A 29-year-old woman, gravida 1 para 0, comes to the office to establish prenatal care. The patient is at 16 weeks gestation by a sure, regular last menstrual period. She had nausea and vomiting for a few weeks, but her symptoms have gradually improved. She has had no vaginal bleeding or cramping. The patient has no chronic medical conditions and has not been taking a prenatal vitamin because she thinks it caused her nausea. She underwent a cold knife conization 2 years ago for cervical intraepithelial neoplasia 3 but has had no other surgeries. Family history is significant for her sister developing gestational diabetes mellitus during her last pregnancy. Temperature is 37 C (98.6 F), blood pressure is 100/64 mm Hg, and pulse is 72/min. BMI is 22 kg/m². Fetal heart rate is 140/min by Doppler ultrasound. Cardiopulmonary examination is normal. The abdomen is soft, nontender, and nondistended. On pelvic examination, there are no cervical lesions or abnormal discharge. Uterine size is consistent with 16 weeks gestation. In addition to routine prenatal care, which of the following additional interventions is indicated in this patient?

Question

A 29-year-old woman, gravida 1 para 0, comes to the office to establish prenatal care.  The patient is at 16 weeks gestation by a sure, regular last menstrual period.  She had nausea and vomiting for a few weeks, but her symptoms have gradually improved.  She has had no vaginal bleeding or cramping.  The patient has no chronic medical conditions and has not been taking a prenatal vitamin because she thinks it caused her nausea.  She underwent a cold knife conization 2 years ago for cervical intraepithelial neoplasia 3 but has had no other surgeries.  Family history is significant for her sister developing gestational diabetes mellitus during her last pregnancy.  Temperature is 37 C (98.6 F), blood pressure is 100/64 mm Hg, and pulse is 72/min.  BMI is 22 kg/m².  Fetal heart rate is 140/min by Doppler ultrasound.  Cardiopulmonary examination is normal.  The abdomen is soft, nontender, and nondistended.  On pelvic examination, there are no cervical lesions or abnormal discharge.  Uterine size is consistent with 16 weeks gestation.  In addition to routine prenatal care, which of the following additional interventions is indicated in this patient?

Quizplus · Accepted Answer

11ec25c8_da7c_78c0_bc81_d918ce4e8110_MD0003_00 During the initial prenatal visit, risk factors for potential obstetric complications are assessed to allow for the implementation of preventive measures. This patient with a prior cold knife conization is at risk for preterm delivery (ie, delivery at <37 weeks gestation). Preterm delivery is a common obstetric complication and a leading cause of neonatal morbidity and mortality. The greatest risk factor for preterm delivery is prior spontaneous preterm delivery, but additional risk factors include tobacco use, multiple gestation, and prior cervical surgery. In particular, removal of part of the cervix by cold knife conization for cervical intraepithelial neoplasia can cause cervical shortening and scarring, which decreases cervical tensile strength and increases the risk for preterm labor. cold knife conization For patients with no prior preterm delivery, a transvaginal cervical length measurement is recommended at 16-24 weeks gestation to assess the risk for preterm delivery (Choice D). Patients with a normal cervical length are at a lower risk for preterm delivery and require no additional intervention. In contrast, those with a short cervix (ie, cervical length ≤2.5 cm on ultrasound) are at high risk for preterm delivery and are offered vaginal progesterone, which can prevent uterine contractions and preterm labor. (Choice A) A 24-hour urine protein collection is performed at <20 weeks gestation to establish a baseline measurement in patients at high risk for preeclampsia (eg, chronic hypertension, diabetes mellitus). This patient has a normal blood pressure and no risk factors for preeclampsia. (Choice B) An early glucose challenge test screens for undiagnosed pregestational diabetes mellitus (DM) and is indicated in patients with BMI ≥25 kg/m² and an additional risk factor (eg, prior gestational DM, first-degree relative with type 2 DM). A first-degree relative with prior gestational DM is not an indication for early testing. ² (Choice C) High-dose (4 mg) folic acid is indicated in patients at increased risk for fetal neural tube defects (eg, prior affected pregnancy). This patient is at average risk. In addition, neural tube closure is generally complete by 5-6 weeks gestation; therefore, initiating folic acid at 16 weeks gestation is unlikely to affect neural tube outcomes. Educational objective: Pregnant patients with prior cervical surgery (eg, cold knife conization) are at increased risk for preterm delivery. These patients require a transvaginal cervical length measurement at 16-24 weeks gestation to guide potential preventive measures (eg, vaginal progesterone). References: Obstetric outcomes after conservative treatment for cervical intraepithelial lesions and early invasive disease. (http://www.ncbi.nlm.nih.gov/pubmed/29095502) Prediction and prevention of preterm birth after cervical conization. (http://www.ncbi.nlm.nih.gov/pubmed/21278880)

A 29-Year-Old Woman, Gravida 1 Para 0, Comes to the Office