A 32-year-old G3P2 woman at 33 weeks gestation with chronic hypertension presents with sudden-onset severe lower abdominal and back pain, dark vaginal bleeding, and a rigid, tender uterus after a motor vehicle collision. Fetal heart tracing shows late decelerations and decreased variability. Transabdominal ultrasound demonstrates the finding marked **A** in the diagram—a 6 × 4 cm hypoechoic-to-isoechoic collection between the placenta and uterine wall. Which of the following is the most appropriate immediate management for this patient?
A. Tocolytic therapy to suppress uterine contractions and allow fetal maturation
B. Admission for observation with antenatal corticosteroids and expectant management
C. Emergency cesarean delivery for fetal distress and maternal compromise
D. Immediate amniotomy to accelerate vaginal delivery and reduce intrauterine pressure
Explanation
Why Emergency cesarean delivery is right
The retroplacental hematoma (A) in this patient represents a Grade 2–3 placental abruption (moderate to severe) with fetal distress (late decelerations, decreased variability) and signs of maternal compromise (rigid uterus, severe pain, dark bleeding). According to ACOG Practice Bulletin 234, when abruption is accompanied by fetal distress, maternal hemodynamic instability, or advanced labor with unfavorable conditions, emergency delivery is mandated. Cesarean delivery is indicated here because of fetal distress; vaginal delivery is only considered if the mother is hemodynamically stable, in advanced labor, and fetal status is reassuring—none of which apply.
Why each distractor is wrong
Admission for observation with antenatal corticosteroids and expectant management: This approach is appropriate only for mild abruption (Grade 1) remote from term in a hemodynamically stable mother with reassuring fetal status. This patient has severe bleeding, fetal distress, and a rigid uterus—all indicators for urgent delivery, not expectant management.
Tocolytic therapy to suppress uterine contractions: Tocolytics are contraindicated in active placental abruption because they may worsen hemorrhage and delay necessary delivery. The goal in abruption with fetal distress is expedited delivery, not prolongation of pregnancy.
Immediate amniotomy to accelerate vaginal delivery: While amniotomy may be considered in stable patients in advanced labor with reassuring fetal status, it is not the first-line intervention in this unstable scenario. Cesarean delivery is safer given the fetal distress and maternal compromise.
High-YieldNEET PG
Placental abruption with fetal distress or maternal instability = emergency delivery (cesarean preferred if fetal distress present); tocolytics are contraindicated.
ACOG Practice Bulletin 234: Antepartum Hemorrhage
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