A 29-year-old woman, gravida 1 para 1, comes to the office for a postpartum visit. Three weeks ago, the patient had a spontaneous vaginal delivery of a 4.2-kg (9-lb 2-oz) male infant after an induction of labor for gestational hypertension. The patient was treated for asymptomatic bacteriuria in the first trimester but had an otherwise uncomplicated pregnancy. Her labor lasted 30 hours, and she pushed for 4 hours. Immediately after delivery, the patient developed uterine atony that resolved with intravenous oxytocin and bimanual massage. The patient had no additional postpartum complications and went home the next day. She has had light vaginal bleeding since delivery, with no passage of clots or pelvic pain. The patient is breastfeeding exclusively, and reports fatigue due to frequent sleep interruption, but otherwise feels well. Blood pressure is 122/74 mm Hg and pulse is 82/min. BMI is 24 kg/m². Physical examination is unremarkable. Which of the following is the best next step in management of this patient?

Question

A 29-year-old woman, gravida 1 para 1, comes to the office for a postpartum visit.  Three weeks ago, the patient had a spontaneous vaginal delivery of a 4.2-kg (9-lb 2-oz) male infant after an induction of labor for gestational hypertension.  The patient was treated for asymptomatic bacteriuria in the first trimester but had an otherwise uncomplicated pregnancy.  Her labor lasted 30 hours, and she pushed for 4 hours.  Immediately after delivery, the patient developed uterine atony that resolved with intravenous oxytocin and bimanual massage.  The patient had no additional postpartum complications and went home the next day.  She has had light vaginal bleeding since delivery, with no passage of clots or pelvic pain.  The patient is breastfeeding exclusively, and reports fatigue due to frequent sleep interruption, but otherwise feels well.  Blood pressure is 122/74 mm Hg and pulse is 82/min.  BMI is 24 kg/m².  Physical examination is unremarkable.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Intimate partner violence (IPV) is any type of physical, psychologic, or sexual harm committed by a partner or spouse (eg, the infant's father). During pregnancy and postpartum, patients and their partners experience marked increases in emotional, physical, and financial stressors (eg, new childcare responsibilities, sleep deprivation). Because of these stressors, the rate of IPV can increase postpartum and cause significant maternal morbidity (eg, physical injury, mental health disorders) and/or infant complications (eg, poor feeding, maltreatment). In addition, patients are often reluctant to disclose IPV due to denial, shame, and fear of repercussions. Therefore, routine postpartum screening for IPV is required soon (eg, 3-6 weeks) after delivery. Patients who screen positive should be assessed for immediate safety and given additional resources (eg, domestic violence program referral) for long-term safety planning (eg, housing, childcare, finances). (Choice A) A postpartum, 2-hour (75-g) glucose tolerance test is used to screen for type 2 diabetes mellitus in patients who had gestational diabetes mellitus. This patient's pregnancy was not complicated by gestational diabetes mellitus. (Choice B) A 24-hour urine total protein collection can distinguish between gestational hypertension and preeclampsia. Patients with antenatal gestational hypertension (such as this patient) can develop preeclampsia up to 6 weeks postpartum; however, this patient is currently normotensive, making this diagnosis unlikely. (Choice C) Pelvic ultrasound can be used to assess for retained products of conception, which may present with postpartum hemorrhage (eg, heavy bleeding with passage of clots) or postpartum endometritis (eg, pelvic pain, fever, tachycardia). This patient has no heavy bleeding or pelvic pain, and her vital signs are normal. (Choice E) Urinalysis and urine culture are used to identify and treat asymptomatic bacteriuria during pregnancy because screening and treatment decrease the rate of pyelonephritis in pregnancy and preterm labor. In contrast, postpartum patients are not screened because screening does not change outcomes in this population. Educational objective: The risk of intimate partner violence (IPV) increases during the postpartum period due to increased emotional, physical, and financial stressors. Therefore, routine postpartum screening for IPV is required to decrease the risk of maternal and infant morbidity. References: Intimate partner violence identified through routine antenatal screening and maternal and perinatal health outcomes. (http://www.ncbi.nlm.nih.gov/pubmed/31619194) The impact of intimate partner violence on women's reproductive health and pregnancy outcome. (http://www.ncbi.nlm.nih.gov/pubmed/18569465)

A 29-Year-Old Woman, Gravida 1 Para 1, Comes to the Office