A 32-year-old primigravida at 34 weeks gestation presents to the emergency department with sudden onset of severe abdominal pain and vaginal bleeding. On examination, she is restless, blood pressure 100/65 mmHg, heart rate 112/min, and the uterus is tender and rigid. Speculum examination shows active vaginal bleeding. Ultrasound reveals a retroplacental clot measuring 4 cm × 3 cm with fetal heart rate 145/min. Hemoglobin is 9.2 g/dL (baseline 11.8 g/dL). What is the most appropriate immediate management?

Explanation

## Clinical Diagnosis: Placental Abruption (Grade 2–3) ### Key Clinical Features Present **Key Point:** This patient has clinical and sonographic evidence of moderate-to-severe abruption: - Sudden severe abdominal pain with rigid, tender uterus (tetanic contraction) - Active vaginal bleeding - Hemodynamic stress (tachycardia, borderline hypotension) - Significant retroplacental clot on ultrasound - Acute drop in hemoglobin (2.6 g/dL) - Viable fetus at 34 weeks (FHR 145/min) ### Why Immediate Cesarean Section? **High-Yield:** In moderate-to-severe abruption with maternal hemodynamic compromise and/or fetal distress, vaginal delivery is contraindicated. The rigid uterus indicates tetanic contractions and ongoing placental separation, making labor induction unsafe and unpredictable. **Clinical Pearl:** The combination of: 1. Maternal instability (tachycardia, hypotension trend) 2. Significant retroplacental clot (>3 cm is concerning) 3. Acute anemia with ongoing bleeding 4. Viable fetus at viable gestational age ...mandates **urgent cesarean delivery** after simultaneous maternal resuscitation (IV access, cross-matched blood, FFP/platelets on standby). ### Management Algorithm ```mermaid flowchart TD A[Suspected Abruption]:::outcome --> B{Maternal hemodynamics?}:::decision B -->|Stable + mild bleeding| C[Expectant if <34 wks]:::action B -->|Unstable OR moderate-severe| D[Resuscitate: IV, blood products]:::action D --> E{Fetal viability & maturity?}:::decision E -->|Viable + any maternal instability| F[Urgent CS after prep]:::urgent E -->|Previable + maternal life threat| G[Hysterectomy consideration]:::urgent F --> H[Deliver, manage coagulopathy]:::action ``` ### Contraindications to Vaginal Delivery in This Case | Feature | Why It Matters | |---------|----------------| | Rigid, tender uterus | Tetanic contractions; risk of uterine rupture | | Hemodynamic stress | Ongoing concealed/revealed hemorrhage | | Retroplacental clot >3 cm | Extensive separation; fetal compromise likely | | Acute anemia with drop | Significant blood loss; coagulopathy risk | **Mnemonic: CRASH** — **C**oagulopathy, **R**igid uterus, **A**cute drop in Hb, **S**evere pain, **H**emodynamic instability → **Cesarean section** ### Concurrent Measures 1. **Maternal resuscitation:** Two large-bore IVs, type & cross-match, CBC, coagulation profile (PT/INR, aPTT, fibrinogen, D-dimer) 2. **Blood products:** Have O-negative RBC, FFP, platelets, cryoprecipitate ready 3. **Fetal monitoring:** Continuous CTG until delivery 4. **Anesthesia alert:** Risk of difficult airway, aspiration; prepare for emergency intubation [cite:Williams Obstetrics 26e Ch 34]