A 34-year-old woman, gravida 2 para 1, at 14 weeks gestation comes to the office for a routine prenatal visit. She is feeling well and has no concerns. The patient had daily nausea and vomiting for the first few weeks of her pregnancy, but symptoms resolved 2 weeks ago. She has had no pelvic pain or vaginal bleeding. The patient has not yet felt fetal movement. Her first pregnancy ended in a cesarean delivery at 30 weeks gestation due to breech presentation and preeclampsia with severe features. The patient has no chronic medical conditions. Her only medication is a daily prenatal vitamin and she has no medication allergies. The patient does not use tobacco, alcohol, or illicit drugs. Blood pressure is 112/74 mm Hg. BMI is 24 kg/m². Fetal heart tones are 155/min. The uterus is gravid and nontender. The remainder of the examination is unremarkable. Which of the following is the best next step in management of this patient?

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11ec25c8_da6e_bd0a_bc81_4725d4ca11dd_MD0003_00 Preeclampsia is a leading cause of maternal and fetal morbidity and mortality due to the increased risk of stroke, placental abruption, and disseminated intravascular coagulation. Preeclampsia likely results from abnormal vasoconstriction and increased platelet aggregation, resulting in placental infarction and ischemia. Patients with predisposing factors, such as chronic kidney disease, chronic hypertension, and preeclampsia in a prior pregnancy (particularly with severe features or at <37 weeks gestation, as in this patient), are at high risk for developing preeclampsia. In high-risk patients, daily low-dose aspirin is the only therapy proven to decrease the risk of preeclampsia because it inhibits platelet aggregation and helps prevent placental ischemia. It is initiated at 12-28 weeks gestation (but optimally before 16 weeks), then continued daily until delivery. (Choice A) Betamethasone helps accelerate fetal lung maturity in patients <37 weeks gestation who are at imminent risk for preterm delivery. If this patient develops preeclampsia requiring preterm delivery, betamethasone would be indicated at that time. (Choice B) High-dose (4 mg) folic acid is indicated in patients at high risk for a fetus with neural tube defects (eg, prior affected pregnancy, use of folate antagonist medications). This patient is at average risk and requires the typical dose (0.4 mg) found in most prenatal vitamins. (Choice C) Intramuscular hydroxyprogesterone is indicated in pregnant patients with prior spontaneous preterm delivery (ie, preterm prelabor rupture of membranes, preterm labor) to decrease the risk of recurrence. It is not indicated in patients who underwent preterm delivery for other indications (eg, preeclampsia with severe features, fetal growth restriction). (Choice E) Vaginal progesterone is indicated to decrease the risk of preterm delivery in patients with a shortened cervix, which is usually identified incidentally on anatomy ultrasound between 16 and 24 weeks gestation. This patient is at 14 weeks. Educational objective: Patients at high risk for preeclampsia (eg, preeclampsia in prior pregnancy) are initiated on low-dose aspirin prophylaxis during pregnancy for preeclampsia prevention. References: ACOG committee opinion no. 743 summary: low-dose aspirin use during pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/29939936) Low-dose aspirin for prevention of morbidity and mortality from preeclampsia: a systematic evidence review for the U.S. Preventive Services Task Force. (http://www.ncbi.nlm.nih.gov/pubmed/24711050) Hypertensive disorders of pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/26926408)

A 34-Year-Old Woman, Gravida 2 Para 1, at 14 Weeks