A 33-year-old woman, gravida 2 para 1 aborta 1, comes to the office for preconception counseling. The patient feels well. Her first pregnancy, approximately 6 years ago, was complicated by diet-controlled gestational diabetes mellitus and by preeclampsia with severe features that required hospitalization at 32 weeks gestation and cesarean delivery at 34 weeks gestation. After delivery, the patient was discharged on antihypertensives, which were discontinued 6 weeks postpartum. She had a normal 2-hour glucose tolerance test at the same visit. Her second pregnancy 4 years ago resulted in a spontaneous abortion at 7 weeks gestation. The patient has no other chronic medical conditions and only takes a daily prenatal vitamin. She practices yoga 4 or 5 times a week. The patient does not use tobacco or illicit drugs but drinks alcohol socially once or twice a month. Blood pressure is 100/70 mm Hg. BMI is 20 kg/m². Pelvic examination is normal. In addition to continuing prenatal vitamins, which of the following is the best advice for this patient?

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Explanation: 11ec2b69_c19d_61d5_8f63_818274daec62_MD0005_00 Preeclampsia, defined as new-onset hypertension and proteinuria and/or end organ damage at >20 weeks gestation, is a leading cause of pregnancy-related morbidity and mortality. Preeclampsia is hypothesized to result from abnormal increases in platelet aggregation and vasoconstriction, resulting in placental infarction and ischemia. Patients with predisposing factors, such as a history of chronic kidney disease, diabetes mellitus, chronic hypertension, autoimmune disease, and preeclampsia in a prior pregnancy (particularly severe features and/or <37 weeks gestation), are at high risk for preeclampsia development. In high-risk patients, daily aspirin initiated at 12 weeks gestation is the only therapy that has been proven to decrease the risk of preeclampsia. Aspirin inhibits platelet aggregation and helps prevent placental ischemia. (Choice A) Folic acid supplementation decreases the risk of neural tube defects (NTDs). Prenatal vitamins contain 0.4 mg of folic acid, an adequate amount for patients at average risk for a fetus with NTDs, such as this patient. High-dose folic acid, 4 mg daily, is indicated for patients at high risk for a fetus with NTDs (eg, prior NTDs, carbamazepine, valproate). neural tube defects (NTDs) (Choice C) Vaginal progesterone is indicated to decrease the risk for preterm delivery in patients found incidentally during transvaginal ultrasound to have a short cervix (<2 cm). Patients with a history of preterm delivery are treated with intramuscular hydroxyprogesterone to prevent preterm birth recurrence. (Choice D) Patients with previous gestational diabetes mellitus are at risk for recurrence in subsequent pregnancies. Obesity is associated with an increased recurrence risk; however, this patient has a normal BMI. A low-carbohydrate diet does not decrease the recurrence risk. Educational objective: Patients with a history of renal disease, diabetes mellitus, hypertension, or prior preeclampsia (particularly preterm preeclampsia with severe features) are at high risk for preeclampsia recurrence. In high-risk patients, aspirin is used for preeclampsia prevention and is started at 12 weeks gestation. References: Low-dose aspirin for preventing preeclampsia and its complications: a meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/25833349) Prevention of preeclampsia and intrauterine growth restriction with aspirin started in early pregnancy: a meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/20664402)

A 33-Year-Old Woman, Gravida 2 Para 1 Aborta 1, Comes