A 28-year-old woman, gravida 3 para 2, at 30 weeks gestation is brought to the emergency department due to vaginal bleeding after a motor vehicle collision. The patient was restrained by a lap and shoulder belt, but the steering wheel struck her abdomen. Her underwear and pants are soaked with blood, and she states that she is "not sure if my water broke." Blood pressure is 90/60 mm Hg, pulse is 136/min, respirations are 22/min, and pulse oximetry is 98% on room air. Physical examination shows an alert but anxious-appearing woman with abdominal tenderness and cool extremities. On speculum examination, 100 mL of blood is evacuated from the vagina, and minimal active bleeding from the cervix is observed. Blood type is O, Rh positive. Fetal heart monitoring shows a baseline of 140/min with minimal to moderate variability; there are no late or variable decelerations. Tocometry reveals uterine contractions every 3 minutes. Intravenous fluids are started. Which of the following is the best next step in management of this patient?

Question

A 28-year-old woman, gravida 3 para 2, at 30 weeks gestation is brought to the emergency department due to vaginal bleeding after a motor vehicle collision.  The patient was restrained by a lap and shoulder belt, but the steering wheel struck her abdomen.  Her underwear and pants are soaked with blood, and she states that she is "not sure if my water broke."  Blood pressure is 90/60 mm Hg, pulse is 136/min, respirations are 22/min, and pulse oximetry is 98% on room air.  Physical examination shows an alert but anxious-appearing woman with abdominal tenderness and cool extremities.  On speculum examination, 100 mL of blood is evacuated from the vagina, and minimal active bleeding from the cervix is observed.  Blood type is O, Rh positive.  Fetal heart monitoring shows a baseline of 140/min with minimal to moderate variability; there are no late or variable decelerations.  Tocometry reveals uterine contractions every 3 minutes.  Intravenous fluids are started.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d985_6edf_bc81_09b0fd17b1bb_MD0003_00 This pregnant patient with abdominal pain, contractions, and vaginal bleeding following blunt abdominal trauma (eg, motor vehicle collision) likely has abruptio placentae (ie, placental abruption). Due to the volume of blood supplied to the uterus, abruptio placentae can cause hypovolemic shock from hemorrhage (ie, hemorrhagic shock), as seen in this patient with hypotension, tachycardia, and cool extremities. Management of the trauma patient with hemorrhagic shock requires rapid resuscitation with replacement of intravascular volume, transitioning from crystalloid to blood products as soon as possible. In addition, pregnant patients are placed in a left lateral decubitus position (if the spine is stable) to displace the uterus off the aortocaval vessels and maximize cardiac output. If hemorrhage or hemodynamic instability continues despite initial resuscitation efforts, massive transfusion protocol (MTP) should be activated. MTP is the administration of packed red blood cells, platelets, and fresh frozen plasma in a 1:1:1 ratio to avoid coagulopathy from dilution of platelets and clotting factors. (Choice A) Emergency cesarean delivery after maternal trauma may be indicated for imminent fetal compromise (ie, category 3 tracing). This patient has a category 2 tracing (due to minimal variability) but otherwise the fetal heart rate is normal with no variable or late decelerations; therefore, she does not require emergency delivery. (Choice B) A fetal biophysical profile evaluates for fetal acidosis and may be indicated for fetal heart rate tracings without accelerations. However, maternal stabilization is the priority over further fetal evaluation in this patient. (Choice C) Kleihauer-Betke testing measures the amount of fetal blood mixed into maternal circulation following trauma, which helps guide anti-D immunoglobulin dosing in Rh-negative patients (ie, to prevent Rh-alloimmunization). Rh-positive patients (such as this one) are not at risk for Rh-alloimmunization, and testing does not change management. Kleihauer-Betke testing Rh-alloimmunization (Choice E) Vasopressor therapy (eg, norepinephrine) is contraindicated in the setting of isolated hemorrhagic shock because peripheral vascular tone is already increased to compensate for decreased blood volume. In addition, vasopressor use can decrease uterine blood flow and therefore impair fetal oxygenation. Educational objective: Blunt abdominal trauma (eg, motor vehicle collision) in pregnancy can cause severe maternal bleeding and hemorrhagic shock (eg, abruptio placentae). Trauma patients with hemorrhagic shock require replacement of intravascular volume, transitioning from crystalloid to blood product resuscitation as soon as possible. References: Trauma in pregnancy: assessment, management, and prevention. (http://www.ncbi.nlm.nih.gov/pubmed/25403036) Optimal fluid therapy for traumatic hemorrhagic shock. (http://www.ncbi.nlm.nih.gov/pubmed/27894494)

A 28-Year-Old Woman, Gravida 3 Para 2, at 30 Weeks