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Difficulty: HardObstetric Complications

A 35-year-old woman, gravida 4, para 3, at 39 weeks gestation is admitted to the labor and delivery unit for labor induction due to diet-controlled gestational diabetes mellitus. Oxytocin augmentation is ongoing. Epidural anesthesia was administered two hours ago. Her current cervical dilation is 8 cm8\text{ cm}. She suddenly becomes extremely anxious and reports severe shortness of breath. Moments later, she becomes obtunded. Her blood pressure is 60/40 mmHg60/40\text{ mmHg}, pulse is 135 /min135\text{ /min}, and respiratory rate is 28 /min28\text{ /min}. Pulse oximetry shows an oxygen saturation of 78%78\% on room air. The nursing staff notes continuous oozing of dark blood from the patient's peripheral intravenous catheter site. The continuous fetal heart rate monitor, which previously showed a Category I tracing, now demonstrates a sudden, prolonged deceleration to 60 /min60\text{ /min} with absent variability.

Which of the following is the most appropriate initial step in management?

  1. Endotracheal intubation and mechanical ventilationAnswer
  2. B
    Immediate transport to the operating room for cesarean delivery
  3. C
    Discontinuation of the oxytocin infusion and administration of intravenous terbutaline
  4. D
    Administration of an intravenous fluid bolus and ephedrine
  5. E
    Administration of intravenous magnesium sulfate

Answer

The most appropriate initial step in management is endotracheal intubation and mechanical ventilation.
The correct answer is endotracheal intubation and mechanical ventilation. This patient is presenting with the classic triad of amniotic fluid embolism (AFE): sudden hypoxemic respiratory failure, cardiogenic shock (hypotension), and disseminated intravascular coagulation (DIC). AFE often occurs during active labor or immediately postpartum. Despite the alarming fetal heart rate tracing (prolonged deceleration), maternal resuscitation—starting with Airway and Breathing—must always take precedence. Securing the airway with endotracheal intubation is the critical first step for an obtunded patient with an oxygen saturation of 78%78\%. Once the airway is secured, the team can focus on circulatory support (vasopressors, massive transfusion) and potential emergent delivery.

Step-by-Step Solution

1
Evaluate maternal clinical stability and vital signs.
The patient is obtunded with severe hypoxia (78%78\%), profound hypotension (60/40 mmHg60/40\text{ mmHg}), and signs of coagulopathy (oozing from IV site).
Identifying the severity of the maternal condition dictates the immediate triage priority over fetal concerns.
2
Identify the etiology of the sudden clinical deterioration.
The acute triad of hypoxemic respiratory failure, cardiogenic shock, and disseminated intravascular coagulation (DIC) during active labor indicates an amniotic fluid embolism (AFE).
Recognizing AFE is critical because it requires immediate, aggressive multidisciplinary resuscitation.
3
Select the definitive next best step based on resuscitation protocols.
Despite the fetal prolonged deceleration, the airway must be secured first.
In any obstetric emergency involving maternal cardiopulmonary collapse, stabilizing maternal ABCs (Airway, Breathing, Circulation) takes absolute precedence over emergent fetal delivery.

Key Concept

In the management of amniotic fluid embolism (anaphylactoid syndrome of pregnancy), maternal stabilization (ABCs, starting with intubation for severe hypoxia) must precede emergency cesarean delivery, despite the presence of fetal distress.
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Obstetric Complications

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