Pregnancy, Childbirth, & the Puerperium


{"ops":[{"insert":"\u0022That\u0027s it for today, doctor\u0022 your nurse announces. You give her a thumbs up. The obstetric clinic is over, and the upcoming long weekend beckons.\n\nThe phone rings. \u0022Hey\u2014I\u0027ve got a pregnant woman with a new-onset headache and GH,\u0022 your colleague from the medical clinic says. \u0022I\u0027ve excluded medical causes. Shall I send her over?\u0022 \n\nYou reply in the affirmative.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/G11_F31.jpg"}},{"insert":"\n\nA short while later, you are introduced to 32-year-old Elizabeth, who is at 30 weeks + 0 days of gestation of her first pregnancy. You recognize the name of her regular obstetrician: a friend of yours who is still recovering following a car cash just last week.\n\n\u0022I\u0027ve been having bad headaches since yesterday,\u0022 Elizabeth says. \u0022I got high blood pressure a couple of months ago\u2014because of my pregnancy, my regular doctor said, poor man!\u2014and he asked me to see him if I started getting headaches. So, here I am.\u0022 She gives you a wan smile.\n\nYou nod in understanding and proceed to ask several follow-up questions.\n"}]}


{"ops":[{"insert":"Elizabeth\u0027s headaches were generalized and severe. They were not exacerbated by coughing, sneezing, or physical activity. There were no associated visual disturbances, blurring of vision, or photophobia. Neither was was there a history of fever, nausea, or vomiting. She has always been in excellent health, with unremarkable medical and surgical histories.\n\nElizabeth\u0027s first trimester was without incident. However, she was found to be hypertensive at 27 weeks of gestation, with a blood pressure of 139\/89 mmHg. She was started on oral labetalol, following which her blood pressure normalized to 115\/75 mmHg. Her blood pressure remained stable afterwards. She has been followed up regularly since. Her urine has been protein free.\n\nHer husband is currently working abroad. \u0022He\u0027s already on the way back\u2014should be here day-after-tomorrow,\u0022 she says.\n"}]}


{"ops":[{"insert":"Proceeding to the examination, you note that Elizabeth\u0027s temperature is 98.4\u02daF (36.9\u02daC), pulse is 90 bpm, blood pressure is 165\/110 mmHg, respiratory rate is 15\/min, and oxygen saturation (SaO2) is 99% on room air. Her weight is 85 kg. She is conscious, rational, and oriented.\n\nIn the general examination, you note bilateral pitting pedal edema up to the ankles. Fundoscopy is normal. On neurological examination, you note generalized hyperreflexia and bilateral ankle clonus. No focal signs are present. Examination of the abdomen reveals a symphysis-fundal height (SFH) of 33 cm and a cephalic presentation. Cardiorespiratory examination is normal.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/G11_F27.jpg"}},{"insert":"\n\nDone with the examination, you peruse the results of the investigations ordered by your colleague in the medical clinic. These are as follows:\n\nFull blood count\n---------------------\nWBC: 10.0 x 10^9 \/L (3.5-11)\nRBC: 4.0 x 10^12 cells\/L (3.9-5)\nMCV: 87 fL (80-100)\nMCH: 27 pg (27-31)\nMCHC: 35 g\/dL (32-36)\nHct: 41% (35-45)\nHb: 12.3 g\/dL (12.0-15.5)\nPLT: 270,000\/mm3 (150,000-450,000)\n\nLiver profile\n----------------\nALT: 48 U\/L (8-48)\nAST: 55 U\/L (7-55)\nAlbumin: 3.9 g\/dL (3.5-5.5)\nINR: 1.0 (0.9 - 1.1)\n\nRenal profile\n----------------\nUrea: 35 mg\/dL (0-50)\nCreatinine: 0.9 mg\/dL (0.6-1.1)\n\nUrinalysis\n-------------\nAppearance: clear\nColor: yellow\npH: 6.2 (5.5-6.5)\nSpecific gravity: 1019 (1010-1025)\nGlucose: negative\nKetones: negative\nNitrites: negative\nLeukocyte esterase: negative\nProtein: ++\nRBC: 1\/hpf (0-4)\nWBC: 0\/hpf (0-5)\n\nYou perform a cardiotocogram, which shows nothing untoward.\n"}]}


{"ops":[{"insert":"Which of the following will you do now?\n"}]}
1. Admit Elizabeth
2. Manage her as an outpatient