A 19-year-old female G1P0 is brought to your department by her mother, because of persistent headaches over the last 24 hours. The headaches are described as throbbing, 8/10 in intensity, and have not gotten much better with Tylenol. She has only passed about 300 ml of urine over the last 24 hours.
On physical examination the patient’s BP is 185/115 mmHg, temperature 37.7°C, pulse 110 bpm, and respirations 20/min. The patient’s fundal height is 34 cm. She is started on labetalol and magnesium sulfate. Few hours later, the patient’s BP is 145/ 100 mmHg, pulse 70 bpm, temperature 37.9°C, and respirations 9/min. She has loss of patellar reflexes.
What is the most appropriate next step in management?
Correct Answer A: This patient presents with severe preeclampsia, which is defined as the presence of 1 of the following symptoms in a pregnant patient who has had preeclampsia: systolic blood pressure of 160 mmHg or higher or diastolic blood pressure of 110 mmHg or higher on 2 occasions at least 6 hours apart, proteinuria of more than 5 g in a 24-hour collection or more than 3+ on 2 random urine samples collected at least 4 hours apart, pulmonary edema, oliguria (< 400 mL in 24 hours), persistent headaches, epigastric pain and/or impaired liver function, thrombocytopenia, oligohydramnios, decreased fetal growth, or placental abruption. While this patient’s BP has not been measured twice following these guidelines, the persistent headaches and oliguria are sufficient to make a diagnosis of severe preeclampsia. Treatment of this condition consists of lowering BP to 140/90 mmHg and the most common drugs used are hydralazine and labetalol; seizure prophylaxis should also be part of treatment to prevent progression to eclampsia. This is accomplished with magnesium sulfate. It is usually given by either the intramuscular or intravenous routes.
The effects and toxicity of magnesium sulfate are dose dependent and usually > 4 mg/dl of magnesium sulfate can accomplish seizure prophylaxis. Minor side effects such as feeling warm, flushing, vomiting, muscle weakness, and dizziness are reported in 35 % of patient on average while severe side effects such as respiratory depression and postpartum hemorrhage are observed in 2.5% of patients. This patient’s respiratory rate of 9/min is an indication of magnesium toxicity and the infusion should be immediately stopped (choice A) and then calcium gluconate can be given to reverse magnesium sulfate toxicity.
→ Administering calcium gluconate (choice B) is done to reverse magnesium sulfate toxicity, but magnesium sulfate infusion should be discontinued first.
→ Labetalol (choice C) is unlikely to be the cause of respiratory depression and patellar reflex loss in this patient.
→ Atropine (choice D), and neostigmine (choice E) are not used to reverse magnesium sulfate toxicity in pregnant patients.
Key point:
In a patient who presents with severe pre-eclampsia, magnesium sulfate should be given for seizure prophylaxis and an appropriate antihypertensive medication to reduce blood pressure. Respiratory depression indicates magnesium sulfate toxicity and should lead to immediate discontinuation of this treatment.
Diagnostic criteria for fetal alcohol syndrome include all of the following except:
Correct Answer C:
Fetal alcohol syndrome is one of the most serious consequences of drinking during pregnancy with prevalence of 1 in 300.
Criteria for Diagnosis of Fetal Alcohol Syndrome:
1- Evidence of a characteristic pattern of facial anomalies that includes features such as short palpebral fissures and abnormalities in the premaxillary zone (e.g., flat upper lip, flattened philtrum and flat midface).
2- Evidence of growth retardation, as in at least one of the following:
3- Evidence of central nervous system neurodevelopmental abnormalities, as in at least one of the following:
The gold standard for the diagnosis of endometriosis is:
Correct Answer A:
Endometriosis is a noncancerous disorder in which functioning endometrial tissue is implanted outside the uterine cavity. These ‘ectopic’ pieces of endometrial tissue can travel and implant in areas such as the ovaries and uterosacral ligament, grow and cause severe pain.
Symptoms depend on location of the implants and may include dysmenorrhea, dyspareunia, infertility, dysuria, and pain during defecation.
Diagnosis is suspected based on typical symptoms but must be confirmed by biopsy, usually via pelvic laparoscopy. These ectopic tissue must be visualized.
Treatments include anti-inflammatory drugs, drugs to suppress ovarian function and endometrial tissue growth, surgical ablation and excision of endometriotic implants, and, if disease is severe and no childbearing is planned, hysterectomy plus oophorectomy.
A 28-year-old woman has a 3-year-history of primary infertility. She presents with increasing symptoms of steady, aching lower abdominal pain at the time of menses. The pain persists throughout menstruation and often after, and radiates into the rectum. Tender nodules in the uterosacral ligaments are noted on pelvic examination.
Which one of the following would be the most contributory investigation?
Correct Answer B:
Endometriosis is a noncancerous disorder in which functioning endometrial tissue is implanted outside the uterine cavity. Symptoms depend on location of the implants and may include dysmenorrhea, dyspareunia, infertility, dysuria, and pain during defecation.
Endometriosis is usually confined to the peritoneal or serosal surfaces of pelvic organs, commonly the ovaries, broad ligaments, posterior cul-de-sac, and uterosacral ligaments.
Pelvic pain, pelvic mass, alteration of menses, and infertility are typical. Some women with extensive endometriosis are asymptomatic; some with minimal disease have incapacitating pain. Dyspareunia and midline pelvic pain before or during menses may develop. Such dysmenorrhea is an important diagnostic clue, particularly if it begins after several years of pain-free menses.
Diagnosis is suspected based on typical symptoms but must be confirmed by biopsy, usually via pelvic laparoscopy.
A patient has episodes of pain associated with menstrual periods. Following appropriate investigations, you diagnose endometriosis.
Which one of the following is the most common pelvic site of involvement found during laparoscopy?
Correct Answer D:
Endometriosis is a noncancerous disorder in which functioning endometrial tissue is implanted outside the uterine cavity. Symptoms depend on location of the implants and may include dysmenorrhea, dyspareunia, infertility, dysuria, and pain during defecation. Diagnosis is by biopsy, usually via laparoscopy. Treatments include anti-inflammatory drugs, drugs to suppress ovarian function and endometrial tissue growth, surgical ablation and excision of endometriotic implants, and, if disease is severe and no childbearing is planned, hysterectomy plus oophorectomy.
The following sites are, in descending order, the most common sites of involvement found during laparoscopy:
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