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 a reassuring cardiotocography (CTG) but ongoing bleeding?

Immediate Cesarean Section After One Dose of Dexamethasone

This patient requires immediate cesarean section after administering a single dose of dexamethasone—maternal hemodynamic instability with ongoing bleeding takes absolute priority over all other considerations, and you should not delay delivery waiting for the second steroid dose. 1

Clinical Reasoning

This presentation of severe abdominal pain, moderate vaginal bleeding, and hypotension at 33 weeks strongly suggests placental abruption with hemodynamic compromise, which is a life-threatening emergency requiring immediate delivery regardless of reassuring CTG findings. 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

Hypotension with ongoing bleeding indicates maternal hemodynamic compromise and is an absolute indication for emergency delivery regardless of reassuring fetal heart rate monitoring. 1 The European Society of Cardiology explicitly states that cesarean section should be considered for patients in acute intractable heart failure or hemodynamic instability, and this patient clearly meets this threshold. 1

Why Each Option is Right or Wrong

Option D (Correct): Immediate CS After One Dose of Dexamethasone

• Give a single dose of dexamethasone (12 mg IM) for fetal lung maturation between 24+0 and 34+0 weeks gestation, but do not delay delivery waiting for the second dose—maternal stability takes precedence. 1
• Corticosteroids reduce neonatal respiratory morbidity at this gestational age, but the single dose provides benefit without compromising maternal safety. 1
• The decision-to-delivery interval should be within 25 minutes for optimal maternal and neonatal outcomes in placental abruption. 2

Option C (Incorrect): Give Dexamethasone and Observe

• Observation is contraindicated in hemodynamically unstable patients—do not delay delivery in these circumstances as maternal stabilization often requires delivery. 3
• Over 80% of severe abruption cases develop disseminated intravascular coagulation (DIC), making delay extremely dangerous. 2
• The bleeding has not stopped since admission, indicating progressive deterioration. 2

Option B (Incorrect): Induction of Labor

• Induction of labor is absolutely contraindicated in hemodynamically unstable patients. 1
• Vaginal delivery takes too long in this emergency situation where minutes matter. 2
• The patient cannot tolerate the prolonged hemodynamic stress of labor given her hypotensive state. 1

Option A (Incorrect): Blood Transfusion Alone

• While blood transfusion is essential, it is not sufficient as the sole intervention. 2
• You must activate massive transfusion protocol AND proceed to cesarean section simultaneously—transfusion supports but does not replace the need for definitive surgical management. 2
• The source of bleeding (likely placental abruption) will not stop without delivery. 2

Critical Management Steps

Immediate Actions (Simultaneous)

• Activate massive transfusion protocol with 1:1:1 ratio of packed red blood cells, fresh frozen plasma, and platelets. 2
• Establish large-bore IV access and begin aggressive fluid resuscitation. 2
• Administer dexamethasone 12 mg IM immediately. 1
• Call for immediate cesarean section, notifying anesthesiology, neonatology, and intensive care. 2
• Administer tranexamic acid 1 g IV immediately to reduce total blood loss. 2

Intraoperative Considerations

• Use general anesthesia—regional anesthesia is relatively contraindicated in hypovolemic shock as it can worsen hypotension. 1
• Keep patient warm (temperature >36°C) as clotting factors function poorly with hypothermia. 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

Post-Delivery Monitoring

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

Common Pitfalls to Avoid

• Do not over-rely on normal CTG—fetal status can deteriorate rapidly despite initially reassuring monitoring. 3
• Do not use crystalloid alone for resuscitation—use blood products to avoid dilutional coagulopathy. 2
• Do not wait for complete laboratory workup before proceeding to surgery in hemodynamically unstable patients. 2
• Do not assume you have time for expectant management when hypotension is present. 3