Delivery Room ( Case Scenario )

Patient R is a 38 years old, gravida 4 para 2, who had spontaneous abortion eight months previous. She
presented at 15 weeks gestation. Her initial obstetric appointment was completed at 11 weeks
gestation. No fetal heart tones were auscultated. Because the patient had a definite last menstrual
period and the uterine size was appropriate at the time of examination, no ultrasound was performed.
Plans were made to schedule an ultrasound at 20 to 22 weeks gestation for complete evacuation
secondary to a family history of cardiac anomaly.

Laboratory results from her first appointment were as follows:

 Hemoglobin :12.2
 Hematocrit : 36%
 WBC: 8,200
 Platelets :172,000
 Blood type : B
 Rh : positive
 Antibody screen : negative
 Venereal disease research test : negative
 Hepatitis B ( HBsAG ) : negative
 HIV : negative
 Urine culture : negative
 Urinalysis : within normal limits, protein and glucose negative
 Pap Smear : normal
 Gonorrhea culture : negative
 Chlamydia culture : negative
 Rubella : immune

Physical examination at the time of her first examination revealed a height of 65 inches, weight
212 lbs, pulse rate 80 beats / min, Blood pressure was 115/ 72 mm HG, Uterine size was
measured to be 10 -12 weeks gestation, cervix was noted to be long and closed. The patient
returned with complaints of brown spotting “ on and off “ for several days, headache, fatigue,
nausea and vomiting, and swelling in her legs. She had been unable to keep food or fluids down
for 24 hours. Her second exam reported a weight of 222 lbs, pulse of 86 betas/min, and BP 160/
90mm Hg. Fundal height was recorded as 20cm, and no fetal heart tones were monitored.
Urinalysis revealed 1+ protein and negative glucose with large ketones. Mucous membranes are
dry, and the patient appears pale. Pitting edema in the calves is noted.

The differential diagnosis for patient R includes :

 Pre- eclampsia
 Multiple gestation
 Hyperemesis
 Molar pregnancy
 Partial molar pregnancy

An ultrasound was ordered and revealed no fetus but the presence of characteristic grape – like
clusters in the uterus, and the diagnosis of complete hydatidiform molar pregnancy was made.
The patient was referred to an obstetrician for evacuation and management of this pregnancy.
Because diagnosis was made before surgical evacuation of the uterus, a chest x-raywas
performed pre=operatively. It was within normal limits, CBC, platelets count, PT, PTT liver
function tests and renal function tests were obtained. An HCG level was also obtained for
baseline. Blood type and Rh type were known from her prenatal work-up. The Patient did not
require RhoGAM.