A 36-year-old woman, gravida 3 para 2, at 13 weeks gestation comes to the office for a prenatal visit. The patient had painless vaginal spotting a few weeks ago that has since resolved. An ultrasound was performed several days ago as a part of the first-trimester integrated screening. The patient's previous 2 pregnancies ended in uncomplicated term vaginal deliveries. She has no chronic medical conditions. Her only surgery was a laparoscopic cholecystectomy. She is the vice principal at a local elementary school and volunteers as a basketball coach. The patient takes a prenatal vitamin and an iron supplement daily. She does not use tobacco, alcohol, or illicit drugs. The patient attends a yoga class 3 times a week. Blood pressure is 110/70 mm Hg and pulse is 68/min. BMI is 26 kg/m². Fetal heart rate is 150/min. The ultrasound reveals a 13-week fetus with a normal nuchal translucency measurement and a 1.8-cm (0.71-in) , crescent, hypoechoic area between the gestational sac and the uterus, which is consistent with a hematoma. The patient's blood type is B, Rh positive. The other results from the first-trimester integrated screening are normal. Item 1 of 2
Which of the following is the best next step in management of this patient?

Question

Quizplus · Accepted Answer

Explanation: 11ec2b69_c01b_2f0c_8f63_b745a847cfdc_MD0005_00 This patient has a subchorionic hematoma, an abnormal collection of blood between the gestational sac and the uterine wall. Subchorionic hematomas are caused by a partial separation of the chorion (outer amniotic membrane) from the uterine wall. Risk factors include the use of anticoagulants, infertility treatment, uterine malformation (eg uterine septum, leiomyoma), and a history of recurrent pregnancy loss. Although subchorionic hematomas can present with vaginal bleeding, they also can be an incidental finding during routine ultrasound. Subchorionic hematomas typically appear on ultrasound as crescent, hypoechoic lesions adjacent to the gestational sac. The majority of patients with subchorionic hematomas have uncomplicated pregnancies, and management is expectant; patients can be followed with serial ultrasounds to help provide reassurance. (Choice A) Amniocentesis is performed for fetal karyotype analysis and would be indicated if this patient's first-trimester integrated screening were abnormal. There is no association between subchorionic hematoma and fetal aneuploidy. Amniocentesis (Choice B) Cerclage placement is indicated to prevent preterm delivery in patients with a history of cervical insufficiency, a structural weakness in the cervix that leads to spontaneous, painless, second-trimester pregnancy loss. Cerclage does not change the clinical outcome in patients with subchorionic hematoma. Cerclage placement (Choice D) Admission for bed rest does not improve the pregnancy outcome in patients with subchorionic hematomas. Bed rest is, however, associated with an increased risk of thromboembolism. (Choice E) The Kleihauer-Betke test determines the amount of fetomaternal hemorrhage that occurred due to delivery, maternal trauma, or first-trimester bleeding in an Rh-negative mother. The Kleihauer-Betke test determines the amount of Rho(D) immune globulin to be administered. This patient is Rh positive. Kleihauer-Betke test Educational objective: A subchorionic hematoma is an abnormal collection of blood between the uterus and the gestational sac. It can present with first-trimester bleeding or as an incidental finding on routine ultrasonography. Management is expectant; serial ultrasounds can be performed to provide reassurance. References: Perinatal outcomes in women with subchorionic hematoma: a systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/21508763)

A 36-Year-Old Woman, Gravida 3 Para 2, at 13 Weeks