A 27-year-old woman, gravida 1 para 0, at 9 weeks gestation comes to the office for an initial prenatal visit. She feels well and has had no abdominal pain or vaginal bleeding. The patient has sickle cell disease and has had multiple hospitalizations and transfusions for acute pain episodes. She was previously on hydroxyurea, but it was discontinued several months ago when she began attempting conception. The patient has had no acute pain episodes since discontinuation of the medication. She has no other chronic medical conditions and her only surgery was a laparoscopic cholecystectomy. The patient does not use tobacco, alcohol, or illicit drugs. She is up to date on vaccinations. Temperature is 36.7 C (98 F), blood pressure is 150/80 mm Hg, and pulse is 76/min. Pulse oximetry is 99% on room air. BMI is 22 kg/m². Cardiac examination reveals a normal rate and regular rhythm. The lungs are clear to auscultation bilaterally. Pelvic examination shows a 9-week-sized uterus without adnexal masses or tenderness. Urine dipstick shows 1+ proteinuria. Ultrasound confirms a 9-week intrauterine gestation with fetal cardiac activity. Which of the following is the next best step in management of this patient?

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Explanation: 11ec2b69_c037_1bbb_8f63_912a1b385966_MD0005_00 This patient has sickle cell disease (SCD), a condition in which multiple episodes of vasoocclusion (ie, pain crises) causes irreversible renal damage, resulting in both nephropathy (eg, proteinuria) and hypertension. SCD comorbidities (eg, nephropathy, hypertension) are all independent risk factors for preeclampsia (hypertension of pregnancy with associated proteinuria and/or signs of end-organ damage). SCD is one of several conditions that increases the risk of preeclampsia; others include diabetes mellitus and systemic lupus erythematosus, which cause renal disease. A 24-hour urine collection for total protein at the initial prenatal visit establishes a baseline (prepregnancy) proteinuria in high-risk patients. The ability to evaluate changes in the amount of proteinuria helps to determine whether blood pressure elevations are due to worsening chronic hypertension or superimposed preeclampsia, which affects antenatal management and delivery timing. Patients with worsening chronic hypertension have blood pressure elevations with no significant changes in proteinuria. These patients are typically managed in an outpatient setting and are delivered at term (37-39 weeks gestation). In contrast, patients with superimposed preeclampsia have worsening hypertension and progressive proteinuria. These patients require inpatient care and preterm delivery (34-37 weeks gestation). In high-risk patients, aspirin therapy beginning in the second trimester decreases the risk of preeclampsia. A 24-hour urine collection also identifies patients with nephrotic-range proteinuria (>3.5 gm/day), who are at risk for thromboembolism and require anticoagulation during pregnancy and postpartum. (Choice B) Cell-free fetal DNA testing (noninvasive prenatal testing) is a screening test for fetal aneuploidy offered to high-risk patients (eg, age >35, previous fetal aneuploidy). Patients with SCD are not at increased risk of fetal aneuploidy. fetal aneuploidy (Choice C) Patients with SCD are not at increased risk for Group B Streptococcus colonization and can be screened routinely at 35-37 weeks gestation. (Choice D) Patients with SCD typically have excess iron from frequent hemolysis and transfusions; therefore, iron supplementation can result in iron overload and is recommended only after an evaluation shows iron deficiency. (Choice E) A purified protein derivative test is indicated for patients who have risk factors for tuberculosis (eg, HIV, incarceration). SCD and hypertension are not risk factors for tuberculosis. Educational objective: In patients at high risk for preeclampsia (eg, sickle cell disease, hypertension), a 24-hour urine collection for total protein at the initial prenatal visit establishes baseline renal function and dictates patient management (ie, early delivery) in the event of worsening hypertension. References: Sickle cell disease in pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/27598360) The obstetric management of sickle cell disease. (http://www.ncbi.nlm.nih.gov/pubmed/22113135) Pregnancy and sickle cell disease: a review of the current literature. (http://www.ncbi.nlm.nih.gov/pubmed/26672916)

A 27-Year-Old Woman, Gravida 1 Para 0, at 9 Weeks