How should I manage a 32‑week pregnant woman with severe abdominal pain, polyhydramnios (amniotic‑fluid index 24 cm), normal fetal heart rate (132 bpm), uterine height 1 finger above the symphysis (loose presenting part) and estimated fetal weight 2100 g?

Immediate Management of 32-Week Pregnancy with Severe Abdominal Pain and Polyhydramnios

This patient requires urgent hospitalization with immediate umbilical artery Doppler assessment and continuous fetal monitoring to determine whether emergency delivery is indicated, as the combination of severe abdominal pain, polyhydramnios (AFI 24 cm), and borderline fetal weight (2100g at 32 weeks, approximately 10th percentile) suggests potential placental abruption, preterm labor, or fetal compromise. 1, 2, 3

Critical First Steps (Within 1 Hour)

Immediate Fetal Assessment

• Perform continuous cardiotocography (CTG) immediately to assess for non-reassuring fetal heart rate patterns that would mandate emergency cesarean delivery 2, 3
• Obtain umbilical artery Doppler studies urgently if not already done, as this determines delivery timing and mode 1, 2, 3
• The fetal heart rate of 132 bpm is reassuring but continuous monitoring is mandatory given the clinical presentation 1

Urgent Maternal Evaluation

• Rule out placental abruption as the primary concern with severe abdominal pain at 32 weeks—assess for vaginal bleeding, uterine tenderness, and hypertonic contractions 4
• Assess for preterm labor given the loose cervical os (1 finger dilated) and severe pain—perform speculum examination to evaluate for cervical change and membrane rupture 5, 6
• Evaluate for preeclampsia with blood pressure measurement, urine protein, and laboratory assessment (complete blood count, liver enzymes, platelet count) as polyhydramnios can be associated with maternal hypertensive disorders 1

Polyhydramnios Management Context

Significance of AFI 24 cm

• An AFI of 24 cm represents moderate-to-severe polyhydramnios (normal AFI at 32 weeks is 8-18 cm) 5
• Polyhydramnios is associated with fetal anomalies in 79% of cases (particularly gastrointestinal obstructive anomalies), gestational diabetes, and fetal infections 5, 6
• The condition increases risk for preterm labor, premature rupture of membranes, abnormal fetal presentation, cord prolapse, and postpartum hemorrhage 5

Immediate Polyhydramnios Workup

• Perform detailed fetal anatomic ultrasound to evaluate for gastrointestinal obstruction, central nervous system anomalies, or other structural defects 5, 6
• Test for gestational diabetes with glucose tolerance testing if not already done 5
• Screen for fetal infections (TORCH titers) if other causes are not identified 5

Delivery Decision Algorithm

Emergency Cesarean Delivery Indicated If:

• Non-reassuring fetal heart rate pattern on continuous CTG (late decelerations, prolonged decelerations, absent variability) 2, 3
• Clinical signs of placental abruption (severe pain, vaginal bleeding, uterine tenderness, fetal compromise) 4
• Umbilical artery Doppler shows absent or reversed end-diastolic velocity (AEDV or REDV)—cesarean delivery should be strongly considered 1, 2, 3

Expectant Management with Intensive Surveillance If:

• Reassuring fetal monitoring and normal umbilical artery Doppler with preserved end-diastolic flow 1, 2, 3
• Pain is controlled and attributable to uterine distension from polyhydramnios rather than abruption or labor 5, 4
• No evidence of active preterm labor after tocolysis consideration 5

Essential Interventions Before Any Delivery Decision

Antenatal Corticosteroids

• Administer betamethasone 12 mg IM immediately, repeat in 24 hours for fetal lung maturation, as delivery may occur before 34 weeks 1, 2, 3
• This reduces neonatal respiratory distress syndrome, intraventricular hemorrhage, and neonatal death 2

Magnesium Sulfate for Neuroprotection

• Administer magnesium sulfate 4-6g IV loading dose followed by 1-2g/hour infusion if delivery is anticipated before 32 weeks 1, 3
• This provides fetal neuroprotection and reduces risk of cerebral palsy 1, 3

Symptomatic Relief for Polyhydramnios

• Consider therapeutic amnioreduction if maternal respiratory distress is severe or if polyhydramnios is causing preterm labor 5, 6
• Amnioreduction at 32 weeks has a low complication rate (1.2% placental abruption, 2.3% preterm delivery) and can prolong pregnancy by median 30 days 6
• NSAIDs (indomethacin) are NOT recommended at 32 weeks due to risk of premature ductus arteriosus closure and oligohydramnios 5

Ongoing Surveillance Protocol (If Expectant Management Chosen)

Fetal Monitoring Intensity

• Daily CTG monitoring if umbilical artery Doppler shows elevated resistance indices (>95th percentile) 1, 3
• Umbilical artery Doppler every 1-2 weeks if resistance indices are elevated but end-diastolic flow is preserved 1, 3
• Twice weekly biophysical profile assessment including amniotic fluid volume 1

Delivery Timing if Expectant Management Continues

• Deliver at 34 weeks if umbilical artery Doppler shows absent end-diastolic velocity 1, 2, 3
• Deliver at 37 weeks if elevated resistance indices but preserved end-diastolic flow 1, 3
• Deliver earlier if fetal growth restriction worsens (EFW <3rd percentile), oligohydramnios develops, or maternal/fetal condition deteriorates 1, 2

Critical Pitfalls to Avoid

• Do not dismiss severe abdominal pain as "normal pregnancy discomfort"—placental abruption must be ruled out urgently 4
• Do not delay corticosteroids while awaiting Doppler results—administer immediately given gestational age and clinical presentation 2, 3
• Do not attempt induction of labor if umbilical artery Doppler shows AEDV or REDV—cesarean delivery is strongly indicated 2, 3
• Do not use indomethacin for polyhydramnios management after 32 weeks due to fetal risks 5
• Do not overlook fetal anomaly screening—79% of polyhydramnios cases have underlying structural defects requiring postnatal surgical planning 5, 6