A 28-year-old primigravida at 32 weeks gestation presents to the emergency department with sudden-onset severe abdominal pain and vaginal bleeding. She has a history of poorly controlled hypertension (BP 160/100 mmHg today). On examination, the uterus is tender and woody hard. Fetal heart rate is 90 bpm. Ultrasound shows a retroplacental hematoma. Her hemoglobin is 8.5 g/dL (baseline 11.2 g/dL), platelet count 95,000/μL, and fibrinogen 180 mg/dL. What is the most appropriate next step in management?

Explanation

## Clinical Diagnosis: Grade 3 Abruptio Placentae **Key Point:** This patient presents with the classic triad of abruptio placentae: sudden severe abdominal pain, vaginal bleeding, and uterine tenderness. The retroplacental hematoma on ultrasound is pathognomonic. ### Severity Assessment | Feature | Grade 1 | Grade 2 | Grade 3 | |---------|---------|---------|----------| | **Vaginal bleeding** | Mild | Moderate | Severe/concealed | | **Uterine tenderness** | Mild | Moderate | Severe (woody hard) | | **FHR abnormality** | Absent | Present | Bradycardia/absent | | **Coagulopathy** | Absent | Mild | Severe (Plt <100k, Fib <200) | | **Maternal stability** | Stable | Compensated shock | Hemorrhagic shock | | **Fetal viability** | Viable | Viable | Often dead/moribund | **High-Yield:** This patient has **Grade 3 abruptio** (severe concealed hemorrhage, coagulopathy, fetal bradycardia at 32 weeks). At this severity, maternal and fetal survival depend on **immediate delivery**. ### Management Algorithm ```mermaid flowchart TD A[Suspected Abruptio Placentae]:::outcome --> B{Severity?}:::decision B -->|Grade 1| C[Expectant management<br/>if stable]:::action B -->|Grade 2| D{Fetal viability<br/>reassuring?}:::decision D -->|Yes| E[Close monitoring<br/>+ corticosteroids]:::action D -->|No| F[Prepare for delivery]:::action B -->|Grade 3| G[EMERGENCY]:::urgent G --> H[Simultaneous resuscitation<br/>+ delivery prep]:::action H --> I[Rapid IV access<br/>2 large bore]:::action I --> J[Type & cross<br/>+ coagulation studies]:::action J --> K[Crystalloid bolus<br/>+ PRBCs/FFP/Plt]:::action K --> L[Emergency LSCS]:::action L --> M[Delivery of baby<br/>+ placenta]:::outcome ``` ### Why Cesarean Section? 1. **Fetal compromise:** FHR 90 bpm is severe bradycardia; vaginal delivery would delay fetal extraction. 2. **Maternal hemorrhage:** Concealed bleeding with coagulopathy (Plt 95k, Fib 180) — vaginal delivery prolongs exposure to uterine contractions and further placental separation. 3. **Gestational age:** At 32 weeks, the fetus is viable; neonatal intensive care is available. 4. **Hypertension:** Uncontrolled BP + abruptio = risk of eclampsia; expedited delivery is indicated. **Clinical Pearl:** In abruptio placentae with Grade 3 severity, **time is uterus** — every minute of delay increases maternal mortality from DIC and fetal mortality from hypoxia. Resuscitation and delivery must occur in parallel, not sequentially. **Warning:** Do NOT delay cesarean for "fetal maturation" — the fetus is already dying from placental separation. Magnesium sulphate is for seizure prophylaxis in preeclampsia, not for management of hemorrhage. [cite:Williams Obstetrics 26e Ch 34]