A 27-year-old woman, gravida 1 para 0, comes to the office for an initial prenatal visit. The patient is uncertain when her last menstrual period occurred, but she has had daily nausea and vomiting for the last 2 months. She has had no vaginal bleeding or pelvic pain. The patient has no chronic medical conditions and has had no surgeries. She takes a daily prenatal vitamin. Vital signs are normal. Abdominal examination reveals a gravid uterus that is nontender, and the fundus is just below the umbilicus. Ultrasound shows 2 intrauterine fetal poles measuring 14 weeks gestation with heart rates of 150/min and 155/min. Cervical length is 4.5 cm (normal: >2.5). Which of the following is the best next step in management of this patient?
Preeclampsia prevention | |
Definition |
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High risk |
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Moderate risk |
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Prevention |
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Patients with certain predisposing factors, such as diabetes mellitus, chronic hypertension, and multiple gestations, are at high risk for preeclampsia, a leading cause of maternal and fetal morbidity and mortality (eg, risk for stroke, placental abruption, disseminated intravascular coagulation). Preeclampsia likely results from abnormal vasoconstriction and increased platelet aggregation, leading to placental infarction and ischemia. Twin gestation, as in this patient, increases the risk nearly threefold, possibly due to greater placental mass and, subsequently, a higher risk for placental hypoperfusion leading to placental ischemia.
In high-risk patients, daily low-dose aspirin is the only proven therapy to decrease the risk for preeclampsia because it inhibits platelet aggregation and helps prevent placental ischemia. It is initiated at 12-28 weeks gestation (but optimally before 16 weeks) and continued daily until delivery.
(Choice A) Cerclage placement decreases the risk for preterm delivery in patients with a short cervix (≤2.5 cm) on ultrasound or a prior preterm delivery caused by cervical insufficiency (ie, painless cervical dilation). This patient's cervical length is normal, and this is her first pregnancy (ie, no prior preterm deliveries).
(Choice B) Indomethacin is a tocolytic used in patients in preterm labor at <32 weeks gestation to halt contractions and delay labor. It is not used as a prophylactic medication to prevent preterm labor.
(Choice D) Low-molecular-weight heparin can be used for venous thromboembolism (VTE) prophylaxis in patients with a prior VTE or a hypercoagulable condition (eg, certain inherited thrombophilias, antiphospholipid syndrome). It is not required for patients with multiple gestations.
(Choice E) Progesterone therapy (eg, intramuscular, vaginal) is offered to patients with a prior spontaneous preterm delivery or with a short cervix (ie, ≤2.5 cm) diagnosed incidentally on transvaginal ultrasound because it may decrease the risk for recurrence. This patient has not had a prior spontaneous preterm delivery, and her cervical length is normal. Although multiple gestations are at increased risk for preterm delivery, progesterone therapy is not routinely recommended in case of multiple gestations and does not improve outcomes in patients without a prior preterm birth.
Educational objective:
Patients at high risk for preeclampsia (eg, multiple gestations) are prescribed low-dose aspirin prophylaxis at 12-28 weeks gestation (but optimally before 16 weeks) for prevention.