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. Appropriate action was taken. Given the ultrasound findings, this patient is at increased risk for which of the following complications?

Question

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Explanation: 11ec2b69_c01b_a43d_8f63_a5e76618cfb8_MD0005_00 Subchorionic hematomas can result in placental dysfunction, particularly when the blood collection is located centrally on the placenta. Therefore, patients with subchorionic hematomas are at increased risk of spontaneous abortion, pregnancy loss (miscarriage) at <20 weeks gestation. In addition, during the third trimester, patients with subchorionic hematomas are at increased risk for abruptio placentae, preterm premature rupture of membranes, preterm labor, preeclampsia, fetal growth restriction, and intrauterine fetal demise. However, the majority of patients with subchorionic hematomas have uncomplicated pregnancies. (Choice A) Risk factors for cervical insufficiency - a structural weakness in the cervix that leads to spontaneous, painless, second-trimester pregnancy loss - include cervical trauma, cervical surgery (eg, conization), and congenital anomalies. (Choice B) Placenta accreta occurs when the placenta implants directly into the uterine myometrium and cannot be separated from the uterus after fetal delivery. Placenta accreta typically occurs in patients who have had prior cesarean deliveries and have placentas that implant directly over the uterine surgical scar. Placenta accreta (Choice C) Placenta previa occurs when the placenta implants over the cervix. It is associated with a history of prior cesarean delivery, multiple gestations, multiparity, and prior placenta previa. Placenta previa (Choice D) Rh alloimmunization, maternal antibody development to fetal red blood cell antigens, develops after an Rh-negative mother is exposed to Rh-positive fetal blood. It can occur at delivery, as a result of maternal trauma, or after first-trimester bleeding. This patient is Rh positive. Educational objective: Subchorionic hematomas can result in placental dysfunction and therefore increase the risk for spontaneous abortion, abruptio placentae, preterm premature rupture of membranes, preeclampsia, preterm labor, fetal growth restriction, and intrauterine fetal demise. References: The effects of subchorionic hematoma on pregnancy outcome in patients with threatened abortion. (http://www.ncbi.nlm.nih.gov/pubmed/25584033)

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