Description
Week 3 Case Scenario 1
Case Scenario 1
Table 1
Standard level of HCG during pregnancy.
GA weeks
HCG level
3 weeks LMP
5-50 mIU/mL
4 weeks LMP
5-426 mIU/mL
5 weeks LMP
18-7340 mIU/mL
6 weeks LMP
1080-56500 mIU/mL
7-8 weeks LMP
7650-229.000 mIU/mL
9-12 weeks LMP
25700-288,000 mIU/mL
13-16 weeks LMP
13300-254,000 mIU/mL
17-24 weeks LMP
4060-165,400 mIU/mL
25-40 weeks LMP
3640-117,00 mIU/mL
Nonpregnant
55-200 ng/mL
(American Pregnancy Association, 2023).
Table 2
Scenario
In a normal ongoing pregnancy, the expectation for the beta HCG level is to double within 48-72 hours.
During a spontaneous abortion (miscarriage), the expectation for the beta HCG level is to decrease by 35-50% within 48-72 hours.
During an ectopic pregnancy, the expectation for the beta HCG level is to increase by less than 50% within 48-72 hours.
During a gestational trophoblastic pregnancy, the expectation for the beta HCG level is to be drastically elevated beyond normal values within 48-72 hours (American Pregnancy Association, 2023).
Table 3
Common complaints during pregnancy.
Keep in mind these symptoms are during pregnancy, make sure the cause, presentation, and treatment are related to the pregnancy status of the patient.
Definition and Cause
Presentation (include possible DDX)
Treatment
Education
Constipation
Excessive straining, a sense of incomplete evacuation, hard stools, and failed attempts to defecate can be caused by iron supplements and slowed peristalsis due to pregnancy (Epocrates, 2024).
Opioid medications, Hypothyroidism, and high levels of calcium Hypercalcemia can cause constipation (Epocrates, 2024).
Bulk laxatives (fiber supplements) prunes and fruit-based alternatives are the first line of therapy. Stool softeners like psyllium and Docusate 100 mg capsules BID PO are commonly used non-prescription stool softeners to ease constipation (Epocrates, 2024).
Adequate fluid intake and regular non-strenuous exercise along with adequate fiber intake can prevent symptoms of constipation (Epocrates, 2024).
Back pain
Lower back pain during pregnancy is extremely common due to the extra weight and strain put on the musculoskeletal system resulting in lordosis (Jordan et al., 2018).
Spinal stenosis is the narrowing of the spinal canal which causes numbness, tingling, and pain radiating to the buttocks and legs (Epocrates, 2024).
Evidence supports that superficial heat and ice for lower back pain and topical analgesics are effective in alleviating back pain. Alternative therapies safe for pregnancy include acupuncture, massage, and pregnancy support belts also provide temporary relief (Epocrates, 2024).
Patients should be educated on reporting worsening back pain to their healthcare provider when OTC and alternative pain-relieving measures do not adequately control their pain. Frequent stretching and ROM exercises help to keep the lumbar muscles from spasming (Epocrates, 2024).
GERD
The growing uterus places upward pressure on GI organs and can cause gastrointestinal reflux in pregnancy (Jordan et al., 2018).
Acid Reflux is usually resolved once the baby is delivered and the organs return to their normal position in the thorax and abdominal cavity. GERD can be mistaken for chest pain in more severe cases (Jordan et al., 2018).
Safe treatments for GERD during pregnancy include Famotidine or Pepcid 40 mg capsule PO twice daily for up to 8 weeks (Epocrates, 2024).
Sitting upright after meals and avoiding foods that are acidic and spicy can help prevent GERD exacerbations (Epocrates, 2024).
Fatigue
An overwhelming desire to sleep or a feeling of lethargy is common in pregnancy due to increasing metabolic demands placed on the mother (Epocrates, 2024).
Anemia Hb<13.5 g/dL in women is common in early pregnancy and may present as symptoms of fatigue (Epocrates, 2024). It is estimated that pregnant women need 500 mg of additional iron and 300-500 mg of folate per day to meet the demands of pregnancy (Jordan et al., 2018). It is important to address symptoms of fatigue with OB/GYN to rule out nutritional/vitamin deficiencies, thyroid disorders, metabolic disorders, and infections. Staying adequately hydrated and maintaining physical activity can also help to combat symptoms of fatigue in pregnancy (Epocrates, 2024),. Heart palpitations Cardiac output increases by 30-50% with the increased volume of fluids in pregnancy. This can result in murmurs and heart palpitations during pregnancy (Jordan et al., 2018). Heart palpitation may present as sinus tachycardia or atrial flutter and all pregnant patients should be closely monitored for hypertension and preeclampsia (Epocrates, 2024). Women experiencing heart palpitations should be closely monitored by their OB/GYN. An ECG, Thyroid levels, electrolytes, and cardiac biomarkers may be checked to assess for underlying thyroid, metabolic, or cardiovascular conditions (Epocrates, 2024) Heart palpitation should be reported to your OB/GYN immediately (Epocrates, 2024). Urinary frequency Urinary frequency is common in pregnancy due to the increased weight and pressure the uterus places on the bladder (Jordan et al., 2018). Urinary frequency can also be caused by urinary tract infections (Epocrates, 2024). Hyperemia and hyperplasia of the connective tissue in the bladder make it more susceptible to infection during pregnancy (Jordan et al., 2018) and a UTI should be assessed when a pregnant patient reports urinary frequency. Staying adequately hydrated, wiping front to back, and urinating before and after sex help to prevent UTIs (Epocrates, 2024). Nausea and Vomiting Nearly 80% of all pregnant women experience nausea and vomiting which is believed to be caused by increased GD15 hormone (LeBlanc, 2023). It is important to assess for cholecystitis, appendicitis, and pancreatitis when nausea and vomiting persist (Epocrates, 2024). Ginger 250 mg orally PO four times daily has been proven to be an effective alternative to medication. Moderate cases may require Vitamin B6 10-25 mg PO TID. Antiemetics and oral antihistamines may also be indicated (Epocrates, 2024). Eat smaller more frequent meals and avoid foods and smells that cause nausea. Eat bland foods that are high in carbohydrates and low in fat. Take prenatal vitamins on a full stomach (Epocrates, 2024). Round ligament pain The shifting of organs and the growing uterus and fetal movement results in the stretching of the round ligament and can cause pain and discomfort in pregnancy (Dhamecha et al. 2023). Braxton Hicks contractions may be mistaken for pain felt from the round ligament (Dhamecha et al, 2023). Stretching, using a heating pad, taking a warm bath, self-massage, using OTC Tylenol, and wearing a supportive pregnancy belt can reduce round ligament pain (Epocrates, 2024). Timing your contractions and keeping a log to share with your OB/ GYN helps differentiate between Braxton Hicks contractions and round ligament pain. Report any worsening abdominal to your OB/GYN immediately (Epocrates, 2024). Hyperpigmentation Elevated levels of estrogen and progesterone contribute to increased melanocyte stimulation and result in hyperpigmentation which is known as the Mask of Pregnancy or Melasma (Jordan et al., 2018). Lupus presents with a butterfly mask on the face but should not be confused with Melasma (Epocrates, 2024). Using sunscreen and avoiding sun exposure during pregnancy can minimize the appearance of Melasma during pregnancy (Epocrates, 2024) Melasma can resolve on its own after pregnancy or be treated with topical medications such as hydroquinone when a woman is no longer pregnant or breastfeeding (Epocrates, 2024). Sleep disturbance Maternal sleep disturbance is common due to increased levels of progesterone, frequent urination, and nausea and vomiting (LeBlanc, 2023). Sleep apnea contributes to daytime fatigue, and sleeplessness due to snoring and suboptimal oxygenation (Epocrates, 2024). Practicing good sleep hygiene, getting regular physical exercise, and adequate hydration and nutrition aids in optimal sleep patterns (Epocrates, 2024). Inadequate sleep correlates with increased rates of spontaneous abortion during the first 20 weeks of pregnancy. * hours of sleep is the recommendation (Epocrates, 2024). An 18-year-old female presents to your office complaining of two months of amenorrhea. Her pregnancy test is positive and her LMP indicates she is 5.6 weeks EGA. She reports she has had some bleeding for the past 3 days, that started as spotting, but has continued to be a light period-like bleeding today. She denies any pain. She indicates plans to continue the pregnancy. Chief Complaint: The patient is an 18-year-old female complaining of “bleeding that has occurred for three days after missing her period for two months.” The Onset of the bleeding began “3 days ago”. The Location of the bleeding is from the vagina. TheCharacter of bleeding is “light period-like bleeding without cramps or any pain”. Aggravating factors are “none”. Relieving factors are “none”. Timing is “consistent”. The Severity is “0/10 no pain.” OB/GYN History: (G0P0AL0) LMP 1/18/2024. The patient reports never having a previous PAP or HPV testing. The patient reports that she has only been with one male sexual partner for 6 months and neither of them has been tested for STIs, including HPV or HIV. The patient reports her periods are regular occurring every 30 days and typically last for 4-5 days with moderate to light bright red bleeding. Sexual History: The patient is heterosexual and identifies as a female. She has no previous history of STIs and has been monogamous with her only male partner for six months. The patient is unsure how many sexual partners her boyfriend has had in the past and would like to be tested for STIs today. The patient denies having any STI symptoms and reports using male condoms in the past, but “not consistently.” The patient denies any Intimate Partner Violence and is open to counseling on contraceptive options if this pregnancy is not successful. The patient states the last time she had unprotected intercourse was three days ago and that the bleeding began after sex. The patient declines information on medication abortions, or adoption at this time. PMH: No past medical history. PSH: No previous surgical history per patient. Immunization Status: The patient is up to date with all of her MMR, Hep B, Varicella, COVID-19, Influenza, and TDAP vaccinations with no history of any reactions to previous immunizations. The patient has not had any HPV vaccinations and would like to receive them when it is appropriate to administer. Medications: No medications. Allergies: NKDA Family History: Father committed suicide. Mother is alive without medical conditions. No family history of breast, uterine, cervical, or ovarian cancer. The patient denies any history or symptoms of depression and has no suicidal ideations. Social History: The patient denies tobacco, alcohol, or drug use. The patient did not plan to become pregnant but intends to keep this pregnancy if it is viable. The patient is a full-time college student who works part-time as a Barista. The patient lives at home with her mother and younger siblings and feels safe in her living environment with access to bus transportation to school and work. The patient has not talked about her pregnancy with her mother, siblings, or boyfriend, and would like support with communication and community resources, based on today’s findings. ROS General/Constitutional: The patient is “anxious” about the bleeding but denies any pain. The patient denies any history or symptoms of depression and has no suicidal ideations. Cardiovascular: The patient denies any shortness of breath, chest pain, or heart palpitations. Respiratory: The patient denies any cough, orthopnea, wheezing, or dyspnea on exertion. Gastrointestinal: The patient denies any abdominal pain, constipation, diarrhea, or blood in her stools. The patient reports normal bowel movements occurring regularly once a day. Reproductive/ Genitourinary: The patient complains of “light, period-like bleeding that began three days ago after unprotected intercourse, with “no pain.” “The patient denies frequency, burning, or urgency with urination. Breast/Lymphatics: The patient denies any changes in her breast tissue or swollen or painful lymph nodes. Integumentary: The patient denies having lesions or cold sores on any other locations of her body. OBJECTIVE PHYSICAL EXAM GENERAL/CONSTITUTIONAL: The patient presents as a well-groomed, well-developed 18-year-old female. The patient appears anxious and is alert and cooperative. VITAL SIGNS: BP: 116/80, HR: 79, RR: 18, O2 Saturation: 98%, Weight: 132 Height: 5’7” BMI: 20.7 (normal weight) Cardiovascular: Regular heart rate and rhythm. No bruits or thrills. No JVD and no edema. Respiratory: The lungs are bilaterally clear to auscultation. No audible wheezes or rales. Integumentary: Skin is warm, dry, and intact. Gastrointestinal: Bowel sounds are present in all 4 quadrants. No abdominal distention, guarding, or rebound tenderness was noted. Reproductive/Genitourinary: (+) Vaginal vault has scant bright red bleeding. No visible excoriation or lacerations were noted. Speculum exam: Cervical os is closed, small, round, and nulliparous. Cervical epithelium is smooth pink and non-friable. No mucopurulent or malodorous discharge was noted. Bright red blood is scant and present on the cervix and in the vaginal vault. Bimanual exam: Negative for adnexal or cervical motion tenderness. Left and Right ovaries are palpable. Rectal exam: Deferred by patient. Breast/ Lymphatic: Breasts are symmetrical with no nipple discharge, palpable lumps, or masses. Lymph nodes are non-palpable and non-tender. POCT: Perform a pelvic exam of genitalia with speculum to assess vaginal and cervical health. Test for chlamydia, gonorrhea, syphilis, Trichomonas, HCV, HCB, and HIV per CDC guidelines at patients’ request and due to pregnancy (CDC, 2024). Perform a quantitative beta HCG test today and again in 48 hours to assess for pregnancy viability. HCG levels should rise >35% in 48 hours and order CBC PT and PTTshould be assessed for coagulation disorders, and Rh(D) incompatibility. Perform transvaginal ultrasound to assess for intrauterine pregnancy with a gestational sac and EGA (Cash, 2024).
Assessment/Diagnosis:
N93.9 Abnormal uterine and vaginal bleeding, unspecified-Vaginal bleeding is considered to be common during the first trimester of pregnancy and occurs in 25% of pregnancies. Bleeding can range from mild spotting to massive hemorrhaging with or without pain. This patient reports no pain and had intercourse three days ago when the bleeding began (Cash, 2024).
DDX:
640.00 Threatened abortion- Occurs when there is vaginal bleeding before 20 weeks gestational age when a positive urine or blood pregnancy test has been performed and the cervical os is closed without evidence of the passage of tissue from the products of conception (Cash, 2024).
O0080 Other Ectopic pregnancy without uterine pregnancy that cannot be carried to full term because it occurs outside of the uterus, usually in the fallopian tubes, and may cause life-threatening bleeding without treatment. Symptoms include unilateral lower abdominal and shoulder pain (Cash, 2024). The patient reports no pain.
PLAN
DIAGNOSTIC LABS: Perform a Pelvic exam with a speculum to assess for the cause of abnormal uterine and vaginal bleeding and assess the appearance of cervical os and any pregnancy tissue. Perform Wet Mount to screen for BV, Candida, and cultures for chlamydia, gonorrhea, and trichomonas testing. Order RPR for Syphilis, HCV, and an HIV rapid blood test per patient request and CDC guidelines (CDC, 2024). Perform transvaginal ultrasound to assess for intrauterine pregnancy. Order beta HCG today and repeat in 48 hours to assess HGC levels for pregnancy viability. Order CBC and PT or PTT, blood type, and Rh antibody screen, and crossmatch to assess for any coagulation and antibody disorders (Cash, 2024).
PHARMACOLOGIC: Administer RhoGAM 50-300 mcg dose IM in the first trimester, if the patient is found to be Rh negative. Prescribe Acetaminophen 500 mg 1 tablet PO every 4-6 hours PRN for pain with a maximum of 10 tablets in one 24-hour period (90 tablets with 1 refill). Prescribe Prenatal vitamin with 400 mg. Folic acid 1 tablet PO once daily, Take with food (90 tablets with 4 refills)(Cash, 2024).
NON-PHARMACOLOGIC: Prescribe pelvic rest and expectant management if abortion is imminent. Provide anticipatory guidance on when the patient can expect her period to return and when she may try to conceive again in 4-6 weeks based on findings (Cash, 2024).
PATIENT EDUCATION: Call your health care provider and go to the ED if you saturate a large maxi-pad in one hour for two hours or experience worsening abdominal or shoulder pain. Repeat the HCG test for 4 days. The HCG levels help determine whether this pregnancy is viable or abnormal. Decreasing HCG levels indicate an abortion is imminent and you may need medication or aspiration interventions in the clinic. HCG levels that do not increase at the expected rate may indicate an abnormal ectopic or molar pregnancy that requires emergency termination and management. Adverse effects of RhoGAM include a hypersensitivity reaction, anaphylaxis, and viral transmission. CALL 911 if you experience any symptoms of anaphylaxis. Adverse effects of Acetaminophen include skin rashes, anemia, anaphylaxis, and hepatotoxicity. Report any adverse symptoms to your health care provider and call 911 or any symptoms of anaphylaxis. Folic acid supplementation of 400 mg per day is essential for a healthy pregnancy. Adverse effects of Prenatal vitamins are nausea and constipation. Discuss a healthy diet and physical exercise (USPSTF, 2024).
REFERRAL: Refer to OB/GYN for pregnancy management and/or ectopic/molar pregnancy surgery, if ectopic or molar pregnancy is suspected. Refer to counseling and social services as needed (Cash, 2024).
FOLLOW-UP: In two days discuss HCG levels. Follow up in one week to discuss STI results, and perform a transvaginal ultrasound to monitor for fetal development, confirm uterine pregnancy, and/or assist with medication or aspiration abortion if pregnancy is not viable (Cash, 2024). Discuss contraception options and when the patient may try to conceive if the pregnancy is not viable.
HEALTH MAINTENANCE: This patient should receive HPV vaccinations once this pregnancy is resolved (CDC, 2024). This patient is due for an eye exam and should repeat Pap in 3 years. Recommendations for a healthy diet and physical exercise were reviewed today along with STI prevention and contraceptive counseling. Depression and IPV screenings were also performed with negative results today (USPSTF, 2024).
2.Case scenario # 2
GA by weeks
Lab Testing and/or
Diagnostic Testing
Medication
Expectations
6-10 weeks
Screening for HIV, syphilis, hepatitis B, rubella, gonorrhea/chlamydia, pap smear, urinalysis, urine culture, thyroid function, A1c, blood pressure and urinalaysis every visit
For women <25 800-1200 mcg of folic acid For women >35 4000 mcg
Splitting S1
Bluish cervix
Increased vaginal discharge
Hemorroids
10-14 weeks
serum screening, cell free fetal DNA screening and ultrasound for nuchal translucency and nasal bones, chorionic villus sample, fundal height
For women <25 800-1200 mcg of folic acid For women >35 4000 mcg
Fetal heart sounds
15-20 weeks
Amniocentesis, Quad screening AFP (alpha-fetoprotein), hCG, estriol, and inhibin-A, fetal echocardiogram.
For women <25 800-1200 mcg of folic acid For women >35 4000 mcg
Fetal movement felt
Fetal heart tone 120-160 bpm
20- 24 weeks
Ultrasound anatomy scan
For women <25 800-1200 mcg of folic acid For women >35 4000 mcg
Extremity edema
24-28 weeks
Glucose tolerance test: non-fasting and fasting. CBC
Tdap vaccine, RhoGam to Rh negative, inactivated flu vaccine. For women <25 800-1200 mcg of folic acid For women >35 4000 mcg
Baby movement
Striae, varicose veins
28-32 weeks
CBC, HIV, TP-PA
Biophysical profile
For women <25 800-1200 mcg of folic acid For women >35 4000 mcg
Melasma (pregnancy mask)
34 weeks
Non-stress fetal heart test
For women <25 800-1200 mcg of folic acid For women >35 4000 mcg
Enlarged breasts, extremities edema, Braxton contraction
36 weeks
Uterus height measure
For women <25 800-1200 mcg of folic acid For women >35 4000 mcg
37 weeks
onwards
Group B stress
weekly amniotic fluid assessments and twice weekly nonstress testing
For women <25 800-1200 mcg of folic acid For women >35 4000 mcg
Fundal height 37 cm
Scenario
A normal on going pregnancy the expectation for the Hcg level is to double within the first 48 to 72 hours
During a spontaneous abortion (miscarriage), the expectation for the beta HCG level is to drop by 24% to 35% within 48-72 hour
During an ectopic pregnancy the expectation is to increase by less than 66% within 48-72 hours.
During a trophoblastic pregnancy the expectation for the beta HCG level is to increase between 50,000 and 10,0000 mIU/ml
During a molar pregnancy, the expectation for the beta
HCG level is to be greater than 100,000 IU/L within 48-72 hour
Subjective
CC: “I’m here for my routine pregnancy check-up. I’ve been also urinating more and with a burning sensation”
HPI: The patient is a 29 year-old 28 weeks pregnant woman who presents for her routine prenatal care and complaining of urination burning and frequency.
Medications: Are you currently taking any medication? “I’m not taking any medication.
Allergies: Do you have any allergies? “I don’t have any allergies.
LMP: When was your last period day? “About 30 weeks ago?.
Gyn/OB history:
How many times were you ever pregnant? “I was pregnant 3 times, including this one. I already have 2 children who were delivered by vaginal birth”.
Are you periods regular” “yes, they are”
How old were you when you first had your period? “I was 12”
Did you receive the HPV vaccine? “I had 3 doses”
Sexual History
How old were you at your first sexual encounter? “At age 16”
When did you have a pap smear for the last time? “About 2 years ago”
Have you ever been diagnosed with an STD? “Never”
How many partners have you had over the past year? “Only my husband”
PMH: Have you ever had surgery? “I haven’t”
Chronic Illness/ Major trauma: Have you ever had any medical problem? “No”
Family Hx:
Are your maternal grandparents still alive? “Maternal grandmother died of pancreas cancer. Maternal grandfather is treated for hypertension and Alzheimer’s disease”.
Are your paternal grandparents still alive? “Paternal grandmother is in remission for lymphoma. Paternal grandfather is treated for hypertension, type 2 diabetes, atrial fibrillation.”
Are your parents still alive? Father: treated for hyperlipidemia. Mother: healthy.
Are your siblings alive ? “1 older brother: denies any medical problems”.
Social Hx:
Who do you live with? I live with my husband and my 2 kids, 7 and 4 year-old.
What do you do for a living? “I’m a stay-at-home mum. Before my third pregnancy I worked as a clerk at the courthouse. I completed an associate degree in criminal justice.
What is your diet typically like? “I pay close attention to my diet for myself, my husband and my children.
Do you exercise? “I try to go on brisk walks every other day.”
Do you drink coffee? Alcohol? “I don’t”
Do you do street drugs? “I don’t”
ROS
Constitutional: Have you noticed night sweats, unintended weight loss, loss of appetite, chills, body aches? “None of those”
Vision : Do you have any vision problems? “My vision is fine”
HEENT: Do you have dizziness, ringing in the ears, vertigo? “None of the above”
Respiratory: Do you have breathing problems like cough, blood in cough, difficulty breathing? “No breathing problems”
Cardiovascular: Do you have chest pain, palpitation? “no”
GI: Do you have abdomen pain? Have you had nausea, vomiting? Have you noticed blood in the stools? Have you noticed a change in your stool habits? “No”
GU/Reproductive:
Have you noticed vaginal discharge? “I have been urinating more than usual, and when I go I feel mild burning and pressure in my pelvic area. I haven’t noticed any discharge nor blood”
Have you been experiencing pain during intercourse? “No”
Have you noticed flank pain? “No”
Integumentary: Have you noticed any non-healing wounds, or changing moles? “No”
stiffness.
Neurological: Have you noticed any changes in coordination or balance? “No”
Psychiatric: Are you feeling safe at home? “Yes” Have you been feeling sad? “No”
Endocrine: ave you you been feeling more thirsty or noticed any change in your hair or nails? “No”
Hematologic: Have you noticed painful or swollen lymph nodes? “no”
Immunologic: Are your vaccines up to date? “I had the Tdap 6 years ago. IHad 3 doses of COVID vaccine”.
What important lab results should you review prior to 28 weeks?
CBC, glucose-tolerance test, urinalysis, STI screening
Objective Data
General
The patient is a pleasant 29 year-old 28 weeks pregnant woman who presents for her routine prenatal care visit. She is fully developed, well nourished, able to convey her state in full, coherent sentences.
VS: BP: 127/68; Pulse: 79; Respiratory: 18; Temperature: 37.6ºC, Height: 167 cm; weight: 69kg; BMI
List body systems- provide findings
Cardiovascular
No pulsation noted on the precordium. S1-S2 auscultated. No bruits nor JVD noted. Capillaries refill under 3 seconds
Gastrointestinal
Gravid abdomen. Bowel sounds present in all 4 quadrants.
Respiratory
Unlabored breathing. Breaths sounds clear to auscultation on all lung fields
Integumentary
No skin lesions or rashes seen or noted upon skin assessment
GYN/GU
No signs of bladder distention noticed upon assessment. No pain elicited upon percussion of the intercoastal area.
Musculoskeletal
All joint ROM 5/5
Hematological
lymph nodes are not palpable
– (You can include answers here to questions posed in the prompt)
Include POCT (Point of Care testing) not labs that you will send to the laboratory
Urinalysis with a dipstick.
Assessment/ Diagnosis
Working diagnosis: Urinary tract infection in pregnancy (ICD10: O23. 40). UTI are frequent during pregnancy. Increased progesterone levels cause urinary tract dilation as well as smooth muscle relaxation which in turn facilitate bacteria colonization of the lower urinary tract infection. Performing urinalysis tests is recommended through pregnancy.
Pertinent positive: Urine dipstick positive for leukocytes, nitrates and blood. Frequency, burning sensation.
Pertinent negative: Fever, chills, at-risk sexual contact.
DDX
Pyelonephritis: (ICD10: N11. 1) it is a UTI complication when the infection progresses along the urinary tract towards the kidneys and may cause systemic serious complications.
Acute cystitis: (ICD10: N30.00)
Chlamydia: (ICD 10: A74.9)
Gonorrhea: (ICD 10: A54)
Plan
Diagnostic tests: Pelvic and kidney ultrasound.
Lab Tests: Microscopic urine culture with albumin, CBC, CMP 18, ESR, STD
Treatment: Drink plenty of fluids, make sure to include cranberry juice.
Medication: Nitrofurantoin 100 mg, twice daily orally for 7 days (ACOG, 2023)
Referrals: None
Education: Avoid strenuous activity. Urinate after sexual intercourse, wipe front to back after using the restroom, perform good hand hygiene, avoid wearing tight garments.
Health Maintenance
Follow up: A urine culture should be performed 1-2 weeks after treatment to check for infection clearance (Matuszkiewicz-Rowińska et al., 2015)
What will you prescribe for this patient? Why? Explain what medications and treatments you would recommend.
The patient should receive a course of 100 mg of macrobid twice daily by mouth for 7 days. Additionally she should receive a Tdap booster, the flu inactivated flu vaccine and the Rh test as according to ACOG guidelines (2023)
Explain treatment guidelines and side effects including any possible side effects of the medication and treatment(s), partner notification, and follow-up plan of care.
Uncomplicated UTI are treated with a course of oral antibiotics. It is safe to use nitrofurantoin (macrobid) 100mg for 7 days on pregnant women. Macrobid may cause urine discoloration and unusual smell. It also can cause diarrhea, nausea, abdominal pain and should be taken with food to mitigate GI upset. Other side-effects such as vaginal itching or feeling indisposed may also occur. The course of antibiotics should be taken entirely even if symptoms improve before (ACOG, 2023).
What patient education is important to include for this patient? What should the patient expect for the upcoming weeks?
The patient should abstain from sexual intercourse until the course of antibiotics is completed. Avoid strenuous activity. Urinate after sexual intercourse, wipe front to back after using the restroom, perform good hand hygiene, avoid wearing tight garments. The symptoms should improve within a few days. A urinalysis should be done in 1 to 2 weeks to evaluate for infection clearance (Cash, 2023).
Explain complications that can occur if patient does not comply with
treatment regimen.
UTI complications in pregnancy can include pyelonephritis, acute respiratory syndrome, preterm labor, low birth weight (ACOG, 2023).
When should the patient return?
The patient should return to the clinic in 1 to 2 weeks for a test of cure (ACOG, 2023). She should call or return earlier if symptoms persist or worsen.
