A 31-year-old woman, G2P1, at 34 weeks gestation is evaluated in the emergency department … — USMLE Step 2 CK

A $31$ -year-old woman, G2P1, at $34$ weeks gestation is evaluated in the emergency department after a high-speed motor vehicle collision. She was an unrestrained driver. On arrival, she is unresponsive with a Glasgow Coma Scale score of $7$ . She is rapidly intubated for airway protection. Vital signs are temperature $36.8^\circ\text{C}$ ( $98.2^\circ\text{F}$ ), blood pressure $72/40\text{ mm Hg}$ , and pulse $142/\text{min}$ . Breath sounds are equal bilaterally. Her abdomen is gravid, tense, and diffusely tender. Uterine tone is markedly increased. A focused assessment with sonography for trauma exam demonstrates a large amount of free fluid in the hepatorenal and splenorenal recesses. External fetal monitoring reveals a baseline fetal heart rate of $105/\text{min}$ with recurrent late decelerations and absent variability. A massive transfusion protocol is initiated. Which of the following is the most appropriate next step in management?

Immediate celiotomy and concurrent cesarean deliveryAnswer
B
Computed tomography imaging of the abdomen and pelvis
C
Left lateral decubitus positioning and reassessment of vital signs
D
Transcervical amnioinfusion and continuous fetal monitoring
E
Transcatheter arterial embolization of the uterine arteries

Answer

Immediate celiotomy and concurrent cesarean delivery

The patient is in class IV hemorrhagic shock with a positive focused assessment with sonography for trauma exam, indicating massive hemoperitoneum. In any trauma patient, hemodynamic instability coupled with a positive abdominal ultrasound mandates immediate surgical exploration of the abdomen (celiotomy) to control the bleeding. Furthermore, this patient is at

34

weeks gestation and exhibits classic signs of placental abruption (a tense, tender uterus) complicated by severe fetal distress (bradycardia, recurrent late decelerations, and absent variability). Performing a concurrent cesarean delivery is essential to rescue the viable fetus and to adequately expose the maternal intra-abdominal organs for hemorrhage control, as a near-term gravid uterus physically obstructs surgical access to the retroperitoneum, aorta, and other viscera.

Step-by-Step Solution

Evaluate the patient's hemodynamic status and trauma primary survey.

The patient is in class IV hemorrhagic shock (blood pressure

72/40\text{ mm Hg}

, pulse

142/\text{min}

) following blunt trauma.

Identifying profound shock establishes the immediate need for source control of the hemorrhage.

Interpret the focused assessment with sonography for trauma results.

The presence of free fluid in multiple recesses indicates massive hemoperitoneum.

A positive ultrasound in an unstable patient identifies the abdomen as the source of life-threatening bleeding.

Assess the obstetric clinical findings.

The patient has a tense, tender uterus with fetal bradycardia and recurrent late decelerations.

These findings are diagnostic of placental abruption with severe fetal distress at a viable gestational age (

34

weeks).

Synthesize trauma protocols with obstetric requirements to determine the next step.

The patient requires immediate abdominal surgical exploration for hemorrhage control, combined with a cesarean delivery.

The gravid uterus physically obstructs surgical access to maternal abdominal organs (e.g., retroperitoneum, aorta, spleen). Delivery is necessary both to save the fetus and to allow the trauma surgeon to repair the maternal injuries.

Key Concept

In a pregnant trauma patient, hemodynamic instability coupled with a positive focused assessment with sonography for trauma exam mandates immediate abdominal surgical exploration. A concurrent cesarean delivery is indicated to address fetal distress and to provide adequate exposure for maternal hemorrhage control.

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