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This is a case of late-pregnancy vaginal bleeding and should be addressed as so. We should not jump to conclusions such as pregnancy + car accident = abruptio placenta, mainly because there is no pain described in the question stem.

1) During primary assessment, the mother seems to be hemodynamically stable, and generally her ABCs seem fine. This may be deceiving, because pregnancy is a hyperdynamic condition and it may take time for shock to manifest clinically as hypotension, thus our suspicion threshold should be low and fluid resuscitation should be aggressive in pregnant trauma patients. A hint for this may be the tachycardia of this mother. However, there is no such option available among the answers. The point is that, as soon as the mother is hemodynamically stable now and the amount of bleeding is not massive, there is no point in proceeding to emergency cesarean delivery.

2) The fetus should be assessed next. There is no rationale for rushing to the delivery or the operating room, as long as there is no evidence of the fetus' well (or not-well) being. Vaginal delivery would be indicated if pregnancy was beyond 36 weeks or if there was evidence that the fetus is dead; none of these are true here. So, I would proceed to fetal monitoring. The findings of cardiotocography will mandate our next steps in management.

3) Between external and internal cardiotocography, I would prefer external, because we don't know whether the membranes have ruptured or not, where does the placenta or the umbilical vessels lie (an ultrasound should be preceded) etc, in order to use internal monitoring. No vaginal manipulations should be made until we assess the status of the pelvic contents. So, I would go for choice C.

4) After the initial assessment of mother and fetus, I would run a series of tests (CBC, blood type and cross-matching, DIC workup). RhoGAM should be administered only if the mother is Rh(-) and within 72 hours post-partum.


Your feedback is valuable, because I am not sure if my rationale is correct (I mean, I haven't taken my ALSO courses yet!)...:happy:
 

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On the other hand, I return to doubt my own reasoning and state that this may be considered a case of placental abruption, for the purposes of the USMLE.

I explain myself: abruptio placentae may infer major damage to the embryo but none to the mother; besides, hemorrhage due to abruptio placentae may be minimal, due to accumulation of blood in the space between the placenta and the decidua.

So, perhaps the USMLE wants us to postulate that is a de facto case of abruptio placenta. However, I still think that fetal monitoring should be our first priority, before rushing to the OR.

Waiting impatiently for your feedback, Dr. RRMadukha!
 
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