At 32 weeks’ estimated gestational age, a 26-year-old multipara has been hospitalized for 10 days for premature rupture of membranes (PROM). She had a previous LTCS (Low Transverse Cesarean Section) because of arrested dilation. For 2 hours she has had light vaginal bleeding and contractions every 15 minutes. Over the past 30 minutes the bleeding has increased slightly, and she experiences lower abdominal pain between contractions. Her temperature is 37.0°C (98.6°F). The uterus is tender and the fetal heart rate is 170 bpm. Platelet count is 130x109 /L, leukocyte count is 14.3x109 /L, serum fibrinogen is 225 mg/dl, and the assay for fibrin split products is positive.
Which of the following is the most likely diagnosis?
Correct Answer C:
Although this patient has had a prior cesarean section, the possibility of a uterine scar separation is low. With the presence of ruptured membranes (ROM), a complete previa is unlikely. Although the uterus is tender, the patient is afebrile. There is literature to suggest that prolonged preterm ROM is associated with an increased risk of abruptio placentae.
→ Ruptured membranes with a complete previa is very unlikely.
→ Chorioamnionitis can be a complication of prolonged preterm rupture of membranes. It can be associated with contractions and uterine pain, but is usually not associated with vaginal bleeding.
→ Uterine scar separation can occur with a prior cesarean, but usually occurs in active labor. This patient is showing signs of early uterine activity at 32 weeks’ gestation, making this diagnosis unlikely.
→ HELLP syndrome is hemolysis, elevated liver enzymes, and low platelets.
A 20-year-old pregnant woman is brought to the emergency department complaining of severe abdominal pain. She is at 37-weeks of gestation. Her pregnancy was uneventful until now. She denies vaginal bleeding or any history of trauma.
The patient is cold and diaphoretic. Her vitals show a BP of 85/45 mmHg, pulse is 120/min, respiratory rate is 20/min and temp is 36.5°C. Pelvic exam shows a closed cervical os without vaginal bleeding.
Which of the following would most likely explain the patient’s presentation?
Placental abruption (choice C) is the most likely diagnosis of this patient. Please be aware that the absence of vaginal bleeding does not rule out placental abruption. This is a common trick on the Boards, don’t fall in this trap. 20 % of abruptio placentae cases occur in the retroplacental space and do not manifest by vaginal bleeding. Abdominal pain is always present.
→ In the absence of fever and risk factors (UTI or membrane rupture) chorioamnionitis (choice A) is unlikely.
→ Placenta previa (choice B) can be ruled out in the absence of vaginal bleeding.
→ Hypertension, proteinuria and edema are the classic triad of preeclampsia (choice D).
→ Thromboembolism (choice E) usually manifests as unilateral limb pain, chest pain, dyspnea, ischemia.
Which one is the most worrisome finding in a post-dated pregnancy?
Correct Answer B: A nonstress test (NST) measures the fetal heart rate in response to the fetus' movements. Generally, the heart rate of a healthy fetus increases when the fetus moves. The NST is usually performed in the last trimester of pregnancy.
A nonreactive/non-reassuring NST is when there is no change in the fetal heart rate when the fetus moves. This may indicate a problem that requires further testing.
A 24-year-old white gravida 2 para 1 at 39 weeks gestation who is currently not in active labor is seen in the labor and delivery suite for evaluation of decreased fetal movement. Her blood pressure is 120/74 mmHg and she has a temperature of 36.80 C (98.4 F). A representative portion of her nonstress test is shown here.
The best management at this time is:
Correct Answer B:
A reactive (negative; normal) nonstress test (NST) is characterized by the presence of 2 or more accelerations of the fetal heart rate in 20 minutes or less. The accelerations must be at least 15 beats per minute above the baseline. Reactive NST is reassuring for fetal well being for 3-4 days.
A nonreactive NST is characterized by fewer than 2 accelerations in a 40-minute interval. This patient's NST does not yield adequate accelerations. If NST is abnormal, a complete biophysical profile (BPP) or a contraction stress test (CST) is performed.
→ NSTs are commonly nonreactive and most CSTs and BPPs subsequently show normal results; therefore, an immediate cesarean section is unwarranted.
→ Estriol and human placental lactogen levels take time to complete and are difficult to interpret.
A prenatal ultrasound will diagnose all of the following at 20 weeks gestation, except:
Correct Answer C: An ultrasound done at 20 weeks gestation can show many things including multiple gestation, polyhydramnios, oligohydramnios and gender. It can assess the risk of Down syndrome but to diagnose a trisomy, further testing such as a triple screen and amniocentesis would need to be done.
Click to expand