A healthy 25-year-old G1P0 at 37 weeks’ gestational age comes to your office to see you for a routine obstetric visit. She reports that on several occasions she has experienced dizziness, light-headedness, and feeling as if she is going to pass out when she lies down on her back to take a nap.
What is the most appropriate plan of management for this patient?
Late in pregnancy, when the mother assumes the supine position, the gravid uterus compresses the inferior vena cava and decreases venous return to the heart. This results in decreased cardiac output and symptoms of dizziness, light-headedness, and syncope. This significant arterial hypotension resulting from inferior vena cava compression is known as supine hypotensive syndrome or inferior vena cava syndrome. Therefore, it is not recommended that women remain in the supine position for any prolonged period of time in the latter part of pregnancy. When patients describe symptoms of the supine hypotensive syndrome, there is no need to proceed with additional cardiac or pulmonary workup.
A 22-year-old primigravida presents to your office for a routine OB visit at 34 weeks’ gestational age. She voices concern because she has noticed an increasing number of spidery veins appearing on her face, upper chest, and arms. She is upset with the unsightly appearance of these veins and wants to know what you recommend to get rid of them.
How should you counsel this patient?
Vascular spiders, or angiomas, are common findings during pregnancy. They form as a result of the hyper-estrogenism associated with normal pregnancies and are of no clinical significance. The presence of these angiomas does not require any additional workup or treatment, and they will resolve spontaneously after delivery. Reassurance to the patient is all that is required.
You are the third year medical student assigned to labor and delivery. A 29-year-old P3003 at 29 weeks with known placenta previa presents to the triage area with a report of vaginal bleeding. The fetal heart tracing is reactive and the bleeding is minimal. You take history and present her to your intern. You accompany the intern to triage to further evaluate the patient together. Your intern confirms the history and prepares to perform a digital cervical examination.
What should your next step be in this situation?
Patient safety has no hierarchy. Placenta previa is a condition where the placenta is implanted over the internal cervical os. Digital cervical examination is contraindicated in this setting due to the possibility of causing severe hemorrhage. The correct next step is to speak up to make sure the intern knows that the patient has a placenta previa and should not have a digital cervical examination.
A healthy 34-year-old G1P0 patient comes to see you in your office for a routine OB visit at 12 weeks’ gestational age. She tells you that she has stopped taking her prenatal vitamins with iron supplements because they make her sick and she has trouble remembering to take a pill every day. A review of her prenatal laboratory tests reveals that her hematocrit is 39%.
Which of the following statements is the best way to counsel this patient?
The amount of iron that can be mobilized from maternal stores and obtained from the diet is insufficient to meet the demands of pregnancy. A pregnant woman with a normal hematocrit at the beginning of pregnancy who is not given iron supplementation will develop iron deficiency during the latter part of gestation, as iron requirements increase significantly during the second half of pregnancy. It is important to remember that the fetus will not have impaired hemoglobin production, even in the presence of maternal anemia, because the placenta will transport the needed iron at the expense of maternal iron store depletion. The hematocrit in pregnancy normally falls in pregnancy due to plasma volume expansion and therefore is not used as a parameter to determine when to begin iron supplementation.
A 19-year-old P0 at 20 weeks’ gestation presents to the emergency department (ED) with complaints of right flank pain. The ED physician orders a renal sonogram as part of a workup for a possible kidney stone. The radiologist reports that no nephrolithiasis is present, but reports the presence of bilateral mild hydronephrosis and hydroureter, which is greater on the right side than on the left.
What is the most appropriate next step in management?
Bilateral mild hydronephrosis and hydroureter are normal findings during pregnancy and do not require any additional workup or concern. When the gravid uterus rises out of the pelvis after 12 weeks, it presses on the ureters at the pelvic brim, causing ureteral dilatation and hydronephrosis. It is also likely that hormonal effect from progesterone contributes to the development of hydroureter and hydronephrosis of pregnancy. In the vast majority of pregnant women, ureteral dilatation tends to be greater on the right side as a result of the dextrorotation of the uterus and/or cushioning of the left ureter provided by the sigmoid colon.
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