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
    •  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


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.


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