A 23-year-old woman at 8 weeks gestation comes to the office for an initial prenatal visit. The patient has no vaginal bleeding or pelvic pain. On examination, areas of bruising in different stages of healing are seen on the chest and abdomen. When asked about the bruises, the patient states that her boyfriend used to hit her during arguments and was initially angry about the pregnancy. Over the past 3 weeks, he has been more supportive, buying prenatal vitamins and offering massages. Ultrasound examination confirms an 8-week intrauterine gestation and normal fetal heart rate. Which of the following is the most appropriate next step in management of this patient?

Question

A 23-year-old woman at 8 weeks gestation comes to the office for an initial prenatal visit.  The patient has no vaginal bleeding or pelvic pain.  On examination, areas of bruising in different stages of healing are seen on the chest and abdomen.  When asked about the bruises, the patient states that her boyfriend used to hit her during arguments and was initially angry about the pregnancy.  Over the past 3 weeks, he has been more supportive, buying prenatal vitamins and offering massages.  Ultrasound examination confirms an 8-week intrauterine gestation and normal fetal heart rate.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec160b_3664_a709_9249_0925eac704d8_MD0001_00 This patient at 8 weeks gestation with bruising is affected by intimate partner violence (IPV), which is any type of physical, psychologic, or sexual harm committed by a partner or spouse. During pregnancy and postpartum, patients and their partners experience marked increases in emotional, physical, and financial stressors. Initially, partners may be angry about the pregnancy but can later become supportive and exhibit gentler behavior. However, as pressure and responsibility increase, the partner may begin to blame the patient and pregnancy. These factors can cause an increase in IPV during pregnancy, particularly in patients who experienced IPV prepregnancy. Because physical violence is typically directed at both the patient and the fetus (eg, hitting the pregnant abdomen), pregnant women are at significant risk for maternal morbidity (eg, injury, depression), homicide, and pregnancy complications (eg, preterm labor, abruptio placentae) due to abdominal trauma. Therefore, screening for IPV is required at the initial prenatal visit, during each trimester, and postpartum. Patients who screen positive should be assessed for immediate safety and given additional resources (eg, information about a domestic violence program) for long-term safety planning (eg, housing, childcare, finances). In some jurisdictions, there may also be mandatory reporting requirements for IPV during pregnancy. (Choice A) Advising the patient to stay with a relative for the duration of the pregnancy is not recommended because the provider cannot predict the partner's response (eg, potential increase in violence) or new safety concerns that may arise if the patient abruptly relocates. (Choice C) Recommending the patient file a restraining order against her boyfriend is inappropriate; the duty of the provider is to assess for imminent risk and provide medical and psychosocial resources, not to offer legal advice. In addition, a restraining order may cause the partner to retaliate. (Choices D and E) Referring the patient and her boyfriend to couples' therapy or recommending that the patient bring her boyfriend to the next prenatal appointment is inappropriate because confrontation or involvement of the partner at this time could endanger both the patient and the provider. Educational objective: Intimate partner violence (IPV) increases during pregnancy and the postpartum period and can cause significant maternal and pregnancy complications. Pregnant patients affected by IPV require immediate safety planning (eg, information about a domestic violence program) and resources for long-term planning. __________ References: Intimate partner violence identified through routine antenatal screening and maternal and perinatal health outcomes. (http://www.ncbi.nlm.nih.gov/pubmed/31619194)

A 23-Year-Old Woman at 8 Weeks Gestation Comes to the Office