A 27-year-old woman, gravida 1 para 0, comes to the office for an initial prenatal visit. The patient is uncertain when her last menstrual period occurred, but she has had daily nausea and vomiting for the last 2 months. She has had no vaginal bleeding or pelvic pain. The patient has no chronic medical conditions and has had no surgeries. She takes a daily prenatal vitamin. Vital signs are normal. Abdominal examination reveals a gravid uterus that is nontender, and the fundus is just below the umbilicus. Ultrasound shows 2 intrauterine fetal poles measuring 14 weeks gestation with heart rates of 150/min and 155/min. Cervical length is 4.5 cm. Which of the following is the best next step in management of this patient?

Question

A 27-year-old woman, gravida 1 para 0, comes to the office for an initial prenatal visit.  The patient is uncertain when her last menstrual period occurred, but she has had daily nausea and vomiting for the last 2 months.  She has had no vaginal bleeding or pelvic pain.  The patient has no chronic medical conditions and has had no surgeries.  She takes a daily prenatal vitamin.  Vital signs are normal.  Abdominal examination reveals a gravid uterus that is nontender, and the fundus is just below the umbilicus.  Ultrasound shows 2 intrauterine fetal poles measuring 14 weeks gestation with heart rates of 150/min and 155/min.  Cervical length is 4.5 cm.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_da6f_594b_bc81_2f73582a2598_MD0003_00 Preeclampsia is a leading cause of maternal and fetal morbidity and mortality due to the increased risk of stroke, placental abruption, and disseminated intravascular coagulation. Preeclampsia likely results from abnormal vasoconstriction and increased platelet aggregation, resulting in placental infarction and ischemia. Patients with certain predisposing factors, such as diabetes mellitus, chronic hypertension, and multiple gestations, are at high risk for preeclampsia development. Twin gestation, as in this patient, increases the risk of preeclampsia nearly threefold, possibly due to greater placental mass and, subsequently, a higher risk of placental hypoperfusion leading to placental ischemia. In high-risk patients, daily low-dose aspirin is the only therapy proven to decrease the risk of preeclampsia because it inhibits platelet aggregation and helps prevent placental ischemia. It is initiated at 12-28 weeks gestation (but optimally before 16 weeks) and continued daily until delivery. (Choice A) Cerclage placement decreases the risk of preterm delivery in patients with a short cervix (<2.5 cm) on ultrasound or a prior preterm delivery caused by cervical insufficiency (ie, painless cervical dilation). This patient's cervical length is normal, and this is her first pregnancy (ie, no prior preterm deliveries). (Choice B) Indomethacin is a tocolytic used in patients in preterm labor at <32 weeks gestation to halt contractions and delay labor. It is not used as a prophylactic medication to prevent preterm labor. (Choice C) Intramuscular hydroxyprogesterone is indicated in patients with a prior spontaneous preterm delivery to decrease the risk of recurrence. (Choice E) Low-molecular-weight heparin can be used for venous thromboembolism (VTE) prophylaxis in patients with a prior VTE or a hypercoagulable condition (eg, certain inherited thrombophilias, antiphospholipid antibody syndrome). It is not required for patients with multiple gestations. Educational objective: Patients at high risk for preeclampsia (eg, multiple gestations) are initiated on low-dose aspirin prophylaxis for preeclampsia prevention. References: Prevalence and risk of pre-eclampsia and gestational hypertension in twin pregnancies: a population-based register study. (http://www.ncbi.nlm.nih.gov/pubmed/31278106) Hidden high rate of pre-eclampsia in twin compared with singleton pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/28317207) ACOG committee opinion no. 743 summary: low-dose aspirin use during pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/29939936) Low-dose aspirin for prevention of morbidity and mortality from preeclampsia: a systematic evidence review for the U.S. Preventive Services Task Force. (http://www.ncbi.nlm.nih.gov/pubmed/24711050)

A 27-Year-Old Woman, Gravida 1 Para 0, Comes to the Office