A 26-year-old pregnant woman, currently at 35 weeks of gestation, arrives at the emergency… — USMLE Step 2 CK

A 26-year-old pregnant woman, currently at 35 weeks of gestation, arrives at the emergency department via ambulance after being the restrained driver in a high-speed motor vehicle collision. She complains of severe, unremitting abdominal pain and reports a sudden onset of dark vaginal bleeding. Her past medical history is unremarkable. Her blood pressure is $82/50 \text{ mmHg}$ , heart rate is $132/\text{min}$ , and respiratory rate is $24/\text{min}$ . Physical examination reveals a rigid, diffusely tender, and "woody" uterus. Initial laboratory studies show a hemoglobin level of $8.5 \text{ g/dL}$ . Continuous electronic fetal monitoring demonstrates a baseline heart rate of $95/\text{min}$ with absent variability and recurrent late decelerations. Which of the following is the most appropriate next step in the management of this patient?

Perform an immediate laparotomy with cesarean deliveryAnswer
B
Transfer the patient to radiology for a contrast-enhanced computed tomography scan
C
Reposition the patient to the left lateral decubitus position to relieve physiologic caval compression
D
Administer a transcervical amnioinfusion to treat the fetal heart rate decelerations
E
Initiate an intravenous oxytocin infusion to augment uterine contractions

Answer

Perform an immediate laparotomy with cesarean delivery

This patient presents with the classic triad of placental abruption (abruptio placentae): sudden-onset vaginal bleeding, severe abdominal pain, and a rigid, hypertonic uterus. Her presentation following a high-speed motor vehicle collision is highly suggestive of a traumatic abruption. Furthermore, she is in hypovolemic shock, and the fetal heart rate tracing is Category III (fetal bradycardia with absent variability and late decelerations), indicating severe fetal hypoxia. In the setting of severe placental abruption with maternal hemodynamic instability and a non-reassuring fetal status, the most appropriate next step is concurrent aggressive maternal resuscitation (intravenous fluids, blood products) and an immediate laparotomy with cesarean delivery to control the hemorrhage and deliver the distressed fetus.

Step-by-Step Solution

Assess maternal hemodynamic status and the physical examination findings.

The patient is in hypovolemic shock (

82/50 \text{ mmHg}

132/\text{min}

) with a rigid, woody uterus and dark vaginal bleeding following trauma.

These findings are highly indicative of a severe, life-threatening placental abruption with massive concealed and revealed hemorrhage.

Evaluate the fetal status based on the continuous electronic fetal monitoring.

The tracing shows fetal bradycardia (

95/\text{min}

), absent variability, and late decelerations (a Category III tracing).

This indicates severe fetal hypoxia and acidemia secondary to uteroplacental insufficiency caused by the abruption.

Determine the definitive next best step in management.

Immediate surgical intervention (exploratory laparotomy with cesarean delivery) alongside concurrent maternal resuscitation.

Both the mother and the fetus are hemodynamically unstable and at imminent risk of death; delaying for imaging or conservative management is absolutely contraindicated.

Key Concept

Management of severe placental abruption complicated by maternal hemodynamic instability and fetal distress requires immediate surgical delivery and aggressive maternal resuscitation.

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