A 32-year-old primigravida at 34 weeks of gestation presents to the emergency department with sudden onset of severe abdominal pain and vaginal bleeding. She reports a history of uncontrolled hypertension (BP 168/104 mmHg) and denies any trauma. On examination, the uterus is tender, firm, and board-like. Fetal heart rate is 90 bpm with minimal variability. Ultrasound shows a large retroplacental clot. Laboratory investigations reveal hemoglobin 8.2 g/dL, platelet count 95,000/μL, fibrinogen 180 mg/dL, and PT/INR prolonged. What is the most appropriate immediate management?

Explanation

## Clinical Diagnosis: Placental Abruption with DIC **Key Point:** This patient has severe placental abruption (Couvelaire uterus) with evidence of disseminated intravascular coagulation (DIC) and fetal distress — this is a life-threatening emergency requiring immediate delivery. ### Diagnostic Features Present - **Maternal signs:** Severe hypertension, sudden severe abdominal pain, vaginal bleeding - **Uterine findings:** Board-like rigidity (Couvelaire uterus) indicating extensive placental separation - **Fetal compromise:** Bradycardia (90 bpm) with minimal variability = fetal distress - **Imaging:** Retroplacental clot on ultrasound (pathognomonic) - **Coagulopathy markers:** Thrombocytopenia, hypofibrinogenemia, prolonged PT/INR = DIC ### Why Cesarean Section? | Indication | Rationale | |---|---| | **Fetal distress** | Bradycardia with minimal variability = imminent fetal death | | **Maternal DIC** | Ongoing placental separation → continued fibrinogen consumption | | **Severe abruption** | Retroplacental clot + Couvelaire uterus = >50% placental separation | | **Hemodynamic instability risk** | Hemoglobin 8.2 g/dL + active bleeding | **High-Yield:** In severe abruption with fetal distress OR maternal hemodynamic compromise, **cesarean delivery is the standard of care** — it stops placental separation and allows resuscitation of mother and fetus simultaneously. ### Concurrent Management 1. **Blood bank activation:** Cross-match 4–6 units PRBC, 4 units FFP, 1 unit platelets, 1 unit cryoprecipitate 2. **IV access:** Two large-bore cannulae; prepare for massive transfusion protocol 3. **Obstetric anesthesia:** Inform of DIC; avoid epidural (platelet count borderline) 4. **Neonatology:** Alert for preterm delivery at 34 weeks **Clinical Pearl:** Couvelaire uterus (board-like rigidity) indicates concealed hemorrhage into the myometrium — this is a marker of severe abruption and uterine atony risk post-delivery. [cite:Williams Obstetrics 26e Ch 34]