A 28-year-old primigravida at 32 weeks gestation presents to the emergency department with sudden onset of severe lower abdominal pain and vaginal bleeding. On examination, her uterus is markedly tender, hypertonic, and described as "wooden-hard." Fetal heart rate monitoring shows recurrent decelerations. Her blood pressure is 160/100 mmHg (baseline 130/85). The structure marked **B** in the diagram is suspected. Which of the following is the MOST appropriate immediate management for this patient?

Explanation

## Why "Immediate cesarean delivery after maternal resuscitation and correction of coagulopathy" is right The clinical presentation — severe abdominal pain, "wooden-hard" tender hypertonic uterus, vaginal bleeding, fetal distress (recurrent decelerations), and maternal hypertension — is pathognomonic for placental abruption (structure **B**). The anchor fact is that placental abruption presents with PAINFUL bleeding and fetal distress, and when severe with evidence of fetal compromise and maternal hemodynamic instability, IMMEDIATE DELIVERY by cesarean section is mandated. The patient requires simultaneous resuscitation (IV access, crossmatching, fluid/blood products) and urgent delivery. Correction of coagulopathy (FFP, cryoprecipitate, platelets) is critical because abruption releases tissue factor, causing DIC in ~10% of cases and worsening hemorrhage risk during delivery. ## Why each distractor is wrong - **Expectant management with corticosteroids and close fetal monitoring**: This is appropriate ONLY for mild, stable abruption at preterm gestations with reassuring fetal status. This patient has SEVERE abruption with fetal distress and maternal hypertension — expectant management is contraindicated and delays life-saving delivery. - **Vaginal delivery with active management of the third stage**: Vaginal delivery may be considered only in mild, stable abruption with advanced labor and reassuring fetal status. This patient has severe abruption with fetal distress — cesarean delivery is mandatory. Attempting vaginal delivery risks massive hemorrhage and fetal demise. - **Ultrasound confirmation before initiating any intervention**: This is a critical error. The clinical diagnosis of abruption is made clinically; ultrasound sensitivity is only 25–50% acutely because retroplacental hematoma may appear isoechoic to placenta. Delaying delivery for imaging confirmation in a patient with fetal distress and severe maternal symptoms is dangerous and contradicts ACOG guidelines. Do NOT exclude abruption based on negative ultrasound. **High-Yield:** Placental abruption = PAINFUL bleeding + wooden-hard tender uterus + fetal distress → IMMEDIATE delivery (C-section if severe/fetal distress); ultrasound may be falsely reassuring — diagnose clinically. [cite: Williams Obstetrics 26e, Chapter 34; ACOG Practice Bulletin 76]