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Review Question - QID 109671

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QID 109671 (Type "109671" in App Search)
A woman presents to the emergency department due to abdominal pain that began 1 hour ago. She is in the 35th week of her pregnancy when the pain came on during dinner. She also noted a clear rush of fluid that came from her vagina. The patient has a past medical history of depression which is treated with cognitive behavioral therapy. Her temperature is 99.5°F (37.5°C), blood pressure is 127/68 mmHg, pulse is 100/min, respirations are 17/min, and oxygen saturation is 98% on room air. On physical exam, you note a healthy young woman who complains of painful abdominal contractions that occur every few minutes. Laboratory studies are ordered as seen below.

Hemoglobin: 12 g/dL
Hematocrit: 36%
Leukocyte count: 6,500/mm^3 with normal differential
Platelet count: 197,000/mm^3

Serum:
Na+: 139 mEq/L
Cl-: 100 mEq/L
K+: 4.3 mEq/L
HCO3-: 24 mEq/L
BUN: 20 mg/dL
Glucose: 99 mg/dL
Creatinine: 1.1 mg/dL
Ca2+: 10.2 mg/dL
Lecithin/Sphingomyelin: 1.5
AST: 12 U/L
ALT: 10 U/L

Which of the following is the best next step in management?

Betamethasone

59%

10/17

Terbutaline

18%

3/17

Oxytocin

0%

0/17

RhoGAM

0%

0/17

Expectant management

24%

4/17

Select Answer to see Preferred Response

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This patient is presenting with premature rupture of membranes prior to 36 weeks gestation with a lecithin:sphingomyelin ratio (L/S ratio) < 2.0. The next best step in management is administration of betamethasone for fetal lung development.

Betamethasone should be administered to patients < 34 weeks gestation, or in any case < 36 weeks gestation with a L/S ratio < 2.0. The L/S ratio suggests fetal lung maturity and should be greater than 2.0. For patients with a L/S ratio < 2.0, betamethasone should be administered to accelerate fetal lung maturity and increase surfactant production.

Incorrect Answers:
Answer 2: Terbutaline is a beta2-agonist and a tocolytic. Tocolysis is not necessary in this situation.

Answer 3: Oxytocin can be used to augment labor, in particular, if the cause is due to weak uterine contractions. There is no evidence suggesting delayed/prolonged labor in this patient.

Answer 4: RhoGAM could be an appropriate management if the mother is Rh- and the fetus is Rh+. There is no evidence suggesting this; however, if RhoGAM was indicated, this would be an appropriate next step in management once betamethasone is administered.

Answer 5: Expectant management would be appropriate in this patient if their L/S ratio was > 2.0 and RhoGAM was not necessary.

Bullet Summary:
Betamethasone should be administered to accelerate fetal lung maturity when the lecithin:sphingomyelin ratio is < 2.0.

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