A 26-year-old gravida 2 para 1 at 36 weeks gestation fell off her bicycle 2 hours ago. She says that she has not felt any fetal movement since the fall. She has abrasions on the left forearm and left leg and otherwise appears uninjured.
Which one of the following would be the most sensitive indicator of fetal compromise in this patient?
Correct Answer A:
Trauma complicates 6%-7% of pregnancies. Risk factors associated with significant risk for fetal deaths include motorcycle and pedestrian collisions, maternal tachycardia, abnormal fetal heart rate, lack of restraint use, serious maternal injury, and vehicle ejections.
Electronic fetal monitoring is the most sensitive indicator of fetal compromise. There is some controversy as to the length of monitoring needed, with reports of delayed fetal death or placental abruption after short monitoring periods (< 6 hours), leading most experts to recommend continuous monitoring for 24 hours. Clinical signs and symptoms such as vaginal bleeding, uterine tenderness, and the presence of frequent uterine contractions are not reliable indicators of fetal well being. Likewise, uterine ultrasonography is not sensitive for predicting placental abruption, and therefore, fetal compromise.
A 20-year-old primigravid comes to you for her first prenatal visit at 12 weeks. She works in a daycare facility and developed a maculopapular rash at 11 weeks’ gestation.
It disappears after 3 days and she feels fine.
Correct Answer C:
If a woman is nonimmune to rubella, then the risk of congenital rubella syndrome is 20% for a primary infection in the first trimester. Cataracts, patent ductus arteriosus, and deafness are the most common findings. In this case, she is coming to you within a few days of having an exanthem; if the patient’s rubella IgG shows immunity, then the rash was not due to rubella. If she is rubella IgG negative, then obtain an IgM titer.
→ Rubella infection in an adult can be a mild viral exanthem. This finding should never be ignored in a pregnant female.
→ No diagnosis of the condition has been made at this time.
→ Streptococcal pharyngitis is usually associated with a fever, lymphadenopathy, and pharyngeal symptoms.
→ Toxoplasmosis is not associated with a maculopapular rash.
A 25-year-old white female with heavy menstrual periods is noted to have a hemoglobin level of 98 g/L. The red cell distribution width is 16.0% (N 11.5 - 14.5) and the mean corpuscular volume is 75 fl (N 80 - 100).
The appropriate treatment for this condition can be enhanced by the use of:
Correct Answer E:
This patient has iron deficiency anemia. There are several substances that decrease the absorption of iron, including antacids, soy protein, calcium, tannin (which is in tea), and phytate (which is found in bran). Since an acidic environment increases iron absorption, ascorbic acid (vitamin C) can enhance absorption of an iron supplement.
A patient at 40 weeks gestation has had a fundal height 3-4 cm greater than expected relative to dates for the last several visits. Ultrasonography 2 days ago showed a fetus in the vertex position with an estimated fetal weight of 4200 g (9 lb 4 oz). On examination today the patient’s cervix is closed, long, posterior, and firm, with the vertex at -2 station. Her pregnancy has been otherwise uncomplicated.
Appropriate management at this point would be:
Correct Answer D:
Fetal macrosomia at term is defined by various authorities as birth weight above 4000 - 4500 g. Ultrasonography, unfortunately, does not provide a particularly accurate estimate of fetal weight for large fetuses. The risk of difficult vaginal delivery and shoulder dystocia does increase with birth weight above 4000 - 4500 g. This has led to attempts to prevent shoulder dystocia and possible birth injury by either performing an elective cesarean section or inducing labor when the fetus is estimated to be macrosomic. However, no studies have shown a benefit to either intervention in otherwise uncomplicated pregnancies. Suspected macrosomnia on its own is not longer considered an indication for induction or cesarean section. However, should this patient not spontaneously go into labor she will soon need to be managed as a post-dates pregnancy and thus a return visit should be scheduled in a week.
A 32-year-old female presents with bilateral pretibial tender, mildly red nodules 2 - 4 cm in diameter. A nodule that appeared earlier resolved, leaving a “bruised” area. She had a similar problem once when she was pregnant but it resolved spontaneously. Her medications include lovastatin (Mevacor) for hyperlipidemia and a low-dose oral contraceptive prescribed 5 months earlier. Her past history and a review of systems are otherwise unremarkable.
The most appropriate next step would be to:
Erythema nodosum (EN) is a panniculitis most often appearing on the shins. In 35% - 55% of cases, no cause is found. EN has been associated with pregnancy and oral contraceptives (choice C). Other drugs including sulfonamides, bromides, iodides, and omeprazole have been associated with EN. Statins have not been associated with EN. Infectious agents associated with EN include beta-hemolytic streptococci, Mycobacterium, Yersinia, fungi, syphilis, Campylobacter, hepatitis C, and Epstein-Barr virus. Inflammatory conditions associated with EN include inflammatory bowel disease, sarcoidosis, Lofgren’s syndrome and Behçet’s syndrome.
EN is usually self-limited or resolves with treatment of the underlying disorder. Glucocorticoids are usually not necessary for idiopathic EN.
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