A 19-year-old woman comes to the office due to vaginal bleeding and cramping that started 2 hours ago. The patient has no nausea, vomiting, fever, chills, or abnormal discharge. Her last menstrual period was 10 weeks ago. She has no chronic medical conditions and takes no medications. The patient does not drink alcohol but smokes a pack of cigarettes daily and uses illicit drugs on occasion. Temperature is 36.7 C (98 F), blood pressure is 120/70 mm Hg, and pulse is 76/min. BMI is 23 kg/m². On physical examination, the abdomen is soft and nontender. Pelvic examination reveals a 10-week-size, nontender uterus; a closed cervix; and a small amount of bright red blood in the vaginal vault. A urine pregnancy test is positive. A urine drug screen is positive for amphetamines. Ultrasound confirms a 10-week intrauterine gestation with a normal fetal heartbeat. This patient is at risk for which of the following pregnancy complications?

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This patient has vaginal bleeding, a closed cervix, and a viable fetus on ultrasound, a presentation consistent with a threatened abortion; spontaneous abortion is a complication of amphetamine abuse. Although amphetamines cross the placenta, they are not linked to congenital structural abnormalities. Amphetamine use during pregnancy is associated with fetal growth restriction, preeclampsia, abruptio placentae, preterm delivery, intrauterine fetal demise, and an increased risk of maternal mortality. Illicit drug use during pregnancy is common and is associated with adolescent pregnancy, late initiation of prenatal care, noncompliance, and poor pregnancy weight gain. Because illicit drug use in pregnancy is associated with an increased risk of obstetric complications and long-term complications in offspring (eg, cognitive delay), all patients should be screened for illicit drug use at the initial prenatal visit. Patients with positive screening should be followed with serial urine drug tests and counseled regarding options for managing cessation. (Choice A) Brachial plexus injury is a complication associated with shoulder dystocia, typically the result of fetal macrosomia. Amphetamine use is associated with fetal growth restriction, making a brachial plexus injury less likely. (Choice B) Cervical insufficiency is painless second-trimester cervical dilation resulting in pregnancy loss. Risk factors include cervical surgery (eg, conization) and congenital abnormalities (eg, in utero diethylstilbestrol exposure). Threatened abortion is not associated with cervical insufficiency. (Choices D and F) Gastroschisis is associated with first-trimester use of nonsteroidal anti-inflammatory drugs. Neural tube defects are associated with folic acid deficiency. Amphetamines do not increase the risk for either of these structural defects. (Choice E) Risk factors for malpresentation (eg, breech, transverse lie) include uterine fibroids, placenta previa, prematurity, and multiple gestation, not amphetamine use. (Choice G) Polyhydramnios is associated with poorly controlled maternal diabetes mellitus and fetal anomalies that interfere with swallowing (eg, esophageal atresia). Amphetamines do not increase the risk of fetal anomalies or diabetes mellitus. (Choice H) Vasa previa is associated with a low-lying placenta or multiple gestation. Neither amphetamine abuse nor threatened abortion is a risk factor for vasa previa. Vasa previa Educational objective: Amphetamine abuse during pregnancy is associated with preterm delivery, preeclampsia, abruptio placentae, fetal growth restriction, and intrauterine fetal demise. References: Methamphetamines and pregnancy outcomes. (http://www.ncbi.nlm.nih.gov/pubmed/25599434) Amphetamines, the pregnant woman and her children: a review. (http://www.ncbi.nlm.nih.gov/pubmed/22652562) Substance use in the perinatal period. (http://www.ncbi.nlm.nih.gov/pubmed/26386836)

A 19-Year-Old Woman Comes to the Office Due to Vaginal