An 18-year-old G2P1001 presents for her first OB visit at 10 weeks. She reports that the first day of her last menstrual period was May 7.
What is this patient’s estimated date of delivery?
The expected date of delivery can be estimated by using Naegele rule. To do this, count back 3 months and then add 7 days to the date of the first day of the last normal menstrual period.
A 36-year-old G1P0 presents to your office for her first prenatal visit. By her last menstrual period she is 11 weeks’ pregnant. She has no medical problems. On physical examination, her uterus is palpable midway between the pubic symphysis and the umbilicus. No fetal heart tones are audible with the Doppler stethoscope.
Which of the following is the best next step in the management of this patient?
At 11 weeks of gestation, the uterus is still within the pelvis and should not be palpable above the symphysis pubis. A uterus that is palpable midway between the symphysis pubis and the umbilicus is 14 to 16 weeks in size. The fetal heart tones are audible in most patients at 10 to 12 weeks. If no fetal heart tones are audible by Doppler auscultation and the patient is 12 weeks or more, an ultrasound of the pregnancy should be ordered. Molar pregnancy, twin gestation, incorrect dates, and uterine fibroids are all possible diagnoses when the uterus is large for dates; therefore, ultrasonography is the first step in the evaluation of size/date discrepancy. Although molar pregnancy is an indication for dilation and curettage, the procedure is not indicated before evaluation of the patient with ultrasonography. This patient is of advanced maternal age (> 35 years of age at the time of delivery); however, genetic amniocentesis should not be performed without first knowing the gestational age and viability of the pregnancy.
A healthy 30-year-old G2P1001 presents to her obstetrician’s office at 34 weeks for a routine prenatal visit. She has a history of a low transverse cesarean delivery performed secondary to fetal malpresentation (footling breech). Her current pregnancy has been uncomplicated. She tells her physician that she would like to undergo a trial of labor during this pregnancy. However, the patient is interested in permanent sterilization and wonders if it would be better to undergo another scheduled cesarean so she can have a bilateral tubal ligation performed at the same time.
How should the physician counsel this patient?
The desire for sterilization is not an indication for an elective repeat cesarean delivery. The morbidity of repeat cesarean is greater than that of vaginal birth with postpartum tubal ligation. The risk of uterine rupture in a woman who undergoes a trial of labor and has had one prior cesarean section is approximately 0.6%. With a history of two prior cesareans, the risk of uterine rupture is about 1.8%. The risk of uterine rupture in someone who has had a classical or T-shaped uterine incision is 4% to 6%. The success rate for a trial of labor is generally about 60% to 80% depending on the indication for the cesarean delivery. Success rates are higher when the original cesarean was performed for breech or a nonreassuring fetal heart rate tracing (ie, potentially nonrecurring), rather than labor dystocia. Induction of labor should not be performed without an obstetrical indication (eg, preeclampsia) at less than 39 weeks.
A 16-year-old primigravida presents to your office at 38 weeks’ gestation. Her first trimester blood pressure was 100/72 mm Hg. On the day of presentation it was 170/110 mm Hg and she has 4+ proteinuria on a clean catch specimen of urine. She has significant swelling of her face and extremities. She reports no contractions. Her cervix is closed and thick. The baby is breech by bedside ultrasonography. She reports the baby’s movements have decreased in the past 24 hours.
Preeclampsia is diagnosed by noting new onset hypertension and either proteinuria or end-organ dysfunction after 20 weeks. In 2013, ACOG eliminated dependence on the diagnosis on proteinuria. In the absence of proteinuria, preeclampsia is diagnosed as hypertension in association with thrombocytopenia, impaired liver function, new onset impaired renal function, pulmonary edema, or new onset cerebral or visual disturbances.
Gestational hypertension is diagnosed if the patient develops hypertension without proteinuria or the aforementioned systemic findings after 20 weeks’ gestation. Chronic hypertension is hypertension that predates pregnancy, and superimposed preeclampsia is chronic hypertension in association with preeclampsia. The treatment for gestational hypertension and preeclampsia at term is delivery. Select preterm patients may be managed conservatively at home or in the hospital depending on the severity of the hypertension. BPP testing is useful when following the patient conservatively. Although bed rest may transiently improve elevated blood pressure, a patient at full term should be delivered. Based on the severity of this patient’s blood pressure, she has preeclampsia with severe features, and she should be delivered. Since this patient’s fetus is breech, cesarean delivery rather than induction of labor is the next best step in her management. Diuretics should not be used in the management of preeclampsia, as they deplete the maternal intravascular volume and may compromise placental perfusion.
While you are on call at the hospital covering labor and delivery, a 32-year-old G3P2002, at 35 weeks’ gestation, presents with a chief complaint of lower back pain. You take her history, and learn that she had been lifting some heavy boxes while preparing the baby’s nursery. The patient’s pregnancy has been complicated by diet-controlled gestational diabetes. She reports no uterine contractions, rupture of membranes, vaginal bleeding, dysuria, fever, chills, nausea, or emesis. She states that the baby has been moving normally. She is afebrile and her blood pressure is normal. On physical examination, you note that she is obese. Her abdomen is soft and nontender, with no palpable contractions or uterine tenderness. No costovertebral angle tenderness can be elicited. On pelvic examination her cervix is closed and thick. The fetal heart tracing is reactive, and there are rare, irregular uterine contractions demonstrated on the tocometer. The patient’s urinalysis shows trace glucose, but is otherwise negative.
The patient’s most likely diagnosis is which of the following?
Lower back pain is a common complaint that is reported by about 50% of pregnant women. It is caused by stress placed on the lower spine and associated muscles and ligaments by the gravid uterus, especially in late pregnancy. The pain can be exacerbated with excessive bending and lifting. In addition, obesity predisposes the patient to lower back pain in pregnancy. Treatment options include heat, massage, and analgesia. This patient has no evidence of labor, since she is lacking regular uterine contractions and cervical change. Without any urinary symptoms or a urinalysis suggestive of infection, a urinary tract infection is unlikely. The diagnosis of chorioamnionitis does not fit since the patient has intact membranes, no fever, and a nontender uterus. Round ligament pain is typically characterized by sharp groin pain.
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