A 40-year-old woman, gravida 5 para 0 aborta 4, at 35 weeks gestation comes to labor and delivery triage because she has not felt her baby move for the past 24 hours. The patient has not eaten much all day and skipped dinner due to nausea. She has a 25-pack-year history of cigarette use but has cut down on her smoking during her pregnancy. Her last ultrasound at 32 weeks gestation showed a fetus in breech position measuring at the 15th percentile and placenta previa. A nonstress test shows a baseline fetal heart rate in the 130s with moderate variability and no decelerations. There are no accelerations after an hour of monitoring despite vibroacoustic stimulation. Tocometry shows no contractions. Item 1 of 2
Which of the following is the most appropriate next step in management of this patient?

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11ec25c8_da50_3855_bc81_ad32a769975f_MD0003_00 This patient presents with decreased fetal movement, a subjective and nonspecific symptom that may be benign (eg, normal fetal sleep cycle) or ominous (eg, central nervous system hypoxia). A nonstress test (NST) is performed to assess fetal status and identify fetuses at risk of adverse outcomes. During an NST, the heart rate of a well-oxygenated fetus rises with fetal movement (accelerations). A reactive NST (>2 accelerations) has a high negative predictive value to rule out fetal acidemia. A nonreactive NST has a high false-positive rate and low positive predictive value and cannot rule in fetal acidemia. reactive NST > A nonreactive NST requires further evaluation with a biophysical profile (BPP) or contraction stress test (CST). These tests are equivalent in assessing fetal status and are selected based on available resources and relevant contraindications. A BPP includes an NST plus an ultrasound evaluation of the amniotic fluid index as well as fetal movement, tone, and breathing. A CST (Choice D) is performed by administering oxytocin or using nipple stimulation until 3 contractions occur every 10 minutes. Contraindications to CST include contraindications to labor (eg, placenta previa, prior myomectomy). Therefore, a BPP is more appropriate for this patient. placenta previa (Choice B) Although this patient's nonreactive NST is concerning, the NST has a high false-positive rate. Should a BPP also be abnormal, cesarean delivery may be warranted for this patient due to placenta previa. (Choice C) Because fetal sleep is a common cause of a nonreactive NST, monitoring should occur for >40 minutes to account for a fetal sleep cycle. Continuing this patient's NST would not be helpful as it has been performed long enough to account for a fetal sleep cycle and vibroacoustic stimulation did not produce a fetal heart rate response. Further workup is needed to determine if the decreased fetal movement and nonreactive NST reflect underlying pathology. > (Choice E) Umbilical artery flow velocimetry is beneficial in monitoring growth-restricted fetuses (estimated fetal weight <10th percentile). This fetus has normal growth. Educational objective: Patients with decreased fetal movement should undergo antenatal fetal testing with a nonstress test (NST) followed by a biophysical profile or a contraction stress test if the NST is nonreactive. A biophysical profile should be performed if labor is contraindicated. References: ACOG practice bulletin no. 145: Antepartum fetal surveillance. (http://www.ncbi.nlm.nih.gov/pubmed/24945455) Antenatal fetal surveillance. (http://www.ncbi.nlm.nih.gov/pubmed/15017340)

A 40-Year-Old Woman, Gravida 5 Para 0 Aborta 4, at 35