A 28-year-old primigravida at 32 weeks gestation presents with sudden onset vaginal bleeding and severe abdominal pain. On examination, she is hemodynamically unstable with a rigid, tender uterus. Ultrasound confirms placental abruption with fetal distress. Regarding the clinical features and management of abruptio placentae, all of the following are true EXCEPT:

Explanation

## Distinguishing Expectant vs. Active Management in Abruption **Key Point:** Expectant (conservative) management in abruption is NOT universally appropriate—it is reserved for highly selected cases with strict criteria and maternal hemodynamic stability. ### Clinical Features of Abruptio Placentae | Feature | Detail | |---------|--------| | **Revealed hemorrhage** | Vaginal bleeding visible; accounts for ~80% of cases | | **Concealed hemorrhage** | Blood trapped behind placenta; ~20% of cases but often more severe | | **Maternal shock** | Occurs earlier than fetal distress due to larger maternal blood volume loss | | **Uterine tetany** | Rigid, tender uterus ("board-like") is pathognomonic | **High-Yield:** In severe abruption, maternal cardiovascular collapse precedes fetal distress because the mother loses blood volume while the fetus is still perfused by placental circulation until complete separation occurs. ### Management Principles **Clinical Pearl:** Expectant management is **only** considered in: - Preterm abruption (< 34 weeks) - Hemodynamically stable mother - No signs of maternal coagulopathy - Reassuring fetal heart rate tracing - Ability for continuous monitoring **Warning:** Once maternal hemodynamic instability, coagulopathy, or fetal distress develops, **immediate delivery** (vaginal or cesarean) is mandatory, regardless of gestational age. ### Anti-D Immunoglobulin in Abruption **Key Point:** All Rh-negative, non-sensitized mothers with abruption require anti-D prophylaxis because: - Placental separation causes fetomaternal hemorrhage (FMH) - Even if fetus is Rh-positive, FMH can sensitize the mother - Standard dose: 500 IU (100 μg) per mL fetal RBCs; Kleihauer–Betke or flow cytometry quantifies FMH **Mnemonic: RhIG in APH** — **R**h-negative, **H**emorrhage (any), **I**mmunoglobulin **G** (anti-D) = always give ## Why Option 3 Is Incorrect Expectant management is **not** the preferred approach in **all** cases of preterm abruption. It is a selective strategy for stable, monitored patients. Hemodynamic instability, maternal coagulopathy, or fetal distress mandates urgent delivery.