# Clinical Cases: Normal Pregnancy and Prenatal Care

## Case 1: First Prenatal Visit and Pregnancy Dating

### Patient Demographics
- **Age:** 28 years
- **Sex:** Female
- **Occupation:** Elementary school teacher

### Chief Complaint
"I think I'm pregnant. I missed my period two weeks ago and had a positive home pregnancy test."

### History of Present Illness
The patient reports her last menstrual period was 6 weeks ago. Her cycles are typically 28 days and regular. She has had mild nausea in the mornings but no vomiting. She denies vaginal bleeding or pelvic pain. This would be her first pregnancy. She takes a daily multivitamin but no prescription medications. She denies tobacco, alcohol, or drug use.

### Past Medical History
- No significant medical conditions
- No prior surgeries
- No known drug allergies

### Obstetric History
- G1P0 (first pregnancy)

### Physical Examination Findings
- **Vital Signs:** BP 118/72 mmHg, HR 76 bpm, BMI 24 kg/m2
- **General:** Well-appearing female in no distress
- **Thyroid:** Normal size, no nodules
- **Breast:** No masses, no discharge
- **Abdomen:** Soft, non-tender, non-distended
- **Pelvic:** Cervix appears bluish (Chadwick sign), uterus slightly enlarged, no adnexal masses

### Diagnostic Workup
- **Urine pregnancy test:** Positive
- **Serum beta-hCG:** 28,500 mIU/mL
- **Transvaginal Ultrasound:** Single intrauterine gestational sac with yolk sac and embryo with crown-rump length of 8 mm, consistent with 6 weeks 4 days gestation; fetal cardiac activity present at 120 bpm
- **Hemoglobin:** 12.8 g/dL
- **Blood Type:** A positive
- **Antibody Screen:** Negative
- **Rubella:** Immune
- **Hepatitis B Surface Antigen:** Negative
- **HIV:** Negative
- **RPR:** Non-reactive
- **Urinalysis:** Normal, culture negative

### Diagnosis
**Intrauterine Pregnancy at 6 weeks 4 days gestation** by crown-rump length measurement

**Estimated Date of Delivery:** Calculated using Naegele's rule and confirmed by first-trimester ultrasound

### Management Plan

**Initial Visit Counseling:**
1. Folic acid supplementation 400-800 mcg daily (already in prenatal vitamin)
2. Dietary counseling: avoid raw fish, unpasteurized dairy, deli meats, high-mercury fish
3. Avoid alcohol, tobacco, and recreational drugs
4. Continue prenatal vitamins
5. Return in 4 weeks for routine prenatal visit

**Prenatal Visit Schedule:**
1. Every 4 weeks until 28 weeks
2. Every 2 weeks from 28-36 weeks
3. Weekly from 36 weeks until delivery

**First Trimester Screening:**
- Offer nuchal translucency ultrasound at 11-14 weeks with PAPP-A and free beta-hCG
- Discuss cell-free DNA screening as an alternative

**Counseling Points:**
- First trimester fatigue and nausea are normal and typically improve by 12-14 weeks
- Fetal heart tones audible by Doppler at 10-12 weeks
- Anatomy ultrasound planned for 18-22 weeks
- Warning signs to report: heavy vaginal bleeding, severe abdominal pain, fever

### Clinical Image
![First Trimester Ultrasound](case_01_image.jpg)

**Image Description:** Transvaginal ultrasound image demonstrating a first-trimester embryo with crown-rump length measurement. The gestational sac is visible with the yolk sac adjacent to the embryo. This measurement provides the most accurate dating in early pregnancy.

**Attribution:** Image from Radiopaedia. Case courtesy of Dr. Mohammad Taghi Niknejad. Licensed under CC BY-NC-SA 3.0. Source: https://radiopaedia.org/cases/normal-first-trimester-pregnancy

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## Case 2: Hyperemesis Gravidarum in Early Pregnancy

### Patient Demographics
- **Age:** 32 years
- **Sex:** Female
- **Occupation:** Accountant

### Chief Complaint
"I can't stop vomiting and I feel extremely weak."

### History of Present Illness
The patient is at 9 weeks gestation and reports severe, persistent nausea and vomiting for the past 3 weeks that has progressively worsened. She is vomiting 8-10 times daily and unable to keep down food or liquids. She has lost 8 pounds (7% of pre-pregnancy weight). She feels dizzy when standing and has not urinated much in the past 24 hours. Ginger and vitamin B6 have not helped. She denies fever, diarrhea, or abdominal pain.

### Past Medical History
- Anxiety disorder treated with counseling (no medications)
- No prior surgeries

### Obstetric History
- G2P1001 (one prior uncomplicated term delivery)
- Mild nausea in first pregnancy that resolved by 12 weeks

### Physical Examination Findings
- **Vital Signs:** BP 95/60 mmHg, HR 105 bpm, Temperature 98.4F, BMI 22 kg/m2
- **General:** Ill-appearing, fatigued female, dry mucous membranes
- **Cardiovascular:** Tachycardic, regular rhythm
- **Abdomen:** Soft, mildly tender epigastrium, no distension
- **Skin:** Decreased turgor, dry lips

### Diagnostic Workup
- **Urinalysis:** Specific gravity 1.035, 3+ ketones, no protein, no blood
- **Serum Electrolytes:** Na 132 mEq/L (low), K 3.2 mEq/L (low), Cl 95 mEq/L (low)
- **BUN/Creatinine:** 22/1.0 mg/dL (elevated BUN indicating dehydration)
- **TSH:** 0.3 mIU/L (low, consistent with gestational hyperthyroidism)
- **Free T4:** 1.8 ng/dL (upper normal)
- **Liver Enzymes:** AST 48, ALT 52 (mildly elevated)
- **Transvaginal Ultrasound:** Single viable intrauterine pregnancy at 9 weeks, normal placenta, no molar pregnancy

### Diagnosis
**Hyperemesis Gravidarum** with:
- Dehydration (ketonuria, elevated BUN)
- Electrolyte abnormalities (hyponatremia, hypokalemia)
- Weight loss >5% pre-pregnancy weight
- Gestational hyperthyroidism (hCG-mediated, transient)

### Management Plan

**Immediate Treatment (Hospitalization):**
1. IV fluid resuscitation with lactated Ringer's solution
2. Electrolyte replacement (potassium supplementation)
3. Thiamine 100 mg IV daily (CRITICAL - prevents Wernicke encephalopathy)
4. NPO initially, then advance diet as tolerated

**Antiemetic Therapy:**
1. Ondansetron 4 mg IV every 8 hours
2. Metoclopramide 10 mg IV every 6 hours as needed
3. Promethazine 12.5-25 mg IV every 6 hours as needed

**Monitoring:**
1. Daily weights
2. Strict intake and output
3. Daily electrolytes until normalized
4. Urine ketones until cleared

**Discharge Criteria:**
- Tolerating oral intake
- Ketones cleared
- Electrolytes normalized
- Weight stable

**Counseling Points:**
- Hyperemesis typically improves by 14-16 weeks
- Fetal outcomes are generally good with appropriate treatment
- May require readmission if symptoms recur
- Home IV therapy may be considered for recurrent admissions

### Clinical Image
![Hyperemesis Gravidarum](case_02_image.jpg)

**Image Description:** Clinical photograph or illustration depicting the pathophysiology of hyperemesis gravidarum, showing the cascade from persistent vomiting to dehydration, ketonuria, and electrolyte abnormalities.

**Attribution:** Illustration adapted from medical education resources. Public domain.

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## Case 3: Advanced Maternal Age Counseling

### Patient Demographics
- **Age:** 38 years
- **Sex:** Female
- **Occupation:** Attorney

### Chief Complaint
"I'm 10 weeks pregnant and worried about my age affecting the baby."

### History of Present Illness
The patient presents for her first prenatal visit at 10 weeks gestation confirmed by LMP and early ultrasound. She conceived spontaneously after 4 months of trying. She is concerned about the risks associated with her age, particularly Down syndrome. She has mild fatigue but no significant pregnancy symptoms. Her sister has a child with a chromosomal abnormality.

### Past Medical History
- Well-controlled hypertension on labetalol 100 mg twice daily
- No diabetes
- No prior surgeries

### Obstetric History
- G2P1001 (one prior term vaginal delivery at age 32, healthy child)

### Physical Examination Findings
- **Vital Signs:** BP 128/78 mmHg, HR 72 bpm, BMI 27 kg/m2
- **General:** Well-appearing female
- **Cardiovascular:** Regular rate and rhythm
- **Abdomen:** Soft, gravid uterus palpable at symphysis
- **Pelvic:** Cervix closed, uterus 10-week size

### Diagnostic Discussion

**Age-Related Risks:**
- At age 38, the risk of trisomy 21 is approximately 1 in 175 (compared to 1 in 1,250 at age 25)
- Risk of any chromosomal abnormality is approximately 1 in 85
- Additional risks include gestational diabetes, preeclampsia, cesarean delivery, and stillbirth

**Screening Options Discussed:**
1. **Cell-free DNA (cfDNA) screening:** >99% detection rate for trisomy 21, low false positive rate; can be done now at 10 weeks
2. **First-trimester combined screening:** Nuchal translucency + serum markers at 11-14 weeks; ~85% detection rate
3. **Diagnostic testing:** Chorionic villus sampling (CVS) at 10-13 weeks or amniocentesis at 15-20 weeks provides definitive diagnosis

### Diagnosis
**Intrauterine Pregnancy at 10 weeks in woman of Advanced Maternal Age (AMA)**
- Chronic hypertension in pregnancy

### Management Plan

**Genetic Counseling:**
1. Patient elects cell-free DNA screening given high detection rate
2. Will consider CVS if cfDNA is positive or inconclusive
3. Detailed anatomy ultrasound at 18-22 weeks regardless of screening results

**Hypertension Management:**
1. Continue labetalol (safe in pregnancy)
2. Monitor blood pressure at each visit
3. 24-hour urine protein at baseline
4. Early screening for preeclampsia development

**AMA-Specific Surveillance:**
1. Earlier glucose screening consideration (given AMA and obesity)
2. Serial growth ultrasounds in third trimester
3. Antenatal testing starting at 36-37 weeks
4. Discussion of delivery timing (typically by 39-40 weeks)

**Counseling Points:**
- cfDNA is a screening test, not diagnostic - positive results require confirmation
- Most women with advanced maternal age have healthy pregnancies
- Close monitoring will help identify and manage any complications early
- Low-dose aspirin 81 mg daily starting at 12 weeks for preeclampsia prevention (multiple risk factors)

### Prognosis
With appropriate prenatal care and surveillance, the likelihood of a healthy pregnancy outcome remains high. The patient's chronic hypertension will require close monitoring for superimposed preeclampsia.