A 32-year-old woman, gravida 1 para 0, at 19 weeks gestation comes to the emergency department due to vaginal pressure and spotting. Over the last few days, the patient has had clear vaginal discharge for which she has used sanitary napkins. Today she has had increasing pelvic pressure and has noticed blood spots on the sanitary napkins. She has had no cramping or pelvic pain; fetal movement has been normal. The patient's pregnancy was previously uncomplicated; initial prenatal laboratory testing was normal. She was scheduled to have an anatomy ultrasound later in the week. The patient has no chronic medical conditions and has had no previous surgeries. She takes a prenatal vitamin daily and acetaminophen as needed for headaches. She was treated for Chlamydia trachomatis cervicitis at age 20. She does not use tobacco, alcohol, or illicit drugs. Temperature is 36.7 C (98.1 F), blood pressure is 110/70 mm Hg, pulse is 65/min, and respirations are 18/min. Fetal heart rate is 145/min by Doppler ultrasound. Speculum examination shows amniotic membranes bulging at the vaginal introitus. There is no blood or pooling of fluid in the vaginal vault. Nitrazine paper does not turn blue on application of the vaginal discharge. The cervix is 3 cm dilated and 100% effaced on digital examination. The patient is informed of examination findings. She asks about the prognosis for this pregnancy. Which of the following is the most appropriate response to this patient at this time?

Question

A 32-year-old woman, gravida 1 para 0, at 19 weeks gestation comes to the emergency department due to vaginal pressure and spotting.  Over the last few days, the patient has had clear vaginal discharge for which she has used sanitary napkins.  Today she has had increasing pelvic pressure and has noticed blood spots on the sanitary napkins.  She has had no cramping or pelvic pain; fetal movement has been normal.  The patient's pregnancy was previously uncomplicated; initial prenatal laboratory testing was normal.  She was scheduled to have an anatomy ultrasound later in the week.  The patient has no chronic medical conditions and has had no previous surgeries.  She takes a prenatal vitamin daily and acetaminophen as needed for headaches.  She was treated for Chlamydia trachomatis cervicitis at age 20.  She does not use tobacco, alcohol, or illicit drugs.  Temperature is 36.7 C (98.1 F), blood pressure is 110/70 mm Hg, pulse is 65/min, and respirations are 18/min.  Fetal heart rate is 145/min by Doppler ultrasound.  Speculum examination shows amniotic membranes bulging at the vaginal introitus.  There is no blood or pooling of fluid in the vaginal vault.  Nitrazine paper does not turn blue on application of the vaginal discharge.  The cervix is 3 cm dilated and 100% effaced on digital examination. The patient is informed of examination findings.  She asks about the prognosis for this pregnancy.  Which of the following is the most appropriate response to this patient at this time?

Quizplus · Accepted Answer

Explanation: Cerclage placement, a procedure during which a suture is placed to reinforce the cervix, has been generally shown to prevent second-trimester loss and preterm delivery in patients with cervical insufficiency. In patients with a history-based diagnosis, a prophylactic cerclage is placed at 12-14 weeks gestation. In patients with second-trimester, painless cervical dilation in the current pregnancy, cerclage placement is typically performed at diagnosis. Cerclage placement Prolapsing amniotic membranes, as seen in this patient, are a predictor for imminent (ie, within the next several days) delivery and indicate a poor prognosis. Prolapse of the membranes into the vagina causes prolonged exposure to vaginal flora and a high risk for intra-amniotic infection (chorioamnionitis), preterm membrane rupture, abruptio placentae, previable or preterm delivery, and maternal mortality. Prolapsed membranes are a relative contraindication to cerclage placement due to a high risk for iatrogenic membrane rupture. Therefore, even with cerclage placement, the prognosis for this pregnancy is poor, and the most likely outcome is a previable or preterm delivery (Choice A). (Choice B) Although cerclage placement will decrease the risk of second-trimester loss and preterm delivery in subsequent pregnancies, discussion of future pregnancies is insensitive and inappropriate at this time. (Choice C) Although amniocentesis can diagnose subclinical intrauterine infection (eg, chorioamnionitis), associated complications include rupture of membranes and preterm delivery. In patients with cervical insufficiency, the diagnosis of infection is not required to determine prognosis. (Choice E) Corticosteroids accelerate fetal lung maturity and decrease the likelihood of neonatal respiratory distress in premature infants. Magnesium decreases the risk of cerebral palsy in premature infants. However, these medications are not generally administered prior to viability (24 weeks gestation). Even with these medications at 19 weeks gestation, the prognosis is dismal due to the extreme prematurity of the fetus. Educational objective: Cerclage placement decreases the risk of second-trimester loss and preterm delivery in patients with cervical insufficiency. However, previable prolapsing amniotic membranes are associated with imminent delivery and a high risk of previable or preterm delivery and are a relative contraindication to cerclage placement. References: Fetal, infant and maternal outcomes among women with prolapsed membranes admitted before 29 weeks gestation. (http://www.ncbi.nlm.nih.gov/pubmed/28002467)

A 32-Year-Old Woman, Gravida 1 Para 0, at 19 Weeks