A 32-year-old G2P1 at 28 weeks’ gestation presents to labor and delivery with a chief complaint of vaginal bleeding. Her vital signs are— blood pressure 115/67 mm Hg, pulse 87 beats per minute, temperature 37.0°C, respiratory rate 18 breaths per minute. She reports no contraction and states that the baby is moving normally. On ultrasound, the placenta is located on the anterior wall of the uterus, and completely covers the internal cervical os.
Which of the following would most increase her risk for hysterectomy?
Prior cesarean delivery and placenta previa, especially with an anteriorly located placenta, increase the risk of placenta accreta, increta, and percreta. These are situations where the placenta is abnormally adherent to the uterine wall. In placenta accreta, the placental villi are abnormally attached to the myometrium. In placenta increta, the villi invade into the myometrium, and in placenta percreta, the villi penetrate through the myometrium. Placenta accreta, increta, or percreta typically require treatment with hysterectomy. The incidence of these disorders has increased due to the increased cesarean delivery rate. Placenta accrete may be suspected on ultrasound, but MRI is often required to confirm the diagnosis. Advanced maternal age, multiparity, prior cesarean delivery, and smoking are all risk factors for placenta previa. Painless bleeding is the most common symptom, and is rarely fatal. Vaginal examination to evaluate for placenta previa is contraindicated, unless the woman is in the operating room prepared for immediate cesarean delivery, because even the most gentle examination can cause significant hemorrhage. Vaginal examinations are rarely necessary, because ultrasound is usually readily available to make the diagnosis of placenta previa. Cesarean delivery is necessary in essentially all cases of placenta previa. Because of the poor contractile nature of the lower uterine segment, uncontrollable hemorrhage may follow removal of the placenta. Hysterectomy may be indicated if conservative methods to control hemorrhage fail. Resuscitation with blood products is the treatment for disseminated intravascular coagulopathy, not hysterectomy. Sterilization itself is not an indication for hysterectomy at the time of cesarean delivery, because the complications of surgery are much increased with a cesarean hysterectomy.
A patient at 17 weeks’ gestation is diagnosed with an intrauterine fetal demise. She desires expectant management. She returns to your office 5 weeks later, and her vital signs are—blood pressure 110/72 mm Hg, pulse 93 beats per minute, temperature 36.38°C, respiratory rate 16 breaths per minute. She has not had a miscarriage, although she has had some occasional spotting. Her cervix is closed on examination.
This patient is at increased risk for which of the following?
In women with intrauterine fetal demise, labor usually occurs within 2 weeks. Women are typically offered expectant management versus active management with surgical or medical evacuation of the uterus. If the fetus is retained longer than 1 month, 25% of women can develop coagulopathy, which is manifested by decreased fibrinogen, elevated fibrin degradation products, and decreased platelets. Septic abortions were more frequently seen during the era of illegal abortions, although occasionally sepsis can occur if there is incomplete evacuation of the products of conception in either a therapeutic or spontaneous abortion. However, since her cervix is closed and no tissue has passed, septic abortion is unlikely. Intrauterine fetal demise has no impact on future fertility or association with ectopic pregnancies.
A 24-year-old G1P0 presents at 30 weeks’ gestation for a new OB visit. She provides you with the official report of a dating ultrasound performed at 12 weeks; however, shortly thereafter, she moved out of state and has not had prenatal care. She has no medical problems, and has a normal BMI. She reports some abdominal cramping and shortness of breath. During her visit, you examine her cervix and it is closed. You measure her fundal height at 50 cm.
What is the next best step in management?
This patient has an abnormally large fundal height. A fundal height should typically measure within 3 cm of the patient’s gestational age. In this case, the gestational age is known because the patient had an early ultrasound, and was able to produce the report for confirmation. Given this early ultrasound, it is unlikely that the patient is having twins, as this would have been identified at her 12-week ultrasound. Gestational diabetes is sometimes associated with polyhydramnios, and the patient does need a glucose tolerance test as part of her prenatal care, but this is not the next best step. It is possible she will have a large baby, but this alone would not explain the size greater than dates measurement. A fundal height of 50 cm requires further investigation, and the best next step is ultrasound.
An ultrasound is performed, and demonstrates a singleton fetus with an estimated fetal weight (EFW) in the 53 percentile. The amniotic fluid index is 30 cm, consistent with a diagnosis of polyhydramnios.
How should you counsel this patient?
Polyhydramnios is defined as an excessive quantity of amniotic fluid, and occurs in 1% to 2% of pregnant women. When diagnosed, it requires further evaluation for genetic or anatomic anomalies, diabetes, and infection, although approximately 40% of cases are determined to be idiopathic. The incidence of associated malformations is about 20%, with CNS and GI abnormalities being particularly common, due to their impact on swallowing and absorption of amniotic fluid. Polyhydramnios accompanies about half of cases of anencephaly, and nearly all cases of esophageal atresia. Edema of the lower extremities, vulva, and abdominal wall is common, and results from compression of major venous systems. The most frequent maternal complications are placental abruption, uterine dysfunction, and postpartum hemorrhage.
During routine ultrasound surveillance of a twin pregnancy, twin A weighs 1200 g and twin B weighs 750 g. Polyhydramnios is noted around twin A, while twin B has oligohydramnios.
Which of the following statements correctly describes this syndrome?
In the twin-to-twin transfusion syndrome (TTTS), the donor twin is always anemic. This is not due to a hemolytic process, but rather to the direct transfer of blood to the recipient twin, who becomes polycythemic. The recipient may suffer thromboses secondary to hypertransfusion and subsequent hemoconcentration. Although the donor placenta is usually pale and somewhat atrophied, that of the recipient is typically congested and enlarged. Polyhydramnios can develop in either twin, but is more frequent in the recipient twin due to circulatory overload. When polyhydramnios occurs in the donor, it is due to congestive heart failure caused by severe anemia.
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