immediate Delivery is Required

• Hypotension with ongoing bleeding indicates maternal hemodynamic compromise, which is an absolute indication for emergency delivery regardless of reassuring fetal heart rate monitoring 2
• The European Society of Cardiology states that cesarean section should be considered for patients in acute intractable heart failure or hemodynamic instability, and this patient clearly meets this threshold 2
• This clinical presentation (severe abdominal pain + vaginal bleeding + hypotension at 33 weeks) strongly suggests placental abruption with hemodynamic compromise, a life-threatening emergency requiring immediate delivery 1
• The American College of Obstetricians and Gynecologists recommends urgent delivery for inability to control bleeding and progressive hemodynamic instability 1

Why Dexamethasone Should Be Given (But Not Delay Delivery)

• A single dose of dexamethasone (12 mg IM) for fetal lung maturation is recommended between 24+0 and 34+0 weeks gestation to reduce neonatal respiratory morbidity 2
• Critically: Do NOT delay delivery waiting for the second dose of steroids—maternal stability takes precedence 2
• The decision-to-delivery interval should be within 25 minutes for optimal maternal and neonatal outcomes in placental abruption 1

Why Other Options Are Incorrect

Option A (Blood transfusion alone): While blood products are essential, transfusion without delivery will not stop the bleeding source. The American College of Obstetricians and Gynecologists recommends beginning blood product transfusion in a 1:1:1 ratio (packed RBCs:FFP:platelets) for hemostatic resuscitation, but this must occur simultaneously with preparation for emergency cesarean section, not as a standalone intervention 1

Option B (Induction of labor): Induction of labor is absolutely contraindicated in hemodynamically unstable patients 2. Vaginal delivery takes too long when the patient is actively bleeding and hypotensive—she needs immediate delivery via cesarean section 1, 2

Option C (Give dexamethasone and observe): Observation is dangerous and inappropriate. The bleeding has not stopped since admission, and the patient is hypotensive—this represents ongoing hemodynamic compromise requiring immediate intervention, not expectant management 1, 2

Immediate Management Algorithm

Pre-Operative Resuscitation (Simultaneous with Cesarean Preparation)

• Activate massive transfusion protocol immediately and prepare for emergency cesarean section 1
• Establish large-bore IV access (two sites minimum) and begin aggressive fluid resuscitation 1
• Order blood products immediately in a 1:1:1 ratio (packed RBCs:FFP:platelets) for anticipated massive transfusion 1, 3
• Administer tranexamic acid 1 g IV immediately, as it reduces total blood loss in severe hemorrhage 1
• Give dexamethasone 12 mg IM once for fetal lung maturation, but proceed to cesarean section without waiting for the second dose 2

Intraoperative Considerations

• General anesthesia is preferred in hemodynamically unstable patients, as regional anesthesia can worsen hypotension and is relatively contraindicated in hypovolemic shock 2
• Maintain left lateral tilt positioning until delivery to avoid aortocaval compression 2
• Keep the patient warm (temperature >36°C) during surgery, as clotting factors function poorly with hypothermia 1
• Anticipate disseminated intravascular coagulation (DIC) in over 80% of severe abruption cases 1, 3
• Prepare for potential hysterectomy if bleeding is uncontrollable after delivery 1

Post-Operative Monitoring

• Continue intensive monitoring in ICU for at least 24 hours postoperatively, as fluid shifts can precipitate complications 1, 2
• Monitor for ongoing coagulopathy and have a low threshold for re-exploration if bleeding continues 1
• Use slow IV oxytocin (<2 U/min) to prevent postpartum hemorrhage while avoiding systemic hypotension 1
• Avoid methylergonovine due to its vasoconstrictive effects and risk of hypertension 1

Critical Pitfalls to Avoid

• Do not delay delivery for laboratory results—proceed based on clinical presentation in hemodynamically unstable patients 1
• Do not use crystalloid alone for resuscitation—use blood products for volume replacement to avoid dilutional coagulopathy 1
• Do not be falsely reassured by a normal CTG—fetal status can deteriorate rapidly in placental abruption as oxygenated blood is shunted away from the uterus 1
• Do not attempt vaginal delivery in a hemodynamically unstable patient with ongoing bleeding 2