A 28-year-old woman, gravida 1, para 0, at 34 weeks gestation is brought to the emergency … — USMLE Step 2 CK

A $28$ -year-old woman, gravida $1$ , para $0$ , at $34$ weeks gestation is brought to the emergency department after being the restrained driver in a high-speed motor vehicle collision. She complains of severe, continuous lower abdominal pain and dark red vaginal bleeding. Her temperature is $37.0^\circ\text{C}$ ( $98.6^\circ\text{F}$ ), blood pressure is $82/50\text{ mmHg}$ , pulse is $130/\text{min}$ , and respirations are $24/\text{min}$ . Physical examination reveals a rigid, hypertonic uterus that is exquisitely tender to palpation. Fetal monitoring reveals a baseline heart rate of $105/\text{min}$ with minimal variability and recurrent late decelerations. Which of the following is the most appropriate next step in management?

Emergency laparotomy and Cesarean deliveryAnswer
B
Computed tomography scan of the abdomen and pelvis
C
Expectant management with continuous maternal and fetal monitoring
D
Prophylactic amnioinfusion
E
Reassurance that her vital signs reflect normal pregnancy changes

Answer

Emergency laparotomy and Cesarean delivery is required due to severe placental abruption causing maternal hemodynamic instability and fetal distress.

The correct action is to perform an emergency Cesarean delivery. The patient's presentation of a rigid, tender uterus with dark vaginal bleeding following abdominal trauma is highly suspicious for placental abruption. The combination of maternal hypovolemic shock (hypotension and tachycardia) and severe fetal compromise (late decelerations and baseline bradycardia) dictates that immediate surgical intervention is necessary to save both the mother and the fetus.

Step-by-Step Solution

Analyze the clinical presentation and physical exam findings.

The patient presents with trauma, dark vaginal bleeding, severe continuous abdominal pain, and a rigid, hypertonic uterus.

These findings are the classic triad for placental abruption, a major obstetric complication.

Assess maternal and fetal stability.

The mother is in hypovolemic shock (blood pressure

82/50\text{ mmHg}

, pulse

130/\text{min}

), and the fetus shows severe distress (bradycardia, minimal variability, late decelerations).

Identifying instability is critical to differentiating between expectant management and the need for emergent intervention.

Determine the most appropriate management based on stability.

Immediate surgical delivery (Cesarean delivery) is indicated.

In the setting of placental abruption with life-threatening maternal hemorrhage and nonreassuring fetal status, emergent delivery and concurrent maternal resuscitation are mandatory.

Key Concept

Management of severe placental abruption with maternal and fetal compromise

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