Immediate Cesarean Section After One Dose of Dexamethasone
This patient requires immediate cesarean section after administering a single dose of dexamethasone (12 mg IM), as the combination of hypotension with ongoing bleeding indicates maternal hemodynamic compromise that takes absolute priority over all other considerations, including fetal lung maturation optimization. 1
Clinical Reasoning
This presentation strongly suggests placental abruption with hemodynamic instability—a life-threatening emergency requiring immediate delivery regardless of reassuring CTG findings. 2 The CTG can be falsely reassuring in placental abruption, as fetal status deteriorates rapidly due to shunting of oxygenated blood away from the uterus. 2
Why Immediate Cesarean Section?
Hypotension with ongoing bleeding is an absolute indication for emergency delivery, regardless of reassuring fetal heart rate monitoring, as maternal hemodynamic compromise takes priority over all other considerations. 1
The American College of Obstetricians and Gynecologists recommends urgent delivery for inability to control bleeding, progressive hemodynamic instability, or placental abruption. 2
Induction of labor is contraindicated in hemodynamically unstable patients—cesarean section is required for obstetric indications when maternal stability is compromised. 1
Why Dexamethasone First?
Administer a single dose of dexamethasone (12 mg IM) for fetal lung maturation between 24+0 and 34+0 weeks gestation (this patient is at 33 weeks). 1
Do not delay delivery waiting for the second dose of steroids—maternal stability takes precedence over completing the full corticosteroid course. 1
Corticosteroids reduce neonatal respiratory morbidity, intraventricular hemorrhage, and neonatal mortality in anticipated preterm delivery. 3
Management Algorithm
Immediate Actions (Simultaneous):
Activate massive transfusion protocol and prepare for emergency cesarean section. 2
Establish large-bore IV access and begin aggressive fluid resuscitation. 2
Order blood products immediately (packed red blood cells, fresh frozen plasma, platelets in 1:1:1 ratio) for hemostatic resuscitation. 2, 1
Administer dexamethasone 12 mg IM as a single dose. 1
Notify anesthesiology, neonatology, and intensive care with decision-to-delivery interval target within 25 minutes. 2
Intraoperative Considerations:
General anesthesia is preferred in hemodynamically unstable patients, as regional anesthesia can worsen hypotension and is relatively contraindicated in hypovolemic shock. 1
Maintain left lateral tilt positioning until delivery to avoid aortocaval compression. 1
Keep patient warm (temperature >36°C) during surgery, as clotting factors function poorly with hypothermia. 2
Critical Pitfalls to Avoid:
Do not use crystalloid alone for resuscitation—use blood products for volume replacement to avoid dilutional coagulopathy and volume overload. 2
Do not wait for laboratory results before proceeding to cesarean section—treat based on clinical presentation. 2
Anticipate disseminated intravascular coagulation (DIC) in over 80% of severe abruption cases. 2
Prepare for potential hysterectomy if bleeding is uncontrollable after delivery. 2
Postoperative Management:
Continue intensive monitoring in ICU for at least 24 hours postoperatively due to potential hemodynamic changes and fluid shifts. 2, 1
Monitor for ongoing coagulopathy and have a low threshold for re-exploration if bleeding continues. 2
Why Other Options Are Incorrect:
Blood transfusion alone (Option A) addresses supportive care but does not resolve the underlying obstetric emergency causing ongoing bleeding.
Induction of labor (Option B) is contraindicated in hemodynamically unstable patients and would delay definitive management. 1
Dexamethasone and observation (Option C) is inappropriate when maternal hemodynamic instability exists—observation is only appropriate when the patient is stable.