Abstract Placental abruption complicated by intrauterine fetal demise (IUFD) is frequently associated with major obstetric hemorrhage, consumptive coagulopathy, and progressive maternal organ dysfunction. In such cases, vaginal delivery is generally preferred to avoid the additional bleeding risk of surgery, although cesarean delivery may become necessary if the maternal condition deteriorates. We report a case in which reassessment after induction of general anesthesia altered the planned mode of delivery and may have avoided laparotomy in a high-risk setting. In her late 20s primigravida at 30 + 3 weeks’ gestation presented with abdominal pain, vaginal bleeding, severe hypertension, and IUFD due to placental abruption. Laboratory findings showed severe coagulopathy, with platelet count = 78 × 10 3 /μL, prothrombin time/international normalized ratio > 10, fibrinogen 960 μg/mL, along with impaired renal function. Vaginal delivery was initially selected because less bleeding was expected than with cesarean delivery. However, labor failed to progress despite cervical ripening and oxytocin, while blood pressure remained uncontrolled and renal dysfunction worsened, prompting a decision for cesarean section under general anesthesia because neuraxial anesthesia was contraindicated. After induction, repeat vaginal examination demonstrated a cervical dilatation of 8 cm. Therefore, the delivery plan was changed, and vacuum-assisted vaginal delivery was completed under general anesthesia without major procedural complications. The patient required intensive postoperative monitoring for acute kidney injury and hemodynamic management but recovered without major complications and was discharged on postoperative day 10. This case highlights that, in carefully selected IUFD cases with severe coagulopathy, repeat vaginal assessment after induction but before incision may help identify a safer delivery route while preserving surgical readiness.
Morioka et al. (Sat,) studied this question.