A 34-year-old woman, gravida 2 para 1, at 38 weeks gestation comes to the emergency department for contractions and vaginal spotting. The contractions started 4 hours ago and are now occurring every 3 minutes. She reports normal fetal movement and no leakage of fluid. The patient had no prenatal care but was hospitalized at 18 weeks gestation for viral gastroenteritis. A fetal ultrasound performed during this hospitalization was normal. The patient's previous delivery, a year ago, was a term cesarean delivery for breech presentation. The patient has no chronic medical conditions and has had no other surgeries. She does not use tobacco, alcohol, or illicit drugs. Temperature is 36.7 C (98 F), blood pressure is 100/60 mm Hg, and pulse is 84/min. The fetal heart rate tracing is shown below: Examination shows the cervix to be 5 cm dilated and 80% effaced, with the fetal head at 0 station. Blood type is O, Rh negative. The patient is admitted and epidural anesthesia is administered. Two hours later, the patient has spontaneous rupture of membranes and becomes acutely uncomfortable. Blood pressure is 140/92 mm Hg and pulse is 100/min. The fetal heart rate tracing now is shown below:
The patient begins to have heavy vaginal bleeding. The cervix is now 5 cm dilated and 80% effaced, with the fetal head at -3 station. Which of the following is the best next step in management of this patient?

Question

A 34-year-old woman, gravida 2 para 1, at 38 weeks gestation comes to the emergency department for contractions and vaginal spotting.  The contractions started 4 hours ago and are now occurring every 3 minutes.  She reports normal fetal movement and no leakage of fluid.  The patient had no prenatal care but was hospitalized at 18 weeks gestation for viral gastroenteritis.  A fetal ultrasound performed during this hospitalization was normal.  The patient's previous delivery, a year ago, was a term cesarean delivery for breech presentation.  The patient has no chronic medical conditions and has had no other surgeries.  She does not use tobacco, alcohol, or illicit drugs.  Temperature is 36.7 C (98 F), blood pressure is 100/60 mm Hg, and pulse is 84/min.  The fetal heart rate tracing is shown below:  Examination shows the cervix to be 5 cm dilated and 80% effaced, with the fetal head at 0 station.  Blood type is O, Rh negative.  The patient is admitted and epidural anesthesia is administered.  Two hours later, the patient has spontaneous rupture of membranes and becomes acutely uncomfortable.  Blood pressure is 140/92 mm Hg and pulse is 100/min.  The fetal heart rate tracing now is shown below:
 The patient begins to have heavy vaginal bleeding.  The cervix is now 5 cm dilated and 80% effaced, with the fetal head at -3 station.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c01c_b5b1_8f63_0190e6b73b5c_MD0005_00 This patient in labor has acutely worsening abdominal pain, vaginal bleeding, loss of fetal station, and an abnormal fetal heart rate tracing with late decelerations. This presentation is concerning for uterine rupture, full-thickness disruption of the uterine wall. Other signs of uterine rupture include the palpation of fetal parts through the abdominal wall and hemorrhagic shock (eg, from intraabdominal bleeding). uterine rupture Risk factors for uterine rupture include a history of cesarean delivery or myomectomy, advanced maternal age, an interpregnancy interval <18 months, and fetal macrosomia. The risk is highest for patients with prior cesarean delivery who undergo labor induction or whose cesarean delivery was via vertical (eg, classical) uterine incision. Uterine rupture places the mother at risk for hemorrhage and the fetus for hypoxia (as seen in the late decelerations on this patient's fetal heart tracing) and death. Management is with emergency laparotomy for delivery and uterine repair. late decelerations (Choice A) Amnioinfusion, the instillation of fluid into the uterine cavity, treats variable decelerations-sharp drops in the fetal heart rate of varying depth and duration-that are caused by umbilical cord compression. Amnioinfusion is not indicated for management of the late decelerations seen in this patient. Increasing the epidural would treat this patient's pain but not the uterine rupture. variable decelerations (Choice C) An operative vaginal delivery is performed during the second stage of labor (when the cervix is 10 cm dilated) to expedite delivery for protracted labor, fetal heart rate tracing abnormalities, or maternal exhaustion. (Choice D) A fetal scalp electrode is placed when external monitoring is technically difficult (eg, maternal obesity). A management strategy of a scalp electrode placement in conjunction with expectant management would increase the risks of maternal hemorrhage and fetal hypoxia. (Choice E) Magnesium sulfate is indicated for preeclampsia with severe features-blood pressure >160/110 mm Hg and/or signs of end-organ dysfunction. Rho(D) immune globulin prevents alloimmunization, maternal antibody formation after an Rh-negative mother is exposed to an Rh-positive infant. It is given after delivery when the infant's blood type is determined. alloimmunization Educational objective: Uterine rupture, a full-thickness disruption of the uterine wall, is an obstetric emergency that presents with acute severe abdominal pain, vaginal bleeding, loss of fetal station, and fetal heart rate tracing abnormalities. Treatment is with emergency laparotomy. References: Uterine rupture associated with VBAC. (http://www.ncbi.nlm.nih.gov/pubmed/23090467) Identifying risk factors for uterine rupture. (http://www.ncbi.nlm.nih.gov/pubmed/18280877)

A 34-Year-Old Woman, Gravida 2 Para 1, at 38 Weeks