During a routine return OB visit, an 18-year-old G1P0 patient at 23 weeks’ gestational age undergoes a urinalysis. The dipstick done by the nurse indicates the presence of trace glucosuria. All other parameters of the urine test are normal.
Which of the following is the most likely etiology of the increased glucose detected in the urine?
The finding of glucosuria is common during pregnancy, and usually is not indicative of a pathologic condition. During pregnancy, there is an increase in the glomerular filtration rate, and a decrease in tubular reabsorption of filtered glucose. In fact, one in six women will spill glucose into the urine during pregnancy. If the patient has risk factors for gestational diabetes, such as obesity, previous macrosomic baby, advanced maternal age, or family history of diabetes, the physician may want to screen for diabetes with a glucose challenge test. If the patient has a urinary tract infection, the dipstick will be more likely to show an increase in WBCs, and the presence of nitrites and blood. A contaminated urine sample would not be a cause of isolated glucosuria.
A 29-year-old G1P0 at 28 weeks’ gestation presents to your office complaining of shortness of breath that is more intense with exertion. She has no significant past medical history and is not on any medication. The patient denies any chest pain. She is concerned because she has always been very athletic and cannot maintain the same degree of exercise that she was accustomed to prior to becoming pregnant. On physical examination, her pulse is 72 beats per minute. Her blood pressure is 90/50 mm Hg. Cardiac examination is consistent with a grade I systolic ejection murmur. The lungs are clear to auscultation.
Which of the following is the most appropriate next step in management of this patient?
The patient’s symptoms and physical examination are most consistent with physiologic dyspnea, which is common in pregnancy. The increased awareness of breathing that pregnant women experience can occur as early as the end of the first trimester, and is caused by an increase in lung tidal volume. The increase in minute ventilation that occurs during pregnancy may make patients feel as if they are hyperventilating, and may also contribute to the feeling of dyspnea. The patient in this case needs to be reassured and counseled regarding these normal changes of pregnancy. She may have to modify her exercise regimen accordingly. There is no need to refer this patient to a cardiologist or to order an ECG. Systolic ejection murmurs are common findings in pregnant women and are caused by the normal increased blood flow across the aortic and pulmonic valves. The incidence of PE in pregnancy is about 1 in 6400, and in many of these cases there is clinical evidence of a DVT. The most common symptoms of a PE are dyspnea, chest pain, apprehension, cough, hemoptysis, and tachycardia.
A 33-year-old G2P1 is undergoing an elective repeat cesarean section at term. The newborn is delivered without any difficulties, but the placenta cannot be removed easily because a clear plane between the placenta and uterine wall cannot be identified. The placenta is removed in pieces. This is followed by uterine atony and hemorrhage.
Match the descriptions with the appropriate placenta type.
placenta accreta occurs when the trophoblastic tissue invades the superficial lining of the uterus. In this instance, the placenta is abnormally adherent to the uterine wall and cannot be easily separated from it. A portion of the placenta may be removed, while other parts remain attached, resulting in hemorrhage. A succenturiate placenta is characterized by one or more smaller accessory lobes located in the membranes at a distance from the main placenta. A retained succenturiate lobe may cause uterine atony and result in postpartum hemorrhage. In placenta previa, the placenta is located very near or over the internal cervical os. Painless hemorrhage can occur without warning, and is caused by tearing of the placental attachments during formation of the lower uterine segment in the third trimester, or with cervical dilation during term or preterm labor. A history of previous cesarean delivery, grand multiparity, and maternal smoking have been associated with an increased risk of placenta previa. Vasa previa occurs when there is a velamentous insertion of the umbilical cord or a succenturiate lobe and the fetal vessels within the membranes traverse the internal cervical os. The fenestrated placenta is a rare anomaly where the central portion of the placenta is missing. In the membranous placenta, all fetal membranes are covered by villi, and the placenta develops as a thin membranous structure. This type of placenta is also known as placenta diffusa.
A 22-year-old G3P2 undergoes a normal spontaneous vaginal delivery without complications. The placenta is spontaneously delivered and appears intact. The patient is later transferred to the postpartum floor where she starts to bleed profusely. Physical examination reveals a boggy uterus and a bedside sonogram indicates the presence of placental tissue.
A placenta accreta occurs when the trophoblastic tissue invades the superficial lining of the uterus. In this instance, the placenta is abnormally adherent to the uterine wall and cannot be easily separated from it. A portion of the placenta may be removed, while other parts remain attached, resulting in hemorrhage. A succenturiate placenta is characterized by one or more smaller accessory lobes located in the membranes at a distance from the main placenta. A retained succenturiate lobe may cause uterine atony and result in postpartum hemorrhage. In placenta previa, the placenta is located very near or over the internal cervical os. Painless hemorrhage can occur without warning, and is caused by tearing of the placental attachments during formation of the lower uterine segment in the third trimester, or with cervical dilation during term or preterm labor. A history of previous cesarean delivery, grand multiparity, and maternal smoking have been associated with an increased risk of placenta previa. Vasa previa occurs when there is a velamentous insertion of the umbilical cord or a succenturiate lobe and the fetal vessels within the membranes traverse the internal cervical os. The fenestrated placenta is a rare anomaly where the central portion of the placenta is missing. In the membranous placenta, all fetal membranes are covered by villi, and the placenta develops as a thin membranous structure. This type of placenta is also known as placenta diffusa.
A 34-year-old G6P5 presents to labor and delivery by ambulance at 33 weeks’ gestational age complaining of the sudden onset of profuse vaginal bleeding. The patient denies any abdominal pain or uterine contractions. She denies any problems with her pregnancy to date but has had no prenatal care. She admits to smoking several cigarettes a day, but denies any drug or alcohol use. The fetal heart rate tracing is normal. There are no contractions on the tocometer.
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