A 24-year-old primigravid woman at 10 weeks gestation is brought to the emergency department for vaginal bleeding. She has colicky pain in the suprapubic region radiating to her back. Her temperature is 37 C (98.7 F), blood pressure is 110/76 mm Hg, pulse is 94/min, and respirations are 18/min. Physical examination shows a dilated cervix with visible products of conception. Suction curettage is performed and all products of conception are evacuated. Maternal serum laboratory results are as follows: Which of the following is the most appropriate next step in management of this patient?

Question

A 24-year-old primigravid woman at 10 weeks gestation is brought to the emergency department for vaginal bleeding.  She has colicky pain in the suprapubic region radiating to her back.  Her temperature is 37 C (98.7 F), blood pressure is 110/76 mm Hg, pulse is 94/min, and respirations are 18/min.  Physical examination shows a dilated cervix with visible products of conception.  Suction curettage is performed and all products of conception are evacuated.  Maternal serum laboratory results are as follows:  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_da82_e16d_bc81_c976b4b453a0_MD0003_00 The Rhesus (Rh) blood group system is composed of 5 antigens. The most common involved in fetal and neonatal disease is the D antigen because it is the most immunogenic. Rh(D) antigen alloimmunization occurs when Rh(D)-positive fetal erythrocytes enter the bloodstream of an Rh(D)-negative pregnant woman and the pregnant woman develops antibodies against the D antigen present on the fetal erythrocytes. Although the anti-D antibodies do not affect the fetus of this index pregnancy, these antibodies are potentially hazardous in subsequent pregnancies. If the alloimmunized woman has a subsequent pregnancy with an Rh(D) positive fetus, the pregnant woman's anti-D antibodies will bind and lyse the fetal erythrocytes. Rh(D) antigen alloimmunization Therefore, the unsensitized Rh(D)-negative pregnant woman should receive anti-D immune globulin (RhoGAM) to lower her risk of Rh(D) alloimmunization and the development of hemolytic disease of the newborn in a subsequent pregnancy. The placenta is a barrier between the pregnant woman and fetus, but fetal erythrocytes may enter the pregnant woman's circulation during an abortion (spontaneous or induced), procedures such as amniocentesis, or during delivery. Anti-D immune globulin is administered at these critical times and binds the D antigens on the fetal erythrocytes in the pregnant woman's circulation, thereby preventing formation of anti-D antibodies. If a mother is already sensitized (elevated antibody titers), administration of anti-D immune globulin is not helpful and close fetal monitoring for hemolytic disease is required. (Choice B) Without treatment, the patient may develop anti-D antibodies that may affect a subsequent pregnancy with an Rh(D)-positive fetus. (Choices C and F) Antiphospholipid antibodies, parental karyotyping, and thyroid-stimulating hormone are typically checked in cases of recurrent pregnancy loss. These do not apply to this patient, who is experiencing a first miscarriage. (Choice D) Patients with septic abortions are typically febrile with sanguinopurulent discharge. Blood and endometrial cultures should be sent when an intrauterine infection is suspected but would be low yield in other spontaneous abortions. (Choice E) Karyotyping of fetal tissue is not indicated after one spontaneous miscarriage but may be considered after recurrent pregnancy loss or loss in the second trimester. Educational objective: Anti-D immune globulin (RhoGAM) is indicated in unsensitized, Rh-negative women at 28 weeks gestation or within 72 hours of any procedure or incident in which there is any possibility of feto-maternal blood mixing. References: ACOG practice bulletin. Prevention of Rh D alloimmunization. Number 4, May 1999 (http://www.ncbi.nlm.nih.gov/pubmed/10458556)

A 24-Year-Old Primigravid Woman at 10 Weeks Gestation Is Brought