Sample Case

[anonperson]

Sample case for the residents/attendings out there. This is based on a real life example I dealt with recently. Consider it oral board prep.

You are covering ED/L and D call for your group/hospital. A 32 year old G10P5 comes into triage with a complaint of contractions. She says she is visiting family in the area and gets prenatal care in another state over 4 hours away. She claims to be 36 weeks pregnant. She has no prenatal records with her. It is 8pm currently.

She has normal vitals and is put on the monitor.
Category 1 fetal tracing.
She is contracting every 5-7 minutes.

Past Hx:
5 prior cesarean deliveries
Abdominoplasty
Breast augmentation
Lap chole

5 term cesarean deliveries for various reasons.
4 pregnancy losses/terminations

She denies any complicating issues this pregnancy other than having 4 prior C sections.
NKDA
BMI 28

She states the contractions are painful (5/10).

You have a 24 hour in house anesthesiologist. You have a fully functioning L and D. You can call in a partner for backup/assists.

What is your next steps in evaluating and managing this patient? Labs? Imaging? Physical exam? Any medications?

Any specific concerns with this patients prior obstetric history?

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[Jecave]

I’d perform a pelvic exam and order an obstetric sonogram for estimated gestational age and placental location. I’d order a cbc, blood type and group, vdrl, hiv, u/a. If she’s dilating but delivery isnt imminent, i’d give her a course of celestone.

 

[Dr G Oogle]

It’s been 3 blissful years since I’ve had to do obstetrics but if possible I’d try to contact hospital where she got prenatal care to confirm dates hopefully the practice she goes to is affiliated with some night time coverage that can look things up for you. After that i think a fundal height might also be helpful if she says she’s 36 weeks and measures 36 weeks than it’s gotta be around that GA; then I’d give beta and check for cervical dilation and do all the things you might need for a 5-Pete: type and cross, CBC, US for GA and presentation etc. maybe also screen for domestic abuse? Not uncommon but traveling that far away at that GA could be a .

 

[anonperson]

US shows an anterior placenta with no obvious previa. Fetus is measuring 37 weeks based on biometry. Cephalic.

You obtain labs and perform a pelvic exam. Cervix is fingertip.
You obtain the clinic number and call. They are closed and will be back the next morning at 9am. There is no forwarding number.

CBC shows a Hgb of 9.3. Normal platelet count.

You give the first dose of betamethasone.

Tracing is category 1.

Her contractions are now every 3-5 minutes and getting more painful (7/10).

She has now been in triage for ~1 hour. On recheck she is still fingertip on cervical check.

How would you proceed at this point?

Questions you should be able to answer off the top of your head with ease. If not, go back and read your practice bulletins and dust off Williams.

1. What are some of the benefits of steroid administration for the preterm fetus in general? (You should be able to list several)
2. What is the mechanism that fetal lung maturity is accelerated by steroid administration?
3. What is the alternative to betamethasone and the dosing?
4. What is the risk of accreta in a patient with no previa and this many prior C- sections?
5. If the patient had a previa, what is the risk of accreta in the setting of one prior c section? Two? Three? Four?
6. This patient has anemia. What is the most common type of anemia in pregnancy? How would you confirm your diagnosis? What is the total iron requirement in pregnancy?
7. What is a suboptimally dated pregnancy by definition?
8. Tell me the error rate of US in regards of pregnancy dating by gestational age.