A 42-year-old G5P4 woman at eight weeks gestation presents for her first prenatal
appointment. She has glycosuria noted on urine dipstick in the office.
... [Show More] She has a history
of four prior vaginal deliveries at full-term with birth weights ranging from 9 to 10.5
pounds. Family history is positive for type 2 diabetes in her mother and two siblings.
Weight is 265 pounds and height is 5 feet 4 inches (BMI is 45.5 kg/m2). Which of the
following recommendations concerning weight gain during this pregnancy is most
appropriate?
A. Maintain current weight
B. Gain 11 - 20 pounds
C. Gain 15 - 25 pounds
D. Gain 25 - 35 pounds
E. Gain 28 - 40 pounds ----CORRECT ANSWER-------B. The Institute of Medicine
(IOM) has developed guidelines (2009) on weight gain in pregnancy. Historical
data show that women who gained within the IOM guidelines experienced better
outcomes of pregnancy than those who did not. The recommendations are:
underweight (BMI < 18.5 kg/m2) total weight gain 28 - 40 pounds; normal weight
(BMI 18.5 - 24.9 kg/m2) total weight gain 25 - 35 pounds; overweight (BMI 25 - 29.9
kg/m2) total weight gain 15 - 25 pounds; and obese (BMI > 30 kg/m2) total weight
gain 11 - 20 pounds.
A 17-year-old G2P0 female has severe right lower quadrant pain. Her last normal
menstrual period seven weeks ago. She notes that last night she began having
suprapubic pain that radiated to her right lower quadrant. This morning, the pain awoke
her from sleep. She has had no vaginal bleeding, no nausea or vomiting. The patient's
history is notable for two first trimester elective abortions and a history of Chlamydia
treated twice. Vital signs are: blood pressure 90/60; pulse 99; respirations 22; and
temperature 98.6°F (37°C). On physical exam, the patient is noted to be curled on a
stretcher in a fetal position and says she hurts too much to move. She has rebound and
voluntary guarding on abdominal examination. She has profound cervical motion
tenderness and rectal tenderness. Her Beta-hCG level is 2500 mIU/ml; hematocrit 24%;
and urinalysis negative. Ultrasound shows no intrauterine pregnancy, a right adnexal
mass that measures 6 x 2 cm, and a moderate amount of free fluid. Which of the
following is the most appropriate next step in the management of this patient?
A. Admit for serial examinations
B. Exploratory surgery
C. Recheck Beta-hCG level in 48 hours
D. Administer methotrexate
E. Dilation and curettage ----CORRECT ANSWER-------B. This patient has a ruptured
ectopic pregnancy until proven otherwise. Her vital signs, examination and
anemia are consistent with an intra-abdominal bleed. Exploratory
laparoscopy/laparotomy is indicated at this point. Conservative management with
observation, serial examinations or repeat Beta-hCG testing could be dangerous
in a patient suspected of having a ruptured ectopic pregnancy. Medical
management (methotrexate) is not used in a patient with an acute surgical
abdomen. Dilation and curettage would not be the next step in management and
might only be considered in this scenario after the patient's abdomen was
explored. [Show Less]