preview

Sample Case Study Of Maria's Scan

Satisfactory Essays

Maria is a 35yo, G3 P2002, who is reportedly 13 weeks 5 days by LMP but appeared much larger on physical exam. She is here today for dating and anatomy. She has a history of chronic HTN and was on HCTZ but stopped about 2-3 months prior to pregnancy. She is obese with a BMI of 38. She has 2 prior full-term deliveries without complications.

On ultrasound there is a live fetus whose biometry is consistent with 20 weeks 5 days. A detailed anatomic survey was unremarkable but spine and RVOT were suboptimal. The placenta is posterior. Abdominal cervical length is reassuring.

Maria’s scan was overall reassuring. We spent today discussing several issues:

1. We discussed dating. I dated her based on today’s scan but we will follow-up in 3 weeks to confirm dates.
2. …show more content…

We also discussed anatomy. We will need to complete spine and heart views at that follow-up scan.
3. We also discussed her chronic HTN and the fact that with normal BP’s often in pregnancy we do not require treatment; however, if her BP’s were to elevate we may need to restart medication at some point.
4. It was too late start a baby aspirin for the prevention of preeclampsia but we will go ahead and follow growth scans and consider antenatal testing if needed.
5. Finally, in regard to AMA, we did a quad screen since anatomy was within normal limits and there was no aneuploidy.

We will also continue to follow growth for multiple reasons. She is scheduled to return in 4 weeks.

Thank you for referring this patient to our office. Please do not hesitate to call us if you have any questions.

THIS REPORT HAS BEEN DICTATED BUT NOT EDITED
Lynlee Wolfe, M.D.
Maternal-Fetal

Get Access