Amniotic fluid embolism US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Amniotic fluid embolism. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Amniotic fluid embolism US Medical PG Question 1: A 35-year-old G3P2 woman currently 39 weeks pregnant presents to the emergency department with painful vaginal bleeding shortly after a motor vehicle accident in which she was a passenger. She had her seat belt on and reports that the airbag deployed immediately upon her car's impact against a tree. She admits that she actively smokes cigarettes. Her prenatal workup is unremarkable. Her previous pregnancies were remarkable for one episode of chorioamnionitis that resolved with antibiotics. Her temperature is 98.6°F (37°C), blood pressure is 90/60 mmHg, pulse is 130/min, and respirations are 20/min. The fetal pulse is 110/min. Her uterus is tender and firm. The remainder of her physical exam is unremarkable. What is the most likely diagnosis?
- A. Placental abruption (Correct Answer)
- B. Eclampsia
- C. Vasa previa
- D. Preterm labor
- E. Preeclampsia
Amniotic fluid embolism Explanation: ***Placental abruption***
- The patient's presentation with **painful vaginal bleeding** after blunt abdominal trauma (motor vehicle accident), a **tender and firm uterus**, maternal **hypotension** and **tachycardia**, and fetal **bradycardia** is highly characteristic of placental abruption.
- Risk factors like **smoking** and trauma further increase the likelihood of placental abruption.
*Eclampsia*
- Eclampsia is characterized by **new-onset grand mal seizures** in a pregnant woman with preeclampsia, which is not present in this scenario.
- While the patient's low blood pressure and tachycardia are concerning, they do not point to eclampsia.
*Vasa previa*
- Vasa previa involves **fetal blood vessels** running within the fetal membranes over the internal cervical os, risking rupture during labor or membrane rupture, leading to **painless vaginal bleeding** and **fetal distress**.
- The bleeding in this case is described as painful, and the uterine tenderness and firmness are not typical of vasa previa.
*Preterm labor*
- Preterm labor is defined by **regular uterine contractions** causing cervical changes before 37 weeks of gestation, which is not aligned with the patient being 39 weeks pregnant or her symptoms.
- While trauma can initiate labor, the severity of the bleeding and maternal/fetal distress point away from isolated preterm labor.
*Preeclampsia*
- Preeclampsia is characterized by **new-onset hypertension** (blood pressure ≥140/90 mmHg) and **proteinuria** after 20 weeks of gestation.
- This patient presents with hypotension and no mention of hypertension or proteinuria, making preeclampsia unlikely.
Amniotic fluid embolism US Medical PG Question 2: A 35-year-old G1 is brought to the emergency department because of sharp pains in her abdomen. She is at 30 weeks gestation based on ultrasound. She complains of feeling a little uneasy during the last 3 weeks of her pregnancy. She mentions that her abdomen has not been enlarging as expected and her baby is not moving as much as during the earlier part of the pregnancy. If anything, she noticed her abdomen has decreased in size. While she is giving her history, the emergency medicine physician notices that she is restless and is sweating profusely. An ultrasound is performed and her blood is sent for type and match. The blood pressure is 90/60 mm Hg, the pulse is 120/min, and the respiratory rate is 18/min. The fetal ultrasound is significant for no fetal heart motion or fetal movement. Her blood work shows the following: hemoglobin, 10.3 g/dL; platelet count, 1.1*10(5)/ml; bleeding time, 10 minutes; PT, 25 seconds; and PTT, 45 seconds. Which of the following would be the best immediate course of management for this patient?
- A. Low-molecular-weight heparin
- B. Fresh frozen plasma
- C. Initiation of labor
- D. D-dimer assay
- E. IV fluids (Correct Answer)
Amniotic fluid embolism Explanation: ***IV fluids***
- The patient presents with **hypotension** (90/60 mmHg) and **tachycardia** (120/min), indicating **hypovolemic shock**, likely due to concealed hemorrhage from abruptio placentae.
- **IV fluids** are the immediate priority to restore circulating blood volume and stabilize the patient's hemodynamic status.
*Low-molecular-weight heparin*
- This patient is experiencing signs of **disseminated intravascular coagulation (DIC)**, including thrombocytopenia, prolonged PT/PTT, and increased bleeding time, which makes anticoagulation contraindicated.
- Administering heparin would **exacerbate bleeding** and worsen her condition.
*Fresh frozen plasma*
- While **fresh frozen plasma (FFP)** can replace clotting factors and is indicated for DIC, stabilization of the patient's circulating volume with **IV fluids** is the most immediate life-saving measure in active shock.
- FFP should be given after initial fluid resuscitation and once the decision to deliver is made, to correct coagulopathy.
*Initiation of labor*
- Although the immediate delivery of the fetus is necessary to resolve ongoing placental abruption and DIC, the patient's **hemodynamic instability** must be addressed first.
- Stabilizing her with **IV fluids** is crucial before proceeding with labor induction or C-section.
*D-dimer assay*
- A **D-dimer assay** is a diagnostic test that would likely be elevated in this patient due to DIC, but it does not provide immediate therapeutic benefit.
- The patient's clinical presentation and other lab values (prolonged PT/PTT, thrombocytopenia) already strongly suggest DIC, and immediate intervention is required, not further diagnostic testing.
Amniotic fluid embolism US Medical PG Question 3: A 25-year-old woman with bipolar disorder and schizophrenia presents to the emergency room stating that she is pregnant. She says that she has been pregnant since she was 20 years old and is expecting a baby now that she is breathing much harder and feeling more faint with chest pain caused by deep breaths. Her hospital medical record shows multiple negative pregnancy tests over the past 5 years. The patient has a 20 pack-year smoking history. Her temperature is 98°F (37°C), blood pressure is 100/60 mmHg, pulse is 110/min, respirations are 28/min, and oxygen saturation is 90% on room air. Her fingerstick glucose is 100 mg/dL. She has a large abdominal pannus which is soft and nontender. Her legs are symmetric and non-tender. Oxygen is provided via nasal cannula. Her urine pregnancy test comes back positive and an initial chest radiograph is unremarkable. What is the next best step in diagnosis?
- A. Ultrasound
- B. D-dimer
- C. Ventilation-perfusion scan (Correct Answer)
- D. CT angiogram
- E. Psychiatry consult for pseudocyesis
Amniotic fluid embolism Explanation: ***Ventilation-perfusion scan***
- The patient presents with **dyspnea, chest pain exacerbated by deep breaths, tachypnea, tachycardia**, and **hypoxia**, all suggestive of a **pulmonary embolism (PE)**. Despite a positive pregnancy test, the long history of claimed pregnancy without prior confirmation and an unremarkable chest X-ray prioritizes immediate investigation for PE.
- While other imaging modalities exist, a **V/Q scan** is a safer initial choice for evaluating PE in pregnant patients compared to a CT angiogram, as it involves less radiation exposure to the fetus, especially when the chest X-ray is normal.
*Ultrasound*
- An ultrasound would confirm **intrauterine pregnancy** and fetal viability, but it would not address the patient's acute respiratory symptoms or rule out a life-threatening pulmonary embolism.
- While important for obstetrical management, it is not the most immediate next step for the patient's acute respiratory distress.
*D-dimer*
- A D-dimer test can be **falsely elevated in pregnancy**, making it less reliable for ruling out acute pulmonary embolism in this context.
- While a negative D-dimer can rule out PE in low-risk patients, a positive D-dimer is nonspecific during pregnancy and would not definitively confirm or exclude PE in this symptomatic patient.
*CT angiogram*
- A **CT pulmonary angiogram (CTPA)** is highly sensitive for PE but involves a higher radiation dose to the fetus compared to a V/Q scan.
- Given the patient's acute symptoms and the availability of a less invasive imaging option (V/Q scan) for PE in pregnant patients with a normal chest X-ray, CTPA is typically reserved if a V/Q scan is nondiagnostic or unavailable.
*Psychiatry consult for pseudocyesis*
- While the patient's history of claiming pregnancy for years and her psychiatric conditions (bipolar and schizophrenia) raise suspicion for **pseudocyesis (false pregnancy)**, her current positive urine pregnancy test means a true pregnancy cannot be immediately ruled out.
- Addressing her acute respiratory symptoms and potential pulmonary embolism takes precedence over a psychiatric consultation, as PE is a medical emergency.
Amniotic fluid embolism US Medical PG Question 4: A 38-year-old primigravid woman at 34 weeks' gestation comes to the emergency department because of progressive shortness of breath for 3 hours. At a prenatal visit 2 weeks earlier, she was diagnosed with gestational hypertension. Amniocentesis with chromosomal analysis was performed at 16 weeks' gestation and showed no abnormalities. The patient has been otherwise healthy, except for a deep venous thrombosis 2 years ago that was treated with low molecular weight heparin. Her current medications include methyldopa and a multivitamin. She appears anxious. Her pulse is 90/min, respirations are 24/min, and blood pressure is 170/100 mm Hg. Crackles are heard over both lung bases. Pelvic examination shows a uterus consistent in size with a 32-week gestation. Examination of the heart, abdomen, and extremities shows no abnormalities. Which of the following is the most likely cause of this patient's shortness of breath?
- A. Pulmonary edema (Correct Answer)
- B. Pulmonary metastases
- C. Idiopathic pulmonary fibrosis
- D. Pulmonary thromboembolism
- E. Amniotic fluid embolism
Amniotic fluid embolism Explanation: ***Pulmonary edema***
- The patient presents with **gestational hypertension** and new-onset **shortness of breath** with **bilateral basal crackles**, a classic presentation for pulmonary edema, often precipitated by conditions like preeclampsia in pregnancy.
- Her elevated blood pressure (170/100 mm Hg) and rapid respiratory rate (24/min) further support increased **pulmonary hydrostatic pressure**, leading to fluid extravasation into the lung alveoli.
*Pulmonary metastases*
- This is unlikely given her young age, lack of a prior cancer diagnosis, and acute onset of symptoms.
- **Pulmonary metastases** typically present with a more gradual onset of symptoms and are less commonly associated with bilateral basal crackles in isolation.
*Idiopathic pulmonary fibrosis*
- **Idiopathic pulmonary fibrosis** is a chronic, progressive interstitial lung disease, typically affecting older individuals, and has a much slower, gradual onset of symptoms.
- The acute presentation of severe shortness of breath in a young, previously healthy pregnant woman does not fit the typical course of this disease.
*Pulmonary thromboembolism*
- While the patient has a history of **DVT** and is pregnant (a hypercoagulable state), the primary presentation with **bilateral crackles** and **hypertension** makes pulmonary edema more likely.
- A pulmonary embolism might cause sudden shortness of breath and an elevated pulse, but significant bilateral crackles are less typical unless there's associated right heart failure leading to pulmonary congestion.
*Amniotic fluid embolism*
- **Amniotic fluid embolism** is a rare but catastrophic event, typically presenting with sudden, severe respiratory distress, hemodynamic collapse, and coagulopathy, often occurring during labor or soon after delivery.
- This patient is not in labor, does not show signs of hemodynamic collapse or coagulopathy, and the onset is progressive over several hours rather than sudden.
Amniotic fluid embolism US Medical PG Question 5: A 32-year-old woman, gravida 2, para 1, at 38 weeks' gestation comes to the emergency department because of vaginal bleeding for the past hour. The patient reports that she felt contractions prior to the onset of the bleeding, but the contractions stopped after the bleeding started. She also has severe abdominal pain. Her first child was delivered by lower segment transverse cesarean section because of a nonreassuring fetal heart rate. Her pulse is 110/min, respirations are 17/min, and blood pressure is 90/60 mm Hg. Examination shows diffuse abdominal tenderness with no rebound or guarding; no contractions are felt. The fetal heart rate shows recurrent variable decelerations. Which of the following is the most likely diagnosis?
- A. Uterine inertia
- B. Amniotic fluid embolism
- C. Uterine rupture (Correct Answer)
- D. Vasa previa
- E. Abruptio placentae
Amniotic fluid embolism Explanation: ***Uterine rupture***
- The patient's history of a prior **cesarean section**, sudden onset of **vaginal bleeding** and **severe abdominal pain**, resolution of contractions, and signs of **hypovolemic shock** (tachycardia, hypotension) coupled with fetal distress (variable decelerations) are highly indicative of uterine rupture.
- Diffuse abdominal tenderness without rebound or guarding, and no palpable contractions, are also consistent with rupture.
*Uterine inertia*
- This condition is characterized by **weak or uncoordinated uterine contractions** leading to prolonged labor, but it does not typically present with acute vaginal bleeding, sudden severe abdominal pain, or hypovolemic shock.
- Fetal distress in uterine inertia would more likely be due to prolonged labor rather than acute compromise following a sudden event.
*Amniotic fluid embolism*
- This is a rare, life-threatening obstetric emergency characterized by sudden **cardiovascular collapse, respiratory distress**, and **coagulopathy**, often occurring during labor or immediately postpartum.
- While it can cause fetal distress, vaginal bleeding and severe abdominal pain are not primary presenting symptoms.
*Vasa previa*
- Characterized by **painless vaginal bleeding** when fetal vessels within the membranes cross the internal cervical os, making them vulnerable to rupture during cervical dilation or amniotomy.
- The bleeding is typically fetal blood, and fetal distress occurs rapidly, but the mother would not experience severe abdominal pain or signs of hypovolemic shock unless the bleeding is substantial and prolonged.
*Abruptio placentae*
- This involves the **premature separation of the placenta**, causing painful vaginal bleeding, uterine tenderness, and frequent, strong contractions.
- While it can cause hypovolemic shock and fetal distress, the description of contractions stopping after bleeding started, along with a previous C-section scar, points more specifically to uterine rupture rather than an abruption.
Amniotic fluid embolism US Medical PG Question 6: A 23-year-old G1P0 woman presents to the emergency department with regular and painful contractions that occur every 3 minutes. She was at home cooking dinner when she experienced a deluge of clear fluid between her legs followed by painful contractions. The patient has a past medical history of obesity. Her pregnancy was not followed by an obstetrician, but she notes that she experienced abdominal pain and headaches frequently towards the end of her pregnancy. Her temperature is 99.5°F (37.5°C), blood pressure is 187/128 mmHg, pulse is 110/min, respirations are 17/min, and oxygen saturation is 98% on room air. The patient is started on magnesium sulfate and labetalol. The patient delivers her baby vaginally 2 hours later. On the labor and delivery floor, the patient is notably somnolent. Vitals are notable for respirations of 6 per minute. Physical exam reveals a somnolent woman who is minimally responsive. Cardiopulmonary exam is notable for hypopnea. Neurological exam reveals absent deep tendon reflexes and 3/5 strength in her upper and lower extremities. Which of the following is the next best step in management?
- A. Discontinue current drug infusion (Correct Answer)
- B. Remove retained fetal parts
- C. Ultrasound
- D. CT scan of the head
- E. Supportive therapy
Amniotic fluid embolism Explanation: ***Discontinue current drug infusion***
- The patient's symptoms, including **somnolence, respiratory depression (hypopnea, 6 respirations/minute), absent deep tendon reflexes, and muscle weakness (3/5 strength)**, are highly suggestive of **magnesium toxicity**.
- Immediate discontinuation of the **magnesium sulfate infusion** is the critical first step to prevent further accumulation and worsening of toxicity.
*Remove retained fetal parts*
- This step is indicated for **postpartum hemorrhage** or infection due to retained placental fragments.
- The patient's symptoms are neurological and respiratory, not related to uterine bleeding or infection.
*Ultrasound*
- An ultrasound might be useful to assess for retained products of conception or other intra-abdominal issues if there were signs of hemorrhage or infection.
- However, the patient's primary symptoms indicate neurological and respiratory depression, which is not an indication for ultrasound.
*CT scan of the head*
- A CT scan of the head would be considered if there were concerns for **intracranial hemorrhage**, stroke, or other neurological emergencies, especially given her history of headaches and severe hypertension.
- While hypertension is present, the constellation of absent deep tendon reflexes and respiratory depression points more directly to drug toxicity than to an acute intracranial event.
*Supportive therapy*
- Supportive therapy (e.g., **calcium gluconate as antidote**, airway management, mechanical ventilation) is essential and should be provided **concurrently** with stopping the magnesium infusion.
- However, the *next best step* prioritizes **stopping the source of toxicity** first, as continued infusion would worsen the patient's condition despite supportive measures.
- Without discontinuing the magnesium sulfate, supportive therapy alone would be insufficient to reverse the ongoing toxicity.
Amniotic fluid embolism US Medical PG Question 7: The patient declines the use of oxytocin or any other further testing and decides to await a spontaneous delivery. Five weeks later, she comes to the emergency department complaining of vaginal bleeding for 1 hour. Her pulse is 110/min, respirations are 18/min, and blood pressure is 112/76 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 97%. Pelvic examination shows active vaginal bleeding. Laboratory studies show:
Hemoglobin 12.8 g/dL
Leukocyte count 10,300/mm3
Platelet count 105,000/mm3
Prothrombin time 26 seconds (INR=1.8)
Serum
Na+ 139 mEq/L
K+ 4.1 mEq/L
Cl- 101 mEq/L
Urea nitrogen 42 mg/dL
Creatinine 2.8 mg/dL
Which of the following is the most likely underlying mechanism of this patient's symptoms?
- A. Infection with gram-negative bacteria
- B. Thromboplastin in maternal circulation (Correct Answer)
- C. Amniotic fluid in maternal circulation
- D. Separation of the placenta from the uterus
- E. Decreased synthesis of coagulation factors
Amniotic fluid embolism Explanation: ***Thromboplastin in maternal circulation***
* This patient's presentation with **vaginal bleeding**, **elevated PT/INR**, and **thrombocytopenia** is highly suggestive of **disseminated intravascular coagulation (DIC)**, which can be triggered by placental abruption or retained products of conception releasing tissue thromboplastin.
* The prior history of a prolonged gestation and refusal of intervention suggests potential for **placental insufficiency** or **intrauterine fetal demise**, both of which can lead to release of **thromboplastin** into the maternal circulation, activating the coagulation cascade and consuming clotting factors and platelets.
* *Infection with gram-negative bacteria*
* While **sepsis** from gram-negative bacteria can cause DIC, there are no overt signs of infection like fever, chills, or a significant rise in leukocyte count disproportionate to bleeding stress.
* The primary presentation is bleeding and coagulopathy, not systemic signs of infection.
* *Amniotic fluid in maternal circulation*
* **Amniotic fluid embolism** is a rare and catastrophic event, typically presenting with sudden **cardiovascular collapse**, **respiratory distress**, and **DIC**.
* This patient's vital signs and oxygen saturation are relatively stable, and she lacks the acute cardiorespiratory symptoms characteristic of amniotic fluid embolism.
* *Separation of the placenta from the uterus*
* **Placental abruption** (separation of the placenta) can cause vaginal bleeding and may
cause DIC by releasing tissue factor from the decidua into the maternal circulation.
* However, DIC itself is the mechanism of the coagulopathy, and the release of thromboplastin from the abrupted tissue is the more direct underlying cause of the coagulation cascade activation.
* *Decreased synthesis of coagulation factors*
* Conditions causing **decreased synthesis of coagulation factors** (e.g., severe **liver disease** or severe **vitamin K deficiency**) typically lead to coagulopathy over time.
* This patient's acute presentation with evidence of platelet consumption (thrombocytopenia) points towards a consumptive coagulopathy like DIC rather than impaired production.
Amniotic fluid embolism US Medical PG Question 8: A 2500-g (5-lb 8-oz) female newborn delivered at 37 weeks' gestation develops rapid breathing, grunting, and subcostal retractions shortly after birth. Despite appropriate lifesaving measures, the newborn dies 2 hours later. Autopsy shows bilateral renal agenesis. Which of the following is the most likely underlying cause of this newborn's respiratory distress?
- A. Displacement of intestines into the pleural cavity
- B. Injury to the diaphragmatic innervation
- C. Collapse of the supraglottic airway
- D. Decreased amniotic fluid ingestion
- E. Pulmonary hypoplasia (Correct Answer)
Amniotic fluid embolism Explanation: ***Pulmonary hypoplasia***
- **Bilateral renal agenesis** (Potter sequence) leads to severely reduced or absent fetal urine production, causing **oligohydramnios**.
- **Oligohydramnios** prevents normal lung development, resulting in **pulmonary hypoplasia**, which is the primary cause of respiratory distress and death in these newborns.
*Displacement of intestines into the pleural cavity*
- This describes a **congenital diaphragmatic hernia**, which can cause respiratory distress due to lung compression.
- However, the autopsy finding of **bilateral renal agenesis** points to Potter sequence as the underlying cause, not a diaphragmatic hernia.
*Injury to the diaphragmatic innervation*
- Injury to the phrenic nerve (diaphragmatic innervation) can lead to **diaphragmatic paralysis** and respiratory distress.
- This is not directly related to **bilateral renal agenesis** or the characteristic findings of Potter sequence.
*Collapse of the supraglottic airway*
- This describes conditions like **laryngomalacia** or other upper airway obstructions.
- While these can cause respiratory distress, they are not typically linked to **bilateral renal agenesis** or the systemic consequences of **oligohydramnios**.
*Decreased amniotic fluid ingestion*
- Fetal swallowing of amniotic fluid is important for gastrointestinal development and recycling of fluid.
- However, decreased ingestion primarily affects **gastrointestinal maturation** and amniotic fluid volume (if there is a swallowing problem), not directly lung development in the way oligohydramnios from renal agenesis does.
Amniotic fluid embolism US Medical PG Question 9: A 29-year-old woman, gravida 1, para 0, at 33 weeks' gestation comes to her doctor for a routine visit. Her pregnancy has been uncomplicated. She has systemic lupus erythematosus and has had no flares during her pregnancy. She does not smoke cigarettes, drink alcohol, or use illicit drugs. Current medications include iron, vitamin supplements, and hydroxychloroquine. Her temperature is 37.2°C (98.9°F), pulse is 70/min, respirations are 17/min, and blood pressure is 134/70 mm Hg. She appears well. Physical examination shows no abnormalities. Ultrasound demonstrates fetal rhythmic breathing for > 30 seconds, amniotic fluid with deepest vertical pocket of 1 cm, one distinct fetal body movement over 30 minutes, and no episodes of extremity extension over 30 minutes. Nonstress test is reactive and reassuring. Which of the following is the next best step in management?
- A. Administer corticosteroids and continue close monitoring (Correct Answer)
- B. Perform cesarean delivery
- C. Discontinue hydroxychloroquine and continue close monitoring
- D. Induction of labor
- E. Reassurance with expectant management
Amniotic fluid embolism Explanation: ***Administer corticosteroids and continue close monitoring***
- The combination of a **nonreactive nonstress test (NST)** and an **amniotic fluid index (AFI) < 5 cm** (deepest vertical pocket of 1 cm) indicates **oligohydramnios** and potential fetal compromise, necessitating corticosteroid administration for lung maturity and close monitoring.
- While the NST is reassuring, the oligohydramnios is a significant concern that warrants intervention to optimize fetal outcomes and prepare for potential preterm delivery.
*Perform cesarean delivery*
- This step is **overly aggressive** given the reactive nonstress test and stable maternal condition.
- There are no immediate signs of **acute fetal distress** that would necessitate emergent delivery.
*Discontinue hydroxychloroquine and continue close monitoring*
- **Hydroxychloroquine** is safe and often continued during pregnancy for patients with systemic lupus erythematosus, as it helps prevent flares and is not associated with adverse fetal outcomes.
- Discontinuing it without a clear indication could lead to a **maternal SLE flare**, which could be detrimental to both mother and fetus.
*Induction of labor*
- Induction of labor is not indicated at this gestational age (33 weeks) unless there is clear evidence of **significant fetal distress** or maternal complications.
- While there is oligohydramnios, the **reactive NST** suggests sufficient fetal reserve to allow for corticosteroid administration to promote lung maturity first.
*Reassurance with expectant management*
- The finding of **oligohydramnios** (deepest vertical pocket of 1 cm) is a significant concern, as it is associated with increased risks of **cord compression**, fetal growth restriction, and adverse perinatal outcomes.
- Therefore, expectant management without intervention would be **inappropriate** given this finding.
Amniotic fluid embolism US Medical PG Question 10: A 25-year-old G2P1001 at 32 weeks gestation presents to the hospital with painless vaginal bleeding. The patient states that she was taking care of laundry at home when she experienced a sudden sensation of her water breaking and saw that her groin was covered in blood. Her prenatal history is unremarkable according to the clinic records, but she has not seen an obstetrician for the past 14 weeks. Her previous delivery was by urgent cesarean section for placenta previa. Her temperature is 95°F (35°C), blood pressure is 125/75 mmHg, pulse is 79/min, respirations are 18/min, and oxygen saturation is 98% on room air. Cervical exam shows gross blood in the vaginal os. The fetal head is not palpable. Fetal heart rate monitoring demonstrates decelerations and bradycardia. Labs are pending. IV fluids are started. What is the best next step in management?
- A. Cesarean section (Correct Answer)
- B. Betamethasone
- C. Red blood cell transfusion
- D. Vaginal delivery
- E. Lumbar epidural block
Amniotic fluid embolism Explanation: ***Cesarean section***
- This patient presents with signs highly suggestive of **placenta previa with possible vasa previa or placental abruption**, with life-threatening complications for both mother and fetus. The presence of **painless vaginal bleeding**, a prior **cesarean section for placenta previa**, and **fetal heart rate decelerations/bradycardia** necessitate immediate delivery via cesarean section to prevent **fetal demise** and severe **maternal hemorrhage**.
- The rapid deterioration of the fetal status, indicated by **decelerations and bradycardia**, confirms the urgency. A **cesarean section** is the quickest and safest way to deliver the baby and address the underlying obstetric emergency.
*Betamethasone*
- **Betamethasone** is administered to promote **fetal lung maturity** in cases of preterm delivery. While this patient is preterm at 32 weeks, the critical nature of the fetal distress and bleeding requires immediate delivery, making the delay for betamethasone administration inappropriate.
- The benefits of steroids for lung maturity are outweighed by the **immediate risk of fetal demise** and severe maternal complications if delivery is delayed.
*Red blood cell transfusion*
- While the patient is actively bleeding and may eventually require a **blood transfusion**, starting IV fluids and proceeding with an **immediate cesarean section** are higher priorities to stabilize the mother and rescue the fetus.
- Transfusions are supportive measures once the source of hemorrhage is addressed and vital signs are stabilized during or after surgery.
*Vaginal delivery*
- Given the patient's history of **placenta previa**, current **painless vaginal bleeding**, and signs of **fetal distress**, a vaginal delivery is contraindicated due to the high risk of **exsanguinating hemorrhage** for the mother and severe fetal compromise.
- The prior **cesarean section for placenta previa** also increases the risk of recurrent previa and **placenta accreta spectrum**, further contraindicating vaginal delivery.
*Lumbar epidural block*
- A **lumbar epidural block** is used for pain management during labor, but in this emergent situation with active bleeding and fetal distress, immediate delivery is paramount.
- The time required to safely administer an **epidural**, along with the potential for **hypotension** in a hypovolemic patient, makes it an inappropriate next step.
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