Prenatal Care Challenges

Case 1: Unexpected Bleeding During the Second Trimester

Mrs. D, a 29 year old G1, P0 at 25 weeks gestation reports bright red spotting that was discovered following her first morning voiding.  There was “blood in the toilet” and “blood on the toilet paper when I wiped”.

HISTORY OF PRESENT ILLNESS
Uncomplicated pregnancy, normal prenatal care. Good fetal movement consistently.  No evidence of rupture of membranes, uterine contractions.

EXAMINATION
On physical exam, Mrs. D's vital signs were: BP 120/70mm Hg, pulse 88bpm. She is 5'7” tall and weighs 160lbs. 

Fundal height: 24cm
FHT: 150 sets
U/A dipstick: Positive for blood, no leukocytes

A speculum exam found white vaginal discharge, no evidence of blood in vault or from cervix. Cervix is long, thick and closed.

ASSESSMENT & TREATMENT PLAN
Mrs. D's bleeding may be caused by an urinary tract infection or the presence of urinary calculi. A culture and sensitivity of the urine is ordered. She is prescribed Macrodantin (nitrofurantoin macrocrystals) 100mg twice daily for 7 days pending the culture results. Mrs. D also receives counseling and patient education regarding cystitis and renal stones.