Examkin

Question

Difficulty: MediumObstetric Complications

A female patient in her first pregnancy presents to the obstetric triage unit at term (3939 weeks of gestation). She reports the continuous leakage of clear vaginal fluid that began approximately 2222 hours prior to arrival. Currently, she is experiencing mild, irregular uterine contractions. Evaluation reveals a maternal core temperature of 39.1∘C39.1^\circ\text{C} (102.4∘F102.4^\circ\text{F}), a blood pressure of 110/70110/70 mm Hg, and a pulse of 115115/min. Fetal monitoring demonstrates a baseline heart rate of 175175/min with moderate variability and an absence of periodic decelerations. Abdominal examination is notable for diffuse fundal tenderness. Pelvic examination shows the cervix is 44 cm dilated and 80%80\% effaced. What is the most appropriate next step in the management of this patient?

  1. A
    Intravenous ampicillin and gentamicin followed by immediate cesarean delivery
  2. B
    Acetaminophen administration, intravenous fluids, and expectant management
  3. C
    Maternal repositioning, amnioinfusion, and continuous fetal monitoring
  4. Intravenous ampicillin and gentamicin followed by oxytocin administrationAnswer
  5. E
    Intravenous vancomycin and piperacillin-tazobactam followed by oxytocin administration

Answer

The most appropriate next step is the administration of intravenous ampicillin and gentamicin followed by labor augmentation with oxytocin.
The patient's presentation of maternal fever, prolonged rupture of membranes, uterine tenderness, and maternal/fetal tachycardia is classic for intra-amniotic infection. Standard management consists of administering intravenous ampicillin and gentamicin to treat the infection, followed by oxytocin to expedite vaginal delivery, which is the safest route in the absence of other obstetric complications.

Step-by-Step Solution

1
Diagnose the patient's acute condition based on clinical findings.
The combination of maternal fever (>39.0∘C>39.0^\circ\text{C}), prolonged rupture of membranes (>18>18 hours), maternal and fetal tachycardia, and uterine fundal tenderness confirms a clinical diagnosis of intra-amniotic infection (chorioamnionitis).
Accurate diagnosis is required to guide both medical therapy and obstetric management.
2
Determine the appropriate medical intervention for the diagnosed infection.
Initiate empiric, broad-spectrum intravenous antibiotics, typically a combination of ampicillin and gentamicin.
Prompt antibiotic therapy reduces the risk of maternal complications (e.g., sepsis, postpartum hemorrhage) and neonatal morbidity (e.g., neonatal sepsis, pneumonia).
3
Determine the optimal route and timing of delivery.
Proceed with augmenting labor using oxytocin to expedite a vaginal delivery.
Intra-amniotic infection alone is not an indication for cesarean delivery. Since the fetal heart rate tracing is reassuring (moderate variability, no decelerations) and there are no standard contraindications to vaginal birth, labor should be augmented because the patient is only having irregular contractions.

Key Concept

Management of intra-amniotic infection (chorioamnionitis) requires the prompt initiation of broad-spectrum antibiotics (ampicillin and gentamicin) and expediting delivery. Vaginal delivery is the preferred route, typically achieved via labor induction or augmentation with oxytocin.
Estimated Time:1m 30s
Rate this question

Topics

Obstetric Complications

More questions from this topic