A 24-year-old P1001 presents at 8 weeks’ gestation and reports a history of pulmonary embolism 3 years ago during her first pregnancy. She was treated with intravenous heparin followed by several months of oral warfarin (coumadin) and has had no further evidence of thromboembolic disease.
How should her current pregnancy be managed?
Pregnancy is considered a hypercoaguable state. Patients with a history of thromboembolic disease in pregnancy are at high risk of developing it in subsequent pregnancies, and therefore should be anticoagulated. Baby aspirin is not considered adequate treatment. Pregnant patients with a history of venous thromboembolism should be treated with either low-dose unfractionated heparin therapy or low molecular weight heparin therapy during the pregnancy and through the postpartum period, as this is the time of highest risk of clot formation. Doppler ultrasonography is the most common way to diagnose a deep vein thrombosis, but is not considered a screening test, and should not be ordered each trimester in the absence of clinical symptoms or signs.
A 29-year-old G3P2 black woman in the 33 week of gestation is admitted to the emergency room because of acute abdominal pain that has been increasing during the past 24 hours. The pain is severe and is radiating from the epigastrium to the back. The patient has vomited a few times and has not eaten or had a bowel movement since the pain started. On examination, you observe an acutely ill patient lying on the bed with her knees drawn up. Her blood pressure is 100/70 mm Hg, her pulse is 110 beats per minute, and her temperature is 38.8°C (101.8°F). On palpation, the abdomen is somewhat distended and tender, mainly in the epigastric area, and the uterine fundus reaches 31 cm above the symphysis. Hypotonic bowel sounds are noted. Fetal monitoring reveals a normal pattern of fetal heart rate (FHR) without uterine contractions. On ultrasonography, the fetus is in vertex presentation and appropriate in size for gestational age; fetal breathing and trunk movements are noted, and the volume of amniotic fluid is normal. The placenta is located on the anterior uterine wall and no previa is seen. Laboratory values show mild leukocytosis (12,000 cells per mL); a hematocrit of 43%; mildly elevated serum glutamicoxaloacetic transaminase (SGOT), serum glutamic-pyruvic transaminase (SGPT), and bilirubin; and serum amylase of 180 U/dL. Urinalysis is normal.
Which of the following is the most likely diagnosis?
The most probable diagnosis in this case is acute pancreatitis. The pain caused by a myoma in degeneration is more localized to the uterine wall. Low-grade fever and mild leukocytosis may appear with a degenerating myoma, but liver function tests are usually normal. The other obstetrical causes of epigastric pain, such as preeclampsia may exhibit disturbed liver function (sometimes associated with the hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome), but this patient has only mild elevation of blood pressure and no proteinuria. Acute appendicitis in pregnancy is one of the more common nonobstetric causes of abdominal pain. Symptoms of acute appendicitis in pregnancy are similar to those in nonpregnant patients, but the pain is more vague and poorly localized and the point of maximal tenderness moves to the right upper quadrant with advancing gestation. Liver function tests are normal with acute appendicitis. Acute cholecystitis may cause fever, leukocytosis, and pain of the right upper quadrant with abnormal liver function tests, but amylase levels would be elevated only mildly, if at all, and pain would be less severe than described in this patient. The diagnosis that fits the clinical description and the laboratory findings is acute pancreatitis. This disorder may be more common during pregnancy, with an incidence of 1 in 100 to 1 in 10,000 pregnancies. Cholelithiasis, chronic alcoholism, infection, abdominal trauma, some medications, and pregnancy-induced hypertension are known predisposing factors.
Leukocytosis, hemoconcentration, and abnormal liver function tests are common laboratory findings in acute pancreatitis. However, the most important laboratory finding is an elevation of serum amylase levels, which appears 12 to 24 hours after onset of clinical disease. Values may exceed 200 U/dL (normal values are 50 U/dL to 160 U/dL). Treatment considerations for the pregnant patient with acute pancreatitis are similar to those in nonpregnant patients. Intravenous hydration, nasogastric suction, enteric rest, and correction of electrolyte imbalance and of hyperglycemia are the mainstays of therapy.
An 18-year-old G1 is diagnosed with asymptomatic bacteriuria (ASB) at her first prenatal visit at 15 weeks’ gestation, based on a urine culture performed as part of her routine new OB laboratory findings.
What is the next step in management?
The term ASB is used to indicate persistent, actively multiplying bacteria within the urinary tract without symptoms of a urinary infection. The reported prevalence during pregnancy varies from 2% to 7%. The highest incidence has been reported in black multiparas with sickle cell trait and the lowest incidence among white women of low parity. In women who demonstrate ASB, the bacteriuria is typically present at the time of the first prenatal visit; after an initial negative culture of the urine, fewer than 1% develop a urinary infection. If ASB is not treated during pregnancy, approximately 25% of infected women develop an acute infection. Untreated ASB has been associated with an increase in complications such as low birth weight, preterm birth, and pyelonephritis.
A 20-year-old G1 at 18 weeks of gestation is hospitalized for intravenous antibiotics for the treatment of acute pyelonephritis. She develops shortness of breath and is found to have tachypnea and decreased oxygen saturation. Chest x-ray reveals pulmonary infiltrates consistent with pulmonary edema.
What is the most likely cause of this complication?
Endotoxin release can cause alveolar injury and lead to pulmonary edema and acute respiratory distress. Endotoxin release can also cause renal dysfunction manifested as increase serum creatinine, but this effect is usually reversible with fluid resuscitation. Uterine contractions and hemolytic anemia are also effects of endotoxin release. Bacteremia can be found in up to 20% of women with pyelonephritis, but it is the endotoxin release that leads to alveolar damage. While allergic reactions to antibiotics can cause respiratory symptoms, they do so by causing bronchoconstriction. Intravenous hydration to ensure adequate urinary output (> 50 mL/h) is the mainstay of therapy. Careful monitoring of the input and output of the patient is necessary so that fluid overload will not compound the pulmonary effects of the endotoxin.
A 30-year-old G1 at 6 weeks’ gestation by last menstrual period presents for prenatal care. Her past medical history is significant for type 1 diabetes, which was diagnosed at the age of 14.
What should you tell her about her insulin requirements during pregnancy?
Pregnancy is characterized by both increased insulin resistance and decreased sensitivity to insulin. The increased insulin resistance is largely due to placental hormones such as human placental lactogen, progesterone, and cortisol. The management of type 1 diabetes in pregnancy focuses on glucose control, maximizing diet, engaging in exercise, and insulin therapy. Insulin requirements will increase during pregnancy, most markedly during the period between 28 and 32 weeks’ gestation.
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