Pregnancy, Childbirth, & the Puerperium


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/G11_F2.jpg"}},{"insert":"\n\nSo far, you\u0027ve had a fairly relaxed morning in the gynecology clinic. The door opens once again, this time revealing a familiar face: 33-year-old Priya. Roughly nine months ago, you helped deliver Priya\u0027s baby girl, whom she named Amaya.\n\n\u201cGood morning, Priya!\u201d you say. \u201cHow can I help you today?\u201d\n"}]}


{"ops":[{"insert":"Priya has been vomiting on and off for the last three days or so\u2014around five to six times per day. \u201cI feel nauseous all the time, and I just haven\u0027t been able to eat or drink much,\u201d she says. There is no correlation between the episodes of vomiting and meals or any other activity. She saw her general practitioner two days ago, who prescribed oral metoclopramide. However, this did not relieve her symptoms.\n\n\u201cIt got me thinking, could I be pregnant again? I\u0027ve not had periods, but I\u0027ve been breastfeeding my daughter, and you know, even before I had her, my periods were all over the place,\u201d Priya says. She then performed a urine pregnancy test at home, which was positive. \u201cBut doctor, I had morning sickness last time, but you know, not anything like this. I thought of coming to see you just in case.\u201d\n\nPriya\u0027s husband is out of the country on a short business trip. She left Amaya with her in-laws, before coming over to your hospital.\n"}]}


{"ops":[{"insert":"You remember that Priya has only been pregnant once before; and that her pregnancy was entirely without complications. Her daughter was delivered vaginally, following an uncomplicated labor. Priya\u0027s medical and surgical histories were also completely unremarkable. You ask and confirm that she is not on any medications currently. Priya was relying on lactational amenorrhea for contraception. Her family history is unremarkable.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/G11_F3.jpg"}},{"insert":"\n\nOn examination, you note that Priya\u0027s weight is 60.0 kg and height is 165 cm. You inquire and learn that she was 63.5 kg in weight the last time she checked, around a week ago. Priya is afebrile, and oriented in time, place, and person. Her blood pressure is 125\/80 mmHg, heart rate is 98 bpm, respiratory rate is 15\/min, and oxygen saturation is 98% on room air. \n\nDuring the general examination you note that Priya\u0027s oral mucosa and tongue are dry. Her eyes are not sunken, but her skin turgor is decreased. Cardiorespiratory and abdominal examination are both unremarkable.\n\nHer breasts are normal, but she complains of mild generalized tenderness during manipulation. Pelvic examination reveals normal appearing external genitalia. Upon insertion of a sterile speculum, you note that the vaginal mucosa is pink; the cervix is parous with no secretions; and Chadwick\u0027s sign is present.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/G11_F6.jpg"}},{"insert":"\n\nExamination over, you ask Priya for a urine sample. The urine provided to you is small in quantity and dark yellow in color. Urine pregnancy testing is positive. Dipstick testing reveals 3+ positivity for ketones.\n"}]}


{"ops":[{"insert":"You sit back and ponder.\n\nWhich of the following do you feel is the probable diagnosis?\n"}]}
1. Ectopic pregnancy
2. Hyperemesis gravidarum
3. Molar pregnancy