A healthy 23-year-old G1P0 has had an uncomplicated pregnancy to date. She is disappointed because she is 40 weeks by a first-trimester ultrasound. She feels like she has been pregnant forever, and wants to have her baby now. The patient reports good fetal movement and no contractions. She has been doing kick counts for the past several days, and reports that the baby moves at least ten times in 2 hours. On physical examination, her cervix is firm, posterior, 50% effaced, and 1-cm dilated, and the vertex is at a-1 station.
What would the next best step in management be if this patient were 41 weeks with an unfavorable cervix and oligohydramnios found on ultrasound?
Patients with oligohydramnios at term should be delivered. If there is no contraindication to vaginal delivery, the patient should be induced. The patient with an unfavorable cervix may undergo cervical ripening after assessment of fetal well-being. If fetal testing is reassuring, the unfavorable cervix can be ripened with a variety of mechanical and pharmacologic agents prior to initiating Pitocin. Pharmacologic agents include PGE 2 preparations available as a vaginal/cervical gel (Prepidil) or vaginal insert (Cervidil). Misoprostol, a synthetic PGE 1 analogue, has been used off-label for preinduction cervical ripening and labor induction. It can be administered via the oral or vaginal route. Mechanical ripening of the cervix can be achieved with laminaria, which is a hygroscopic dilator that is placed in the cervical canal and absorbs water from the surrounding cervical tissue. The cervix can also be mechanically dilated with a balloon catheter. Pitocin is not considered a cervical ripening agent, but a laborinducing agent. In patients with oligohydramnios, cervical ripening should be performed in the hospital under continuous fetal monitoring, and therefore it is not appropriate to provide a ripening agent and send her home.
A healthy 30-year-old P1001 at 24 weeks’ gestation presents for a routine OB visit. She has no medical problems, and her pregnancy has been uncomplicated. Her last pregnancy was uncomplicated as well. However, she tells you that with her last pregnancy, her obstetrician performed an ultrasound at every visit to reassure her that “everything was alright.” She requests that you also perform an ultrasound at every visit to provide her reassurance that the pregnancy is progressing normally.
How should you counsel her regarding the safety of ultrasound during pregnancy?
Diagnostic ultrasound studies of the fetus are generally considered safe in pregnancy. The World Health Organization performed a systematic review of the literature that did not show a close association between ultrasound and adverse pregnancy outcomes. However, there were limitations to this study, and there is no firm evidence demonstrating safety. “Keepsake fetal videos” are considered by the FDA to be an unapproved use of a medical device. Prenatal ultrasound should only be used when clinically indicated, and it is not appropriate to perform an ultrasound at every visit in order to reassure the patient.
A 27-year-old G3P2002, who is 34 weeks’ gestational age, calls the on-call obstetrician on a Saturday night at 10:00 pm reporting decreased fetal movement. She says that the previous day her baby moved only once per hour. For the past 6 hours she has felt no movement. She is healthy, has had regular prenatal care, and reports no complications so far during the pregnancy.
Which of the following is the best advice for the on-call physician to give the patient?
Maternal perception of decreased fetal movement may precede fetal death in utero. Therefore, kick counts have been employed as a method of antepartum assessment. The optimal number of fetal movements that should be perceived per hour has not been determined. However, studies indicate that the perception of 10 distinct movements in a period of up to 2 hours is reassuring. Since this patient is experiencing only one movement per hour, and this movement is decreased from her previous baseline, further antepartum testing is indicated. A NST is the preferred modality. A contraction stress test involves provoking uterine contractions and evaluating the response of the fetal heart rate tracing to contractions. As this patient is preterm, provoking contractions should be avoided. Delivery is not indicated until nonreassuring fetal status can be documented.
Your patient reports decreased fetal movement at term. You recommend a modified BPP test. NST in your office was reactive.
The next part of the modified BPP is which of the following?
The BPP consists of five components, which include a NST and four observations made by real-time ultrasound. These observations are as follows:
Each of these components is assigned a score of 2 (normal) or 0 (abnormal or absent). In the modified BPP, only the NST and determination of amniotic fluid volume are assessed. Amniotic fluid volume reflects fetal urine production, and can be used to evaluate placental function. The modified BPP combines the NST, as a short-term indicator of fetal acid-base status, with an amniotic fluid volume assessment, as an indicator of long-term placental function. The results of a modified BPP are considered normal if the NST is reactive and there is a 2 cm deep pocket of amniotic fluid. The results are considered abnormal if either the NST is nonreactive, or there is not a 2 cm deep pocket of amniotic fluid present (indicating oligohydramnios).
You are seeing a patient in the hospital for decreased fetal movement at 36 weeks’ gestation. She is healthy and has had no prenatal complications. You order a BPP. The patient scores an 8 on the test. Two points were deducted for lack of fetal breathing movements.
How should you counsel the patient regarding the results of the BPP?
A BPP score of 8 or 10 is normal. A score of 6 is equivocal and requires repeat testing and usually delivery if persistent. A score of 4 or less is abnormal and often requires delivery.
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