Hyperemesis Gravidarum and OB Emergencies Less than 26 Weeks’ Gestation Case File

Hyperemesis Gravidarum and OB Emergencies Less than 26 Weeks’ Gestation Case File

Eugene C. Toy, MD, Barry C. Simon, MD, Terrence H. Liu, MD, MHP, Katrin Y. Takenaka, MD, Adam J. Rosh, MD, MS

Case 27

A 25-year-old G1P0 woman at 11 weeks’ gestation is noted to be lethargic by her husband. The patient was noted to have numerous episodes of nausea and vomiting over the past 1 1/2 months, which has persisted despite antiemetic therapy and adjustments in her diet. The patient had been admitted to the hospital 2 weeks ago due to emesis. She was brought in by EMS when her husband arrived after work to find her unarousable. On examination, the patient is lethargic but will respond to painful stimuli and open her eyes. Her blood pressure is 92/44 mm Hg and heart rate 130 beats per minute. Her respiratory rate is 14 breaths per minute. O2 saturation is 99% on room air. The patient’s mucous membranes are dry. She otherwise has a normal examination. The fetal heart tones are 150 beats per minute. The urinalysis shows a dipstick of specific gravity 1.027 and 3+ ketones.

⯈ What is the most likely diagnosis?

⯈ What is your next step in management?

⯈ What is the differential diagnosis?

ANSWER TO CASE 27:

Hyperemesis Gravidarum and OB Emergencies Less than 26 Weeks’ Gestation

Summary: A 25-year-old G1P0 woman at 11 weeks’ gestation has a 6-week history of persistent emesis. She is found to be lethargic and noted to be hypovolemic with blood pressure of 92/44 mm Hg and heart rate of 130 beats per minute. Her respiratory rate is 14 breaths per minute. The fetal heart tones are 150 beats per minute. The urinalysis shows a dipstick of specific gravity 1.027 and 3+ ketones.

• Most likely diagnosis: Hyperemsis gravidarum, severe
• Next step in management: Immediate isotonic fluid replacement, and also assess for electrolyte abnormalities and correction of these problems
• Differential diagnosis: Acute pancreatitis, molar pregnancy or twin pregnancy, peptic ulcer disease, hyperthyroidism, and cholelithiasis

ANALYSIS

Objectives

1. Know the common complications in pregnant women less than 26 weeks’ gestation.
2. Understand the diagnostic strategy and management of those complications.
3. Know the physiologic changes in pregnancy and their impact on common diseases in pregnancy.

Considerations

This patient described in the scenario above is significantly ill and needs aggressive fluid replacement, electrolyte replacement, and correction of metabolic abnormalities. Replacement with 2 L of normal saline quickly is warranted. Assessment of comprehensive metabolic panel, electrolytes, amylase, lipase, urinalysis for leukocytes, calcium, magnesium, and CBC with differential should be performed. She has complicated hyperemesis gravidarum, and needs a diagnostic workup such as pelvic ultrasound if not previously performed, right upper quadrant ultrasound, and thyroid function tests. The patient should be admitted to the hospital. Antiemetic therapy, and fluid replacement and nothing by mouth should be initiated. The patient should be followed carefully once discharged to ensure that she doesn’t become so volume depleted.

Approach To:

Medical Complications in Pregnancies Before 26 Weeks

INTRODUCTION

There are numerous emergencies or urgencies that bring a pregnant woman into the emergency department. For this chapter, the discussion will be focused on: hyperemesis gravidarum, spontaneous abortion, asthma exacerbation, hyperthyroidism/ thyroid storm, preterm premature rupture of membranes, and pyelonephritis.

Hyperemesis Gravidarum

Nausea and vomiting in pregnancy is very common, affecting up to 75% of pregnant women. However, hyperemesis gravidarum, which is defined as intractable emesis with volume depletion and metabolic/electrolyte alterations is less common, with prevalence of about 2% of pregnancies. Typically it occurs in women in the first trimester, and is diagnosis of exclusion. The emergency physician should not be lulled into complacency because nausea and vomiting is so common in pregnant women. The evaluation should include addressing the degree of volume depletion and exploring the possibility of metabolic issues such as electrolyte abnormalities, renal or liver function abnormalities, and the possibility of other etiologies. A urinalysis should also be performed. Hyperemesis gravidarum is a diagnosis of exclusion.

Pregnant women are typically young and healthy, and significant hypovolemia with compensation without appearing ill. A careful history should be taken regarding the amount of oral intake, medications taken if any, and the presence of other possible causes of emesis. The differential diagnosis includes pancreatitis, gall stones, peptic ulcer disease, appendicitis, ovarian torsion, pyelonephritis, and gastroenteritis. Additionally, high hCG level as associated with molar pregnancies or multiple gestation is seen with hyperemesis. Thus an ultrasound should be performed to assess for adnexal masses and to define the type of pregnancy.

Treatment depends on the severity of the patient’s condition. Patients with mild volume depletion can be given IV hydration or a trial of oral fluids, and prescribed antiemetic medications. Pyridoxine (vitamin B6) has efficacy as a first-line agent. Ondansetron (Zofran), while pregnancy Class B, has become the most common parenteral and oral antiemetic used in US emergency departments due to its efficacy, and it has become the first choice in hyperemesis in the last several years. As an adjunctive agent, corticosteroids have also been used. For patients who have failed outpatient therapy, or who have moderate to severe volume depletion should be hospitalized for more intensive therapy and monitoring. Rarely, patients will be so severely affected that total parenteral nutrition is required.

Spontaneous Abortion

Patients who present with vaginal bleeding during pregnancy are said to have a threatened abortion. In this circumstance, approximately 10% of cases will involve ectopic pregnancy (see Case 26), 40% will result in a spontaneous abortion, and 50% will result in a normal pregnancy carried to term. When the patient presents to the emergency department, a careful history and physical examination should be

performed including assessing for cramping, passage of tissue, risk factors for ectopic pregnancy, and hemodynamic alterations. The physical examination should be focused on assessing volume status, abdominal tenderness, pelvic examination for the state of the cervix, and the presence of adnexal masses or tenderness. The hCG level and transvaginal ultrasound usually help to determine the type of pregnancy. For instance, if the hCG level is above the threshold of 1500 mIU/mL and nothing is seen in the uterus indicating an intrauterine pregnancy, in the absence of history indicative of tissue passing, this is consistent with an ectopic pregnancy. Women with threatened abortion should be instructed to bring in any passed tissue for histologic analysis.

An inevitable abortion must be differentiated from an incompetent cervix. With an inevitable abortion, the uterine contractions (cramping) lead to the cervical dilation. With an incompetent cervix, the cervix opens spontaneously without uterine contractions and, therefore, affected women present with painless cervical dilation. This disorder is treated with a surgical ligature at the level of the internal cervical os (cerclage). Hence, one of the main features used to distinguish between an incompetent cervix and an inevitable abortion is the presence or absence of uterine contractions.

The treatment of an incomplete abortion, characterized by the passage of tissue and an open cervical os, is dilatation and curettage of the uterus. The primary complications of persistently retained tissue are bleeding and infection. A completed abortion is suspected by the history of having passed tissue and experiencing cramping abdominal pain, now resolved. The cervix is closed. Serum hCG levels are still followed to confirm that no further chorionic villi are contained in the uterus.

Asthma Exacerbation

Asthma is one of the most common medical conditions complicating pregnancy, with an incidence of 4% to 9%. The clinical course of asthma in pregnancy is relatively unpredictable; however, there is evidence to suggest that worsening of asthma may be related to baseline asthma severity. Approximately one-third of pregnant asthmatics experience worsening of symptoms while one-third improve and onethird remain the same. Exacerbations are more common in the second and third trimester and are less frequent in the last 4 weeks of pregnancy. Asthma typically follows a similar clinical course with successive pregnancies. As such, this patient would be expected to do relatively well given that her symptoms were well controlled prior to this pregnancy and in previous pregnancies.

Asthma symptoms correlate poorly with objective measures of pulmonary function. Therefore, the next step in the evaluation of this patient is to perform an objective measure of airway obstruction. The single best measure is the forced expiratory volume (FEV1), which is the volume of gas exhaled in 1 second by a forced exhalation after a full inspiration. This value, however, can only be obtained by spirometry, thus limiting its clinical use. The peak expiratory flow rate (PEFR) correlates well with FEV1 and can be measured with inexpensive, disposable portable peak flow meters. Both the FEV1 and PEFR remain unchanged throughout pregnancy and may be used as measures of asthma control and severity.

Treatment of an acute exacerbation during pregnancy is similar to that of nonpregnant asthmatics. In other words, a rule of thumb is that pregnant women should be treated similarly to nonpregnant asthmatics. Patients should be taught how to recognize the signs and symptoms of early exacerbations so that they may begin treatment at home promptly. Initial treatment consists of a short-acting inhaled beta-2-agonist (albuterol), up to three treatments of 2 to 4 puffs by MDI (metereddose inhaler) at 20 minute intervals for up to three treatments, or single nebulizer treatment for up to 1 hour. A good response is characterized by PEFR greater than 80% of personal best and resolution of symptoms sustained for 4 hours. Patients may be continued on beta-2-agonists every 3 to 4 hours for 24 to 48 hours. Inhaled corticosteroids (ICS) should be initiated or if already taking ICS, the dose should be doubled. Follow-up appointment with their physician should be made as soon as possible. Inadequate response to initial therapy (PEFR <80%) or decreased fetal activity warrants immediate medical attention.

Prevention of hypoxia is the ultimate goal for the pregnant woman who presents to the hospital during an acute asthma attack. Initial assessment should include a brief history and physical examination to assess the severity of asthma and possible trigger factors such as a respiratory infection. Patients with imminent respiratory arrest include those who are drowsy or confused, have paradoxical thoracoabdominal movement, bradycardia, pulsus paradoxus, and decreased air movement (no wheezing). Intubation and mechanical ventilation with 100% oxygen should be performed in these circumstances and the patient should be admitted to the intensive care unit. Because of the changes in the respiratory physiology in pregnancy (ie, a respiratory alkylosis with partially metabolic compensation), different thresholds for action exist (Table 27–1). A PaCO2 greater than 35 mm Hg, with a pH less than 7.35 in the presence of a falling PaO2 is a sign of impending respiratory failure in a pregnant asthmatic. Intubation is warranted when the PaCO2 is 45 mm Hg or more and rising.

Premature Rupture of Membranes

Premature rupture of membranes (PROM) is defined as the ROM prior to the onset of labor. Preterm PROM (PPROM) is the ROM that occurs prior to 37 completed weeks. Approximately 3% of all pregnancies are complicated by PPROM and is the underlying etiology of one-third of preterm births. Normal fetal membranes are biologically very strong in preterm pregnancies. The weakening mechanism is likely multifactorial. Studies have shown PPROM to be associated with intrinsic (intrauterine stretch/ strain from polyhydramnios and multifetal pregnancies, cervical incompetence) and

extrinsic factors (ascending bacterial infections). There is evidence demonstrating an association between ascending infection from the lower genital tract and PPROM. This section will be restricted to gestational age less than 26 weeks.

PPROM is associated with significant maternal and fetal morbidity and mortality. The time from rupture of membranes to delivery is known as “latency.” The latency period is inversely proportional to the gestational age at PPROM. Latency period of 1 week or less is present in 50% to 60% of PPROM patients. During this period amnionitis occurs in 13% to 60%, and abruptio placentae occurs in 4% to 12%. Maternal and fetal complications decrease with increasing gestational age at the time of PPROM. Multiple complications have been associated with PPROM.

The primary maternal morbidity is chorioamnionitis. Incidence varies with population and gestational age at PPROM, with reported frequency from 15% to 40%. Chorioamnionitis typically precedes fetal infection but this is not always the case, and therefore close clinical monitoring is required. Fetal morbidity and mortality varies with gestational age and complications, particularly infection. The most common complication is respiratory distress syndrome (RDS). Other serious fetal complications include necrotizing enterocolitis, intraventricular hemorrhage, and sepsis. The three causes of neonatal death associated with PPROM are prematurity, sepsis, and pulmonary hypoplasia. Preterm infants born with sepsis have a mortality rate four times higher than those without sepsis.

Management of PPROM starts with initial evaluation and diagnosis of rupture of membranes. The primary patient complaint is experiencing a “gush” of fluid but some patients will report persistent leakage of fluid. This patient history of rupture of membranes is accurate in 90% of cases. Diagnosis is established on sterile speculum evaluation. Confirmatory findings include pooling of amniotic fluid in posterior fornix and/or leakage of fluid on Valsalva; positive nitrazine test of fluid (vaginal pH 4.5-6.0, amniotic fluid pH 7.1-7.3, nitrazine turns dark blue above 6.0-6.5); amniotic fluid ferning on microscopy. Should the initial tests be ambiguous or negative, in the face of continued clinical suspicion other diagnostic modalities can be utilized. The ultrasound finding of oligohydramnios is usually confirmatory.

At the time of the initial evaluation, the patient’s cervical os should be visually assessed for dilatation and possible prolapse of umbilical cord or fetal limb. In general, a digital examination of the cervix should be avoided since bacterial may be theoretically inoculated with an examination. Ultrasound evaluation of the gestational age, fetal weight, fetal presentation, placental location, and assessment of amniotic fluid index (AFI) are vital for treatment planning. A low AFI (<5.0 cm) and low maximum vertical fluid pocket (<2.0 cm) at the time of initial assessment is associated with shorter latency, increased RDS, and increased composite morbidity.

Management

Patients diagnosed with PPROM would benefit from an admission to the hospital in all likelihood until delivery. Once PPROM is verified, the treatment plan must balance the maternal, fetal, neonatal risks/benefits of prolonged pregnancy or expeditious delivery and possible inclusion of medical intervention. For those gestations that are previable, observation in the hospital or careful follow-up with an obstetrician is advisable.

In the absence of clinical signs of labor, abruption, or maternal or fetal signs of infection most patients in this gestational age will benefit from an expectant management with daily assessment of the maternal and fetal well-being.

Maternal and fetal assessment

1. Maternal: The criteria for the diagnosis of clinical chorioamnionitis include maternal pyrexia, tachycardia, leukocytosis, uterine tenderness, malodorous vaginal discharge, and fetal tachycardia. During inpatient observation, the woman should be regularly examined for such signs of intrauterine infection and an abnormal parameter or a combination of them may indicate intrauterine infection. The frequency of maternal and fetal assessments (temperature, pulse, and fetal heart rate auscultation) should be between 4 and 8 hours.
2. Fetal: Electronic fetal heart rate tracing is useful when the gestation is considered viable, because fetal tachycardia may represent a sign of fetal infection and is frequently used in the clinical definition of chorioamnionitis in some studies. Fetal tachycardia is often the earliest sign of infection. However, checking intermittent fetal heart activity for previable gestation is preferable.

Use of steroids: A meta-analysis of 15 randomized controlled trials involving more than 1400 women with preterm rupture of the membranes demonstrated that antenatal corticosteroids reduced the risks of respiratory distress syndrome. This is generally administered at 24 weeks or beyond in the absence of clinical infection.

Use of antibiotics: The use of antibiotics following PPROM was associated with a statistically significant reduction in chorioamnionitis. There was a significant reduction in the numbers of babies born within 48 hours and 7 days. Neonatal infection was significantly reduced in the babies whose mothers received antibiotics.

PPROM under 23 weeks: There are insufficient data to make recommendations in the setting of PPROM under 23 to 24 weeks including the possibility of home, day-care, and outpatient monitoring. It would be considered reasonable to maintain the woman in hospital for at least 48 hours before a decision is made to allow her to go home. The management of these cases should be individualized and outpatient monitoring restricted to certain groups of women after careful consideration of other risk factors and the access to the hospital.

Hyperthyroidism

Hyperthyroidism in pregnancy is more difficult to recognize due to the hyperdynamic physiologic changes in pregnancy. However, unintended weight loss, nervousness, palpitations, tachycardia, or tremor are clinical manifestations that bear evaluation. The diagnosis is made clinical suspicion and thyroid function tests, such as thyroid-stimulating hormone (TSH) and free T4 levels. The immediate treatment includes β-blocking agents and thioamides.

The patient who presents acutely to the emergency department should be started on β-blockers urgently to relieve the adrenergic symptoms of tachycardia, tremor, anxiety, and heat sensitivity by decreasing the maternal heart rate, cardiac output, and myocardial oxygen consumption. Longer-acting agents, such as atenolol and metoprolol 50 to 200 mg/d, are recommended. β-Blockers are contraindicated in patients with asthma and congestive heart failure and should not be used at the time

of delivery due to possible neonatal bradycardia and hypoglycemia.

Thioamides inhibit thyroid hormone synthesis by reduction of iodine organification and iodotyrosine coupling. Both propylthiouracil (PTU) and methimazole have been used during pregnancy, but PTU has been traditionally preferred because of concern regarding reduced transplacental transfer of PTU compared to methimazole. However, recent studies do not confirm this finding. Teratogenic patterns associated with methimazole include aplasia cutis and choanal/esophageal atresia; however, these anomalies do not occur at a higher rate in women on thioamides compared to the general population.

Side effects of thioamides include transient leukopenia (10%); agranulocytosis (0.1%-0.4%); thrombocytopenia, hepatitis, and vasculitis (<1%) as well as rash, nausea, arthritis, anorexia, fever, and loss of taste or smell (5%). Agranulocytosis usually presents with a fever and sore throat. If a CBC indicates agranulocytosis, the medication should be discontinued. Treatment with another thioamide carries a significant risk of cross-reaction as well.

Initiation of thioamides in a patient with a new diagnosis during pregnancy requires a dose of PTU 100 to 150 mg three times daily or methimazole 10 to 20 mg twice daily. Free T4 levels are used to monitor response to therapy in hyperthyroid patients and should be checked in 4 to 6 weeks. The PTU or methimazole can be adjusted in 50 mg or 10 mg increments, respectively, with a therapeutic range for free T4 of 1.2 to 1.8 ng/dL. The goal of treatment is to maintain the free T4 in the upper normal range using the lowest possible dose in order to protect the fetus from hypothyroidism. The required dose of thioamide during pregnancy can increase up to 50% for patients with a history of hyperthyroidism prior to conception. The patient’s TSH should be checked at the initial prenatal visit and every trimester. Medication adjustments, testing intervals, and therapeutic goals for the free T4 are the same as for patients with new-onset disease.

The most common cause of hyperthyroidism is Graves disease, which occurs in 95% of all cases at all ages. The diagnosis of Graves disease is usually made by the presence of elevated free T4 level or free thyroid index with a suppressed TSH in the absence of a nodular goiter or thyroid mass. The differential diagnosis of hyperthyroidism, in the order of decreasing frequency, includes subacute thyroiditis, painless (silent or postpartum) thyroiditis, toxic multinodular goiter, toxic adenoma (solitary autonomous hot nodule), iodine-induced (iodinated contrast or amiodarone), iatrogenic overreplacement of thyroid hormone, factitious thyrotoxicosis, struma ovarii (ovarian teratoma), and gestational trophoblastic disease. The general symptoms of hyperthyroidism include palpitations, weight loss with increased appetite, nervousness, heat intolerance, oligomenorrhea, eye irritation or edema, and frequent stools. The general signs include diffuse goiter, tachycardia, tremor, warm, moist skin, and new-onset atrial fibrillation. Diagnosis during pregnancy is even more difficult because the signs and symptoms of hyperthyroidism may overlap with the hypermetabolic symptoms of pregnancy. Discrete findings with Graves disease include a diffuse, toxic goiter (common in most young women), ophthalmopathy (periorbital edema, proptosis, and lid retraction in only 30%), dermopathy (pretibial myxedema in <1%), and acropachy (digital clubbing).

The pathogenesis of Graves disease is characterized by an autoimmune process with production of thyroid-stimulating immunoglobulins (TSIs) and TSH-binding inhibitory immunoglobulins (TBIIs) that act on the TSH receptor on the thyroid gland to mediate thyroid stimulation or inhibition, respectively. These antibodies, in effect, act as TSH agonists or antagonists, to stimulate or inhibit thyroid growth, iodine trapping, and T4/T3 synthesis. Maternal Graves disease complicates 1 out of every 500 to 1000 pregnancies. The frequency of poor outcomes depends on the severity of maternal thyrotoxicosis with a risk of preterm delivery of 88%, stillbirth of 50%, and risk of congestive heart failure of over 60% in untreated mothers.

Thyroid Storm

Maternal thyroid storm is a medical emergency characterized by a hypermetabolic state in a woman with uncontrolled hyperthyroidism. Thyroid storm occurs in less than 1% of pregnancies but has a high risk of maternal heart failure. Usually, there is an inciting event, such as infection, cesarean delivery, or labor, which leads to acute onset of fever, tachycardia, altered mental status (restlessness, nervousness,

confusion), seizures, nausea, vomiting, diarrhea, and cardiac arrhythmias. Shock, stupor, and coma can ensue without prompt intervention, which includes OB-ICU admission, supportive measures, and acute medical management. Therapy includes a standard series of drugs, each of which has a specific role in suppression of thyroid function: PTU or methimazole blocks additional synthesis of thyroid hormone, and PTU also blocks peripheral conversion of T4 to T3. Saturated solutions of potassium iodide or sodium iodide block the release of T4 and T3 from the gland. Dexamethasone decreases thyroid hormone release and peripheral conversion of T4 to T3. Propranolol inhibits the adrenergic effects of excessive thyroid hormone. Phenobarbital can reduce extreme agitation or restlessness and may increase catabolism of thyroid hormone. Fetal surveillance is performed throughout, but intervention for fetal indications should not occur until the mother is stabilized.

Pyelonephritis

A pregnant woman is at greater risk for pyelonephritis and its complications such as sepsis and acute respiratory distress syndrome (ARDS). Most cases of pyelonephritis in pregnancy are caused by infection with gram-negative aerobic bacteria, but an increasing number are due to group B Streptococcus. Approximately 7% of affected women will develop pulmonary insufficiency due to ARDS (see Figure 27–1), presumably related to release of endotoxin. For these reasons, a pregnant patient with pyelonephritis should be admitted to the hospital. The diagnosis is established with the classic triad of fever, costovertebral angle (CVA) tenderness, and pyuria.

The patient should be placed on IV hydration, antibiotics aimed at the most common etiology, E Coli, and monitored for complications. Bacteria and/or their component toxins can produce a sepsis syndrome that, unchecked, will develop into septic shock. The cornerstone of management is early diagnosis, but often that is not easy. A program of early goal-directed therapy has been shown to reduce mortality from septic shock. However, not all patients with septic shock require the same treatment interventions. The woman in our case scenario, for example, requires aggressive fluid resuscitation and transfer to an intensive care unit. Per hour 1 to 2 L

Figure 27–1. CXR showing diffuse bilateral alveolar opacities consistent with ARDS. (Reproduced,

with permission, from Longo DL, Fauci As, Kasper DL, et al. Harrison’s Principles of Internal Medicine.

18th ed. New York, NY: McGraw-Hill; 2010. Figure 27-1.

(not the 125 cc/h she was receiving) would be appropriate. The total volume needed should be determined by monitoring central venous pressure. An arterial catheter should be placed to monitor blood pressure and obtain timely pH and blood gas measurements. If adequate fluid resuscitation has not elevated the mean arterial pressure above 65 mm Hg, then vasopressors would be indicated. Adequate oxygenation should be maintained, with endotracheal intubation and mechanical ventilation, if necessary. The ceftriaxone she was receiving likely does not need to be changed, but some authorities prefer ampicillin and gentamicin for the treatment of pyelonephritis in pregnancy. Surgical intervention is seldom necessary for septic shock secondary to pyelonephritis, but prolonged hypotension and ischemia can lead to gangrene of the extremities and amputation in severe cases. When septic shock results from necrotizing fasciitis, extensive debridement of necrotic tissue is an essential component of management. Antibiotic therapy should include vancomycin for methicillinresistant Staphylococcus and clindamycin for Streptococcus; there is evidence that clindamycin may directly inhibit synthesis of group A streptococcal toxins.

COMPREHENSION QUESTIONS

27.1 A 35-year-old woman G2P1 at 24 weeks’ gestation comes into the emergency department with fever of 102°F, dysuria, and costovertebral angle tenderness. The urinalysis shows numerous bacteria and leukocytes. The patient asks whether she can be treated as an outpatient. Which of the following is the best response?

A. Outpatient therapy with oral cephalexin is acceptable.

B. Outpatient therapy with an initial dose of ceftriaxone IM and then oral nitrofurantoin is acceptable.

C. Outpatient therapy is acceptable if this is the patient’s first episode of pyelonephritis.

D. In-patient therapy is preferred in this patient.

27.2 The patient in Question 27.1 is treated with antibiotic therapy for 2 days, and develops acute shortness of breath and is noted to have an O2 sat of 89% on room air. Which of the following is the most likely cause of her hypoxemia?

A. Pulmonary embolism

B. Pneumonia

C. ARDS

D. Aspiration

27.3 A 28-year-old G1P0 woman is noted to be at 7 weeks’ gestation by dates. She comes into the ED with vaginal bleeding. The physical examination is otherwise unremarkable. There are no adnexal masses or tenderness and the uterus is nontender and the cervix is closed. The hCG level is 2000 mIU/mL, and the transvaginal ultrasound shows no intrauterine gestation, no adnexal masses, and no free fluid. Which of the following is the most likely diagnosis?

A. Ectopic pregnancy

B. Completed abortion

C. Incomplete abortion

D. Molar pregnancy

27.4 A 31-year-old woman G3P2 woman at 19 weeks’ gestation complains of jitteriness, weight loss, and palpitations. She has a history of Graves disease and had been taking PTU and propranolol until she stopped 2 weeks ago due to concern about the medications’ effect on her pregnancy. The patient is noted to have a temp of 102°F, BP 160/100 mm Hg, heart rate 130, and she is confused and disoriented. Which of the following is the most likely diagnosis?

A. Acute β-blocker withdrawal syndrome

B. Sepsis due to PTU-induced neutropenia

C. Thyroid storm

D. Hyperparathyroidism

27.5 A 27-year-old G1P0 woman at 18 weeks’ gestation complains of significant nausea and vomiting throughout her pregnancy, and has not been able to keep any foods or liquids down. She has been admitted to the hospital numerous times. Her BP is 100/60 mm Hg and heart rate 110, and urinalysis shows negative nitrates, negative leukoesterase, and ketones is 2 +/4. Which of the following statements is most accurate about this patient?

A. The presence of ketones in the urine in consistent with significant volume depletion.

B. The patient’s gestational age of 18 weeks is expected for hyperemesis gravidarum.

C. Vitamin B1 is useful for this patient’s condition.

D. The patient may be expected to have hyperkalemia.

27.6 A 31-year-old G2P1 woman is noted to be at 20 weeks’ gestation. She presents to the ED with a history of leakage of fluid per vagina earlier in the day. On speculum examination, there is no fluid in the vagina. The fern and nitrazine tests are negative. Which of the following is the best next step for this patient?

A. Inform the patient that she does not have rupture of membranes.

B. Hospitalize the patient and assume that she has rupture of membranes.

C. Treat with an oral antibiotic for presumed UTI.

D. Perform an ultrasound examination.

ANSWERS

27.1 D. Pregnant women with pyelonephritis should be admitted to the hospital in general because of the complications such as sepsis, preterm labor, miscarriage, or ARDS. Endotoxin-induced pulmonary injury is a well-documented complication of pyelophritis and occurs more commonly in pregnant women.

27.2 C. A patient who develops acute shorness of breath and hypoxemia after treatment for pyelonephritis should be assumed to have endotoxin-mediated pulmonary injury, or ARDS. A chest x-ray will usually reveal patchy bilateral infiltrates in the lung fields. The treatment is supplemental oxygen and supportive therapy.

27.3 A. When the hCG level exceeds the threshold of 1500 and no gestational sac is seen on TV ultrasound, the likelihood of an ectopic pregnancy is high (in the range of 85%). These patients usually go to laparoscopy to confirm the diagnosis. When the hCG level is below the threshold, then the next step is generally to repeat the hCG level in 48 hours to assess for a normal rise (>66% rise) which would indicate a normal intrauterine pregnancy, versus an abnormal rise (<66%) which would be either an ectopic pregnancy or a miscarriage.

27.4 C. Thyroid storm is present with hyperthyroidism in conjunction with CNS dysfunction (seizures, confusion, lethargy), and/or autonomic instability (fever). Thyroid storm carries a worse prognosis and usually requires immediate admission to the ICU and aggressive therapy consisting of PTU, β-blockers, and steroids. A common precursor to thyroid storm is a patient who has stopped taking medications and a stressor such as infection or surgery.

27.5 A. With hyperemesis gravidarum, the presence of moderate to significant ketones is associated with significant volume depletion. The patient is typically hypokalemic. The usual gestational age for hyperemesis is the first trimester, although less commonly, women can persist later and ever rarer, throughout the pregnancy. Vitamin B6 is a useful adjunctive treatment.

27.6 D. When the history suggests PROM, but the speculum examination is negative, ultrasound to assess for amniotic fluid volume is helpful. If oligohydramnios is diagnosed, the patient is assumed to have ROM, and should be admitted to the hospital.

CLINICAL PEARLS

⯈ Nausea and vomiting in pregnancy is common, so that significant volume or metabolic derangements in these patients can be minimized.

⯈ Hyperemesis is a diagnosis of exclusion.

⯈ The physiologic changes of pregnancy should be considered when interpreting ABGs. For instance when the PCO2 exceeds 40 mm Hg in a pregnant asthmatic, severe hypercarbia is present and intubation should be considered.

⯈ Dyspnea and hypoxemia after treatment for pyelonephritis is usually caused by endotoxin-related pulmonary injury, ARDS.

⯈ Hyperthyroidism is typically treated with methimazole or PTU, and a β-blocker.

⯈ When the hCG level exceeds the threshold of 1200 to 1500 mIU/mL and no gestational sac is seen in the uterus on transvaginal ultrasound, then an ectopic pregnancy is highly likely.

⯈ The history for a gush of fluid followed by constant leakage is 90% accurate for rupture of membranes.

⯈ In there is strong clinical suspicion, and the speculum examination is negative for ROM, an ultrasound assessment for amniotic fluid volume is helpful.

References

American College of Obstetricians and Gynecologists. Diagnosis and treatment of gestational trophoblastic disease. ACOG Practice Bulletin 53. Washington, DC: 2004. 

American College of Obstetricians and Gynecologists. Medical management of abortion. ACOG Practice Bulletin 67. Washington, DC: 2005. 

Andrews JI, Shamshirsaz AA, Diekema DJ. Nonmenstrual toxic shock syndrome due to methicillinresistant staphylococcus aureus. Obstet Gynecol. 2008;112:933-938. 

Casey BM, Leveno KJ. Thyroid disease in pregnancy. Clinical expert series. Obstet Gynecol. 2006;108:1238-1292. Katz VL. Recurrent and spontaneous abortion. In: 

Katz VL, Lentz GM, Lobo RA, Gersenson DM, eds. Comprehensive Gynecology. 5th ed. St. Louis, MO: Mosby-Year Book; 2007:359-388. 

Lu MC, Hobel CJ. Antepartum care: preconception and prenatal care, genetic evaluation and teratology, and antenatal fetal assessment. In: Hacker NF, Moore JG, Gambone JC, eds. Essentials of Obstetrics and Gynecology. 4th ed. Philadelphia, PA: Saunders; 2004:83-103. 

Martin SR, Foley MR. Intensive care in obstetrics: an evidence-based review. Am J Obstet Gynecol. 2006;195:673-689. 

Neal DM, Cootauco AC, Burrow G. Thyroid disease in pregnancy. Clin Perinatol. 2007;34:543-557. 

Parillo JE. Septic shock—vasopressin, norepinephrine, and urgency. N Engl J Med. 2008;358:954-956.

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