A healthy 26-year-old G1P0 presents for her first OB visit at 10 weeks’ gestation. She has no significant personal or family medical history.
When should she have her screening test for gestational diabetes?
Most organizations recommend universal screening for gestational diabetes for all pregnant women. A 1-hour glucose challenge test should be performed between 24 and 28 weeks’ gestation. This screen involves administration of a 50 g oral glucose solution followed by a 1-hour venous glucose determination. Certain women at high risk for gestational diabetes should be screened earlier (ie, at the first prenatal visit). This includes women with a history of gestational diabetes, body mass index greater than 30, family history of diabetes, age older than 35 years, or a history of fetal macrosomia in a prior pregnancy. If gestational diabetes is not diagnosed during this early screen, the test should be repeated at 24 to 28 weeks’ gestation.
A healthy 26-year-old G1P0 presents for her first OB visit at 10 weeks’ gestation. She has no significant personal or family medical history
She fails her 1-hour glucose challenge test at 26 weeks. What is the next best step in management?
The two-step approach to testing is based on first screening with a 1-hour glucose tolerance test (described earlier). Those individuals meeting or exceeding the screening threshold should then undergo a 100 g, 3-hour diagnostic oral glucose tolerance test. Two out of four elevated values results in a diagnosis of gestational diabetes. The 1-hour glucose tolerance test is a screening test, and must be followed up with a diagnostic test. In most cases, it would not be appropriate to offer therapy for gestational diabetes (such as diabetes education, insulin, or oral therapy) based on results of a screening test alone.
A healthy 31-year-old G3P2002 patient presents at 34 weeks for a routine OB visit. She has had an uneventful pregnancy to date. Her baseline blood pressures were 100 mm Hg to 110/60 mm Hg to 70 mm Hg in the first trimester, and she has gained a total of 20 lb so far. During the visit, the patient complains of swelling in both her feet and ankles that sometimes causes her feet to ache at the end of the day. Her urine dip indicates trace protein, and her blood pressure in the office is currently 115/75 mm Hg. She has no other symptoms or complaints. On physical examination, there is pitting edema of both her feet and ankles extending to the lower one-half of her legs. There is no calf tenderness.
Which of the following is the most appropriate response to the patient’s concern?
Increased fluid retention manifested by pitting edema of the ankles and legs is a normal finding in late pregnancy. During pregnancy, there is a decrease in colloid osmotic pressure and a fall in plasma osmolality. Moreover, there is an increase in venous pressure created by partial occlusion of the vena cava by the gravid uterus. These physiologic changes contribute to bilateral pedal edema. Diuretics are sometimes given to pregnant women who have chronic hypertension, but should not be given in pregnancy to treat physiologic pedal edema. More commonly, furosemide is used in the acute setting to treat pulmonary edema associated with severe preeclampsia. This patient is not hypertensive and does not have any other signs or symptoms of preeclampsia and therefore does not need to be admitted for further workup. Trace protein in the urine is common in normal pregnancies and is not of concern. Doppler studies of the lower extremities are not indicated in this patient since the history and examination (specifically, the lack of calf tenderness) are consistent with physiologic edema. The normal swelling detected in pregnancy is not prevented by a low-sodium diet or improved with a lower intake of salt.
A 28-year-old G1P0 presents to your office at 24 weeks’ gestation for an unscheduled visit secondary to right-sided groin pain. She describes the pain as sharp and occurring with movement and exercise. She reports no change in urinary or bowel habits, and no fever or chills. Sitting down and putting her feet up helps alleviate the discomfort.
As her obstetrician, what should you tell her is the most likely etiology of this pain?
This patient reports a classic description of round ligament pain. Each round ligament extends from the lateral portion of the uterus below the oviduct, travels in a fold of peritoneum downward to the inguinal canal, and inserts in the upper portion of the labium majus. During pregnancy, these ligaments stretch as the gravid uterus grows farther out of the pelvis, and can therefore cause sharp pain, particularly with sudden movements. Round ligament pain is more frequently experienced on the right side due to the dextrorotation of the uterus that commonly occurs in pregnancy. Usually this pain is greatly improved by avoiding sudden movements, changing position slowly, and by sitting and elevating the feet. Local heat and analgesics may also help with pain control. The diagnosis of appendicitis is not likely because the patient is not experiencing any fever or anorexia. In addition, because the gravid uterus pushes the appendix out of the pelvis, pregnant women with appendicitis often have pain located much higher than the groin area. The diagnosis of preterm labor is unlikely because the pain is localized to the groin area on one side, and is alleviated with elevation of her feet. Labor contractions generally cause generalized abdominal and low back pain. In addition, when labor occurs, the pains continue at rest, not just with movement. A urinary tract infection is unlikely because the patient has no urinary symptoms. A kidney stone is unlikely because this usually presents with pain in the back and flank—not low in the groin—and would persist at rest as well.
A 19-year-old G1P0 presents to her obstetrician’s office for a routine OB visit at 32 weeks’ gestation. Her pregnancy has been complicated by gestational diabetes requiring insulin for control. She has been noncompliant with diet and insulin therapy. She has had two prior normal ultrasound examinations at 20 and 28 weeks’ gestation. She has no other significant past medical or surgical history. During the visit, her fundal height measures 38 cm.
Which of the following is the most likely explanation for the discrepancy between the fundal height and the gestational age?
The fundal height in centimeters has been found to correlate with gestational age in weeks with an error of 3 cm from 16 to 36 weeks. Uterine fibroids, polyhydramnios (excessive amniotic fluid), fetal macrosomia, and twin gestation are all plausible explanations of why the uterine size would measure larger than expected for the patient’s dates. Breech presentation does not cause the uterus to be larger than expected for the gestational age. Since this patient has had two prior ultrasound examinations, hydrocephaly, fibroids, and twins would have previously been diagnosed. In this uncontrolled diabetic, the most likely cause for the excessive fundal height is polyhydramnios, which is a sign of poor glucose control.
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