Ibrah I: Pregnancy Problems

Pregnancy, Childbirth, & the Puerperium


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/G13_F2.jpg"}},{"insert":"\n\nEstrogen, progesterone, and prolactin: the triad of hormones that control the great miracle of birth. Sometimes you feel that they rule your life as well, given your role as an obstetrician.\n"}]}


{"ops":[{"insert":"Your first patient is shown in: Ibrah, a 33-year-old stay-at-home mom of an Iraqi migrant family. She was referred to your clinic by her midwife, after her first antenatal lab work-up revealed low hemoglobin levels.\n\nIbrah is currently 9 weeks + 2 days pregnant, as per her last menstrual period. Her pregnancy was planned; and news of her being pregnant highly welcomed. This is her fourth pregnancy. All of her previous pregnancies were carried to term and were delivered vaginally, at home, without complications. Her children are 4, 2, and 1 years old respectively\n\nShe complains of \u0022low energy\u0022 and intermittent nausea since the start of her pregnancy. Her menstrual periods were regular, with a cycle length of 24 days. She is not on any medications. She consumes a normal diet \u2013 but as a devout Muslim, avoids pork and alcohol.\n\nIbrah\u0027s family history is unclear, as she was raised by a distant relative. She is also unable to give a clear family history of her husband, the father of all her children, as his family perished long ago in war-torn Iraq. \n\nYou confirm that all the necessary recommendations regarding diet, exercise, smoking and vitamin supplementation have been provided to her at the first antenatal visit. \n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/G13_F3.jpg"}},{"insert":"\n\nProceeding to the physical examination, you note that she is afebrile; her pulse is 60 bpm and regular; her blood pressure is 120\/80 mmHg; her respiratory rate is 19\/min. Her weight is 62 kg and body mass index (BMI) is 24.\n\nShe is wearing a hijab, but her general appearance reveals no morphological features or peripheral stigmata of chronic conditions. However, you do note conjunctival pallor. The remainder of the examination is normal.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/G13_F4.jpg"}},{"insert":"\n\nIbrah\u0027s lab results are as follows:\n\nFull blood count\n----------------------\nWBC: 5,600\/mm3 (4,600-11,00)\nHb: 9.0 g\/dL (11-18)\nMCV: 70 fL (75-95)\nMCH: 27 pg\/cell (28-32)\nHct: 27% (35-45)\nPlt: 220,000\/mm3 (150,000-400,000)\n\nPeripheral blood film + reticulocytes\n-------------------------------------------------\nPeripheral blood film: hypochromic microcytic red cells and anisopoikilocytosis.\nReticulocytes: 0.7% (0.2-2)\n\nIron studies\n----------------\nSerum iron: 20 \u03bcg\/dL (50 to 170)\nTIBC: 180 \u03bcg\/dL (50\u2013170)\nSerum ferritin: 10 ng\/mL (12-150)\nTransferrin: 366 mg\/dL (204\u2013360) \n\nOther\n--------\nBlood group: B+\nRubella IgG antibodies: 15 IU\/mL (\u003E7) \nHBs antigen: negative.\nHIV antibodies: negative.\nVDRL: non reactive\nUrinalysis: normal\n"}]}


{"ops":[{"insert":"You feel that you know what the diagnosis is. However, you also realize that a couple of additional tests need to be ordered.\n\nWhich of the following investigations will you additionally request?\n"}]}
1. Serum vitamin B12 + folate levels
2. Hemoglobin electrophoresis
3. High performance liquid chromatography (HPLC)