In a 33‑week pregnant woman with severe abdominal pain, persistent moderate vaginal bleeding, and hypotension due to suspected placental abruption, what is the most appropriate initial management?

Immediate Cesarean Section After Maternal Stabilization

In a 33-week pregnant woman with severe placental abruption presenting with hypotension, persistent moderate vaginal bleeding, and reassuring fetal status, the most appropriate initial management is immediate cesarean delivery after one dose of dexamethasone (Option D), preceded by aggressive resuscitation with massive transfusion protocol activation.

Critical First Steps: Simultaneous Resuscitation and Delivery Preparation

The clinical picture—severe abdominal pain, persistent bleeding, and maternal hypotension at 33 weeks—indicates a severe placental abruption with ongoing hemorrhage that has already compromised maternal hemodynamic stability. 1

Immediate Resuscitation Protocol

• Activate massive transfusion protocol immediately with a 1:1:1 ratio of packed red blood cells, fresh frozen plasma, and platelets to restore circulating volume and prevent disseminated intravascular coagulopathy. 1

• Establish large-bore intravenous access (two 14-16 gauge peripheral lines or ≥8-Fr central line) and begin aggressive fluid resuscitation with warmed physiologic electrolyte solutions. 2

• Administer tranexamic acid 1 g IV over 10 minutes immediately, as effectiveness declines by approximately 10% for every 15 minutes of delay, and it reduces bleeding-related mortality when given within 3 hours of delivery. 3

• Obtain baseline laboratory tests urgently: complete blood count, PT, PTT, Clauss fibrinogen (target >200 mg/dL in pregnancy), and crossmatch for at least 4-6 units of packed red cells—but do not delay transfusion waiting for results. 1, 2

• Maintain maternal temperature >36°C throughout, as clotting factors function poorly at lower temperatures. 1, 2

Why Immediate Cesarean Section Is Indicated

Maternal Indications

• Hypotension despite admission indicates ongoing blood loss that has already exceeded the body's compensatory mechanisms, placing the mother at high risk for disseminated intravascular coagulopathy, renal failure, and hemorrhagic shock. 4, 5

• Persistent bleeding that has not stopped since admission signals that conservative management has already failed and definitive delivery is required to achieve hemostasis. 6

• Placental abruption involving >50% of the placenta is frequently associated with severe maternal complications including the need for blood transfusions, emergency hysterectomy, and disseminated intravascular coagulopathy. 4

Fetal Considerations at 33 Weeks

• At 33 weeks gestation with reassuring fetal heart tracing, the fetus is viable and delivery is appropriate, especially given maternal instability. 4, 7

• One dose of dexamethasone should be administered to provide some fetal lung maturity benefit, but delivery should not be delayed beyond the time needed for immediate maternal stabilization and operating room preparation. 7

• The complete two-dose dexamethasone course (option C: "give dexa and observe") is inappropriate when the mother is hypotensive with ongoing bleeding, as continued observation risks both maternal and fetal death. 4

Why Other Options Are Inappropriate

Option A (Blood Transfusion Alone)

• While blood transfusion is absolutely necessary and should be initiated immediately, transfusion alone without definitive delivery will not stop the bleeding source in severe placental abruption. 1

• The placenta must be delivered to achieve hemostasis; ongoing abruption will continue to bleed regardless of transfusion support. 4, 7

Option B (Induction of Labor)

• Induction of labor is contraindicated in the presence of maternal hemodynamic compromise (hypotension) and ongoing hemorrhage. 4, 7

• Labor induction takes hours to achieve delivery, during which time the mother will continue to bleed and deteriorate, risking disseminated intravascular coagulopathy and maternal death. 6, 5

• Vaginal delivery is only appropriate in placental abruption when maternal and fetal status are stable or when fetal demise has already occurred. 4

Option C (Dexamethasone and Observation)

• Observation is absolutely contraindicated in a hypotensive patient with ongoing bleeding. 6, 7

• The maternal mortality rate in placental abruption is seven times higher than the overall maternal mortality rate, and delay in definitive management is the primary modifiable risk factor. 5

Intraoperative Considerations

• Continue the 1:1:1 transfusion ratio throughout surgery and monitor fibrinogen levels closely, as levels <200 mg/dL are associated with severe postpartum hemorrhage. 1

• Hypofibrinogenemia (fibrinogen <200 mg/dL in pregnancy) is the most predictive biomarker of severe postpartum hemorrhage and occurs commonly with abruption; transfuse cryoprecipitate if fibrinogen <100 mg/dL, though pregnancy targets should be >200 mg/dL. 1, 3

• Avoid acidosis and maintain normothermia, as both impair coagulation function. 2

• If blood loss exceeds 1,500 mL, re-dose prophylactic antibiotics. 1

Common Pitfalls to Avoid

• Do not delay delivery waiting for complete steroid course when the mother is hemodynamically unstable—one dose provides some benefit and delivery must proceed. 7

• Do not underestimate blood loss—clinical estimation is notoriously inaccurate in obstetric hemorrhage, and hypotension indicates significant volume depletion. 1

• Do not attempt vaginal delivery in the setting of maternal compromise, as this delays definitive hemostasis and risks maternal death. 4, 6

• Do not delay tranexamic acid administration—each 15-minute delay reduces its effectiveness by approximately 10% and offers no benefit after 3 hours. 3