Pregnancy, Childbirth, & the Puerperium


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/G11_F1.jpg"}},{"insert":"\n\n"},{"insert":"It is yet another Monday morning, and you are in your office daydreaming about the fishing trip you recently went on.\r\n \r\nDoing absolutely nothing felt so incredibly good .....\n\nYour chair squeaks in protest as you shift position, jarring you out of your reverie.\r\n \r\nClearing your throat, you call for the nurse to let in the first patient of the day; this is no time to be daydreaming.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/G11_F2.jpg"}},{"insert":"\n\n"},{"insert":"A few moments later, a woman enters your office.\r\n \r\n\u0022Good morning ma\u0027am!\u0022 you greet her. \u0022How are you doing today?\u0022\r\n\r\n\u0022Not too good, actually,\u0022 she replies.\n\nPriya is 33 years old, and the proud mother of a 14-month-old girl named Amaya. She is in your office today because she has been feeling sick for the past couple of days.\r\n\r\n\u0022I\u0027ve been vomiting a lot lately and I feel it\u0027s getting worse,\u0022 she says, and adds,\r\n \r\n\u0022My family doctor gave me some medicines, but they didn\u0027t help much\u0022.\n\n\u0022I see,\u0022 you nod in sympathy. \u0022Are there any other issues?\u0022 you ask.\r\n\r\n\u0022Well, my breasts have been feeling sore lately, and I noticed some vaginal spotting earlier today. I\u0027ve also lost about 5 kilos over the last couple of weeks,\u0022 she replies.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/G11_F3.jpg"}},{"insert":"\n\n"},{"insert":"On physical examination, Priya is afebrile, and oriented in time, place, and person. She is visibly unwell.\r\n \r\nHer blood pressure is 125\/80 mmHg, heart rate is 100 bpm, respiratory rate is 15 cpm, and SaO2 is 98% on ambient air.\r\n\r\nHer weight is 60 kg, and height is 165 cm.\n\nPriya opens her mouth upon your request and you notice that her oral mucosa and tongue are dry. Her eyes do not look sunken, but her skin turgor is decreased.\n\nOn auscultation her lungs are clear, and her heart sounds are regular in tone and intensity.\r\n \r\nOn inspection her breasts look normal, however, she does complain of pain during manipulation.\n\nAn abdominal examination reveals that her abdomen is semi-globose, without tenderness, masses, organomegaly or bruits.\r\n \r\nPelvic examination shows no inguinal adenopathy, the external genitalia seem normal, and the vaginal mucosa looks pink.\n\nUpon insertion of a speculum, you see a parous cervix, with no secretions, and a positive Chadwick\u0027s sign.\r\n \r\nThe uterus is anterior, midline, smooth, and not enlarged. No adnexal tenderness is noted. The rectovaginal wall is intact, and the rectal vault is free of masses.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/G11_F2.jpg"}},{"insert":"\n\n"},{"insert":"You discover that Priya has been relying on lactational amenorrhea for contraception. Prior to her first and only pregnancy, her periods used to be irregular unless regulated by the pill.\r\n \r\nAmaya was conceived naturally and the pregnancy was uneventful, with the baby being born at term following an uncomplicated labor and vaginal delivery.\n\nFurther questioning reveals no other relevant medical or family history. However, on her husband\u0027s side of the family, multiple multifetal pregnancies have been reported.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/G11_F5.jpg"}},{"insert":"\n\n"},{"insert":"You ask Priya for a urine sample for further analysis of her condition.\r\n \r\nSubsequently, the urine provided to you is of a very small amount and dark yellow.\n\nYou perform a urine dipstick test and a pregnancy test. The former shows ketones to be +++, while the latter is positive.\r\n\r\n\u0022Congratulations, Priya! You\u0027re pregnant,\u0022 you announce cheerfully.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/G11_F6.jpg"}},{"insert":"\n\n"},{"insert":"Priya attempts to put on a happy smile, but seems too exhausted to be fully delighted by the good news.\r\n \r\n\u0022However,\u0022 you continue, \u0022I am concerned about your weight loss and the findings of the urine test, so I\u0027ll have to admit you.\u0022\n\nFrom the very outset, you\u0027d considered the possibility that Priya\u0027s signs and symptoms might be due to hyperemesis gravidarum (HG). The positive pregnancy test merely affirms your suspicion.\n\nThus, you make arrangements to have Priya admitted, and start her on oral rehydration solution and antiemetics, while also ordering several investigations.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/G11_F7.jpg"}},{"insert":"\n\n"},{"insert":"A while later, you receive the results of the relevant investigations:\r\n\r\nhCG: 450,000 mIU\/ml (non-pregnant: \u003C25)\r\n \r\nNa+: 132 mEq\/L (135-145)\r\nK: 3.3 mEq\/L (3.5-5.0)\r\nCl\u2212: 9.0 mg\/dL (9-10.5)\r\nCa2+: 2.2 mmol\/L (2.2-2.6)\n\nWBC: 9.1 x 10^9 \/L (3.5 - 11)\r\nRBC: 4.3 x 10^12 cells\/L (3.9 - 5)\r\nMCV: 83 fL (80 - 100)\r\nMCH: 28 pg (27 - 31)\r\nMCHC: 35 g\/dL (32 - 36)\r\nHct: 45% (35 - 45)\r\nHb: 12 g\/dL (12.0 - 15.5)\r\nPLT: 350,000\/mm3 (150,000 - 450,000)\n\nALT: 45 U\/L (8-48)\r\nAST: 49 U\/L (7-55)\r\nAlbumin: 4 g\/dL (3.5-5.5)\r\nBUN: 10 mg\/dL (7-18)\r\nCreatinine: 0.9 mg\/dL (0.6 to 1.1)\r\nUric acid: 5.1 mg\/dL (2.4-6.0)\r\nRandom plasma glucose: 133 mg\/dL (\u003C200)\n\nUrine Color \u0026 turbidity: Dark yellow \u0026 cloudy\r\npH: 5.9 (5.5-6.5)\r\nSpecific gravity: 1000 (1010-1025)\r\nGlucose: None\r\nKetones: +++\r\nNitrites \u0026 leukocyte esterase: Negative\r\nProtein: Negative\r\nRBCs: 2 RBCs\/hpf (0-4)\r\nWBCs: 0 WBCs\/hpf (0-5)\n\nNow that the lab tests rule out other causes of disease and display the classical electrolyte imbalance of HG, you are in little doubt of her diagnosis.\n"}]}