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Difficulty: Very hardNormal Pregnancy and Prenatal Care

A 29-year-old nulliparous woman at 27 weeks of gestation comes to the obstetric clinic for a scheduled evaluation. She mentions that lately she feels "out of breath" when climbing stairs at home and has noticed her shoes feeling tight by the evening. She has no history of cardiopulmonary disease. Blood pressure is 114/72 mm Hg, pulse is 98/min, and respirations are 20/min. Cardiopulmonary auscultation reveals a grade 2/6 systolic murmur heard best over the left sternal border and clear breath sounds bilaterally. Trace pitting edema is noted around her ankles.

Laboratory analysis shows:
Leukocyte count: 14,200/mm314,200/\text{mm}^3
Hemoglobin: 10.7 g/dL10.7 \text{ g/dL}
Platelet count: 128,000/mm3128,000/\text{mm}^3
Serum creatinine: 0.5 mg/dL0.5 \text{ mg/dL}
Urine dipstick: 1+ glucose, negative for protein and blood.

Her blood type is O, Rh-positive.

Which of the following is the most appropriate next step in the management of this patient?

  1. A
    Request a transthoracic echocardiogram to assess the cardiac murmur
  2. B
    Prescribe therapeutic ferrous sulfate for maternal anemia
  3. Order an oral glucose challenge test for gestational diabetes screeningAnswer
  4. D
    Instruct the patient to collect a 24-hour urine sample for total protein
  5. E
    Perform a ventilation-perfusion scan to rule out a pulmonary embolism

Answer

The correct answer is to order an oral glucose challenge test for gestational diabetes screening.
The correct answer is to proceed with routine screening, which includes a 50-g oral glucose challenge test. This patient presents with multiple clinical and laboratory findings that, while appearing abnormal in a non-pregnant patient, represent normal physiologic adaptations to pregnancy. Her dyspnea is due to progesterone-induced increased tidal volume. The 2/6 systolic murmur is a physiologic flow murmur resulting from increased cardiac output. The trace edema is due to decreased plasma oncotic pressure and inferior vena cava compression. Furthermore, her laboratory findings show a normal dilutional anemia of the second trimester (hemoglobin > 10.5 g/dL is normal), mild physiologic leukocytosis, gestational thrombocytopenia, decreased serum creatinine (due to increased GFR), and normal physiologic glycosuria. Because all findings are physiologic, she requires standard prenatal care, which at 24 to 28 weeks gestation mandates universal screening for gestational diabetes mellitus.

Step-by-Step Solution

1
Analyze the patient's clinical presentation and vital signs.
The patient has mild dyspnea, trace edema, and a 2/6 systolic murmur with normal vitals.
To differentiate between normal physiologic adaptations of pregnancy and potential cardiopulmonary pathology.
2
Evaluate the laboratory findings against pregnancy-specific reference ranges.
Hemoglobin (10.7 g/dL) is normal for the second trimester (>10.5 g/dL). Mild leukocytosis, thrombocytopenia, decreased creatinine, and trace glycosuria are also present and normal.
To identify any true hematologic or renal abnormalities requiring intervention.
3
Synthesize the findings to determine the patient's overall health status.
All clinical and laboratory findings reflect normal physiologic adaptations to pregnancy. No acute pathology is present.
To avoid unnecessary diagnostic testing for expected pregnancy changes.
4
Apply the standard prenatal care timeline to a normal pregnancy at 27 weeks gestation.
The 24 to 28-week window requires universal screening for gestational diabetes mellitus.
To select the most appropriate proactive management step for this specific routine visit.

Key Concept

Normal physiologic adaptations to pregnancy and the standard prenatal screening timeline
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Topics

Normal Pregnancy and Prenatal Care

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