CREOG Quiz #374

A 35 year-old woman, G2P1001, at 27w2d, was  transferred from a referring hospital to the medical center’s L&D Triage Unit for an evaluation of severe headache and elevated blood pressure. The patient was diagnosed 1 week previously with gestational hypertension and was treated with oral alpha-methyldopa, 500mg twice daily. Upon admission to triage, her BP was 160/96 mmHg, pulse 102 bpm, platelets 100,000/mm3, and urine protein 4+. Betamethasone was administered, 12mg intramuscularly, q24h x 2 doses. Her cervix was posterior, firm, uneffaced, and closed. On day 3 of admission her Protein:Cr ratio was 3,930, platelets 88,000/mm3, AST 46, and ALT 61. Sonography  showed a footling breech presentation with an estimated fetal weight in the 7th percentile.  The amniotic fluid index was 4.3 cm (largest vertical pocket of fluid = 1.5 cm), and umbilical artery Doppler showed absent end-diastolic flow.  The ultrasound component of the biophysical profile showed 2 points for fetal movement and 2 points for fetal tone. Her headache persisted, and she now expressed concern about double vision. The fetal heart rate tracing is shown below:

  1. What is the interpretation of this fetal heart rate tracing?

    •  Non-reactive with minimal variability and intermittent variable
           decelerations
    •  Reactive with minimal variability
    •  Reactive with moderate variability
    •  Absent variability with late decelerations


  2. Which of the following is the most appropriate plan of management for this patient?

    •  Observation
    •  Induction of labor
    •  External cephalic version followed by induction of labor
    •  Cesarean delivery





Summary

This patient has severe pre-eclampsia, manifested by thrombocytopenia and abnormal liver function tests, and evidence of significant fetal compromise. The fetal heart rate tracing is non-reassuring. The fetus is growth restricted, and umbilical artery Doppler studies are abnormal. Given these findings plus the footling  breech presentation, cesarean delivery is indicated.

Reference

Access our PDF, Hypertension in Pregnancy



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