# Clinical Cases: Prenatal Care and Pregnancy Complications

## Case 1: Preeclampsia with Severe Features

### Clinical Image
![Preeclampsia](case_01_image.jpg)
*Source: [Wikipedia - Preeclampsia](https://en.wikipedia.org/wiki/Pre-eclampsia) - CC BY-SA 4.0*

### Case Presentation
A 32-year-old G1P0 at 34 weeks gestation presents to labor and delivery with a severe headache, visual changes ("seeing spots"), and right upper quadrant pain for the past 6 hours. Her pregnancy has been uncomplicated until now. Blood pressure is 168/108 mmHg (confirmed on repeat after 15 minutes). Physical examination reveals 3+ pitting edema of the lower extremities, brisk deep tendon reflexes (3+), and right upper quadrant tenderness without peritoneal signs. Fetal heart rate tracing shows a baseline of 145 bpm with moderate variability and no decelerations. Laboratory studies reveal: platelet count 89,000/uL (low), AST 245 U/L (elevated), ALT 198 U/L (elevated), creatinine 1.2 mg/dL (elevated from baseline 0.6), LDH 580 U/L (elevated), and urine protein/creatinine ratio 1.2 (significant proteinuria). Peripheral smear shows schistocytes. The diagnosis is preeclampsia with severe features and HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets). Magnesium sulfate is initiated for seizure prophylaxis (4g IV loading dose, then 2g/hour). IV labetalol is given for blood pressure control. Betamethasone is administered for fetal lung maturity. After 24 hours of maternal stabilization and completion of a steroid course, she undergoes cesarean delivery due to an unfavorable cervix. A healthy 2.1 kg infant is delivered. The mother's blood pressure and laboratory values normalize over the following week.

### Key Learning Points
- Preeclampsia is defined as hypertension (>140/90) after 20 weeks gestation with proteinuria or end-organ dysfunction; severe features include BP >160/110, thrombocytopenia, renal insufficiency, liver involvement, or neurologic symptoms
- HELLP syndrome is a severe variant characterized by hemolysis (schistocytes, elevated LDH, low haptoglobin), elevated liver enzymes, and low platelets
- Magnesium sulfate prevents seizures (eclampsia); delivery is the only definitive treatment for preeclampsia
- At gestational ages <34 weeks, corticosteroids for fetal lung maturity should be given before delivery when maternal and fetal status allow a 24-48 hour delay

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## Case 2: Gestational Diabetes Mellitus

### Clinical Image
![Gestational Diabetes](case_02_image.jpg)
*Source: [Wikipedia - Gestational diabetes](https://en.wikipedia.org/wiki/Gestational_diabetes) - CC BY-SA 3.0*

### Case Presentation
A 33-year-old G2P1 at 26 weeks gestation presents for routine prenatal care. Her first pregnancy 3 years ago was complicated by gestational diabetes controlled with diet. Her pre-pregnancy BMI is 31 and she has a family history of type 2 diabetes in her mother. Given her history, she underwent early glucose screening at her first prenatal visit, which was normal. At 24 weeks, she completed a 50-gram glucose challenge test with a 1-hour glucose of 162 mg/dL (elevated). She then completed a 100-gram oral glucose tolerance test with results: fasting 98 mg/dL, 1-hour 192 mg/dL, 2-hour 168 mg/dL, 3-hour 145 mg/dL. With three abnormal values (fasting >95, 1-hour >180, 2-hour >155, 3-hour >140), the diagnosis of gestational diabetes mellitus is confirmed. She is referred to a diabetes educator and registered dietitian for medical nutrition therapy and glucose self-monitoring instruction. Her target glucose values are fasting <95 mg/dL and 1-hour postprandial <140 mg/dL. After 2 weeks of dietary management, her fasting values remain elevated at 105-115 mg/dL despite compliance. Bedtime NPH insulin is initiated. Her postprandial values are well-controlled with diet alone. Growth ultrasounds are performed, showing appropriate fetal growth. She undergoes successful induction of labor at 39 weeks and delivers a healthy 3.6 kg infant. Postpartum glucose tolerance testing at 6-12 weeks is planned to screen for persistent diabetes.

### Key Learning Points
- Gestational diabetes reflects inadequate insulin secretion to overcome the insulin resistance of pregnancy; screening is universal at 24-28 weeks, with earlier screening for high-risk women
- The two-step approach uses a 50g glucose challenge test followed by a 100g OGTT if screening is abnormal; GDM is diagnosed with 2 or more elevated values
- Medical nutrition therapy is first-line; insulin is added when diet fails to achieve targets (fasting <95, 1-hour postprandial <140, 2-hour postprandial <120 mg/dL)
- Complications include fetal macrosomia, birth injury (shoulder dystocia), neonatal hypoglycemia, and substantially increased risk of maternal type 2 diabetes postpartum

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## Case 3: Placenta Previa

### Clinical Image
![Placenta Previa](case_03_image.jpg)
*Source: [Wikipedia - Placenta praevia](https://en.wikipedia.org/wiki/Placenta_praevia) - CC BY-SA 3.0*

### Case Presentation
A 35-year-old G4P2 at 32 weeks gestation with a history of two prior cesarean deliveries presents to the emergency department with sudden onset of painless, bright red vaginal bleeding. She reports soaking two pads over 30 minutes. She denies contractions, abdominal pain, or trauma. Fetal movement has been normal. A routine 20-week anatomy ultrasound had noted a low-lying placenta, with follow-up recommended. Vital signs show heart rate 92 bpm and blood pressure 118/72 mmHg. Physical examination reveals a soft, non-tender uterus. Digital cervical examination is NOT performed. Continuous fetal monitoring shows a reassuring fetal heart rate pattern. Speculum examination shows blood in the vaginal vault with no cervical lesions. Transvaginal ultrasound confirms complete placenta previa, with the placenta entirely covering the internal cervical os. No retroplacental clot is seen. Laboratory studies show hemoglobin 10.2 g/dL. She is admitted for observation, pelvic rest, and betamethasone administration for fetal lung maturity. The bleeding stops spontaneously. She is counseled about the need for cesarean delivery (vaginal delivery is contraindicated with placenta previa) and the increased risk of placenta accreta given her prior cesarean deliveries. MRI is performed, which shows no evidence of placenta accreta. She remains hospitalized until delivery by planned cesarean at 36 weeks following repeat corticosteroids.

### Key Learning Points
- Placenta previa presents with painless, bright red vaginal bleeding in the second or third trimester; digital cervical examination is absolutely contraindicated as it may precipitate hemorrhage
- Risk factors include prior cesarean delivery, prior uterine surgery, multiparity, and advanced maternal age
- Transvaginal ultrasound accurately diagnoses placenta previa and is safe when performed carefully
- Women with placenta previa and prior cesarean delivery are at increased risk for placenta accreta spectrum disorders; delivery must be by cesarean section