A 30-year-old primigravida at 8 weeks gestation comes to the emergency department due to pelvic pain. The patient has had intermittent right lower quadrant pain for the last week, but yesterday it became constant and severe with associated nausea and vomiting. She takes a prenatal vitamin daily and has no chronic medical conditions. Blood pressure is 128/82 mm Hg and pulse is 104/min. BMI is 23 kg/m². Ultrasound shows an intrauterine fetal pole measuring 8 weeks gestation with cardiac motion at 160/min. There is free fluid in the pelvis, and the right ovary is enlarged and has decreased blood flow on Doppler. The patient undergoes emergency laparoscopy for ovarian torsion, and the right ovary containing the corpus luteum is removed due to necrosis of the ovary. Postoperative ultrasound shows positive intrauterine fetal cardiac activity and free fluid in the pelvis. Which of the following is the best next step in management of this patient?

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Quizplus · Accepted Answer

11ec25c8_d9d9_d002_bc81_479c92dbe802_MD0003_00 Ovulation occurs when a secondary oocyte is released from the dominant ovarian follicle, leaving behind cells that form an ovarian structure called the corpus luteum (CL). Following fertilization, the CL enlarges and produces high levels of progesterone, which thickens the endometrial lining in preparation for implantation. Progesterone also promotes implantation of the embryo and maintains the pregnancy. In early pregnancy, the CL is the primary source of progesterone until the placenta takes over production at 8-10 weeks gestation (ie, the luteal-placental shift). If the CL is removed prior to 10 weeks gestation (as in this patient who required an emergency oophorectomy due to ovarian torsion), progesterone levels decrease precipitously; as a result, the pregnancy becomes at high risk for spontaneous abortion (Choice E). Therefore, patients with corpus luteum removal prior to 10 weeks gestation require postoperative progesterone supplementation (eg, vaginal progesterone) to prevent pregnancy loss. Supplementation can be discontinued after 10 weeks gestation. ovarian torsion (Choice A) High-dose (4 mg) folic acid supplementation is indicated in patients at high risk for a fetus with neural tube defects (eg, prior affected pregnancy, use of folate antagonist medications). CL removal does not affect the risk of neural tube defects. (Choice B) Intramuscular methotrexate is a folate antagonist used to treat ectopic pregnancy, which can present with pelvic pain and free fluid in the pelvis (as in this patient). This patient has an intrauterine pregnancy and her pelvic free fluid was likely due to torsion; therefore, methotrexate is not indicated. ectopic pregnancy (Choice C) Daily low-dose aspirin decreases the risk of preeclampsia in high-risk patients (eg, pregestational diabetes mellitus, chronic hypertension). This patient has no chronic medical conditions. (Choice F) Vaginal misoprostol is a prostaglandin that causes uterine contractions. It is used for medical management of spontaneous abortions or cervical ripening during an induction of labor. Educational objective: During early pregnancy, the corpus luteum produces progesterone, which prepares the endometrium for implantation, promotes implantation, and maintains the pregnancy through 10 weeks gestation. Patients who have the corpus luteum removed (eg, oophorectomy) prior to 10 weeks gestation require progesterone supplementation to prevent pregnancy loss. References: The role of progesterone therapy in early pregnancy: from physiological role to therapeutic utility. (http://www.ncbi.nlm.nih.gov/pubmed/28277122) Progesterone in normal and pathological pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/27662646) Case report: ovarian torsion in pregnancy-diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/23810116)

A 30-Year-Old Primigravida at 8 Weeks Gestation Comes to the Emergency