A 17-year-old girl complains of severe bleeding during her menstrual cycle. She uses 20 tampons per cycle, and it lasts for 7 days. She denies being sexually active.
What is the first-line medical therapy for this patient's condition?
Correct Answer A:
Menorrhagia is a term used to define menstrual periods lasting longer than seven days. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil, Motrin, others), help reduce menstrual blood loss. NSAIDs have the added benefit of relieving painful menstrual cramps (dysmenorrhea). NSAIDs are the first-line medical therapy in ovulatory menorrhagia.
→ Iron supplements (choice B): If the condition is accompanied by anemia, iron supplements are recommended.
→ Oral contraceptives (OCP’s) (choice D): aside from providing effective birth control, oral contraceptives can help regulate ovulation and reduce episodes of excessive or prolonged menstrual bleeding. They are a popular first-line therapy for women who want contraception (which is not emphasized in this patient).
→ Surgical management (choice E) has been the standard of treatment in menorrhagia due to organic causes or when medical therapy fails to alleviate symptoms. Surgical treatment ranges from a simple dilatation and curettage to a full hysterectomy.
A 28-year-old pregnant woman develops sudden onset of dyspnea and tachycardia.
Which one of the following is the most likely explanation for her symptoms?
Correct Answer B: Thromboembolic disease is the leading cause of death in pregnant women. In thromboembolic disease, blood clots form in blood vessels. They may travel through the bloodstream and block an artery. The risk of developing thromboembolic disease is increased for about 6 to 8 weeks after delivery. Most complications due to blood clots result from injuries that occur during delivery. The risk is much greater after a cesarean section than after vaginal delivery.
Blood clots usually form in the superficial veins of the legs as thrombophlebitis or in the deep veins as deep vein thrombosis. Symptoms include swelling, pain in the calves, and tenderness. The severity of the symptoms does not correlate with the severity of the disease. A clot can move from the legs to the lungs, where it may block one or more arteries in the lungs. This blockage, called pulmonary embolism, can be life threatening.
If pulmonary embolism is suspected, a lung ventilation and perfusion scan may be performed to confirm the diagnosis.
A 24-year-old woman appears at 8 weeks of pregnancy and reveals a history of pulmonary embolism 7 years ago during her first pregnancy. She was treated with intravenous heparin followed by several months of oral warfarin and has had no further evidence of thromboembolic disease for over 6 years.
Which of the following statements about her current condition is true?
Correct Answer D: As with deep venous thrombosis (DVT), pulmonary embolism (PE) requires objective diagnostic testing to confidently confirm or exclude the diagnosis. This is particularly true in pregnancies because the diagnosis of DVT or PE requires (1) prolonged therapy (< 9 months of heparin during pregnancy), (2) prophylaxis during future pregnancies, and (3) avoidance of oral contraceptive pills.
Arterial blood gases, D-dimer levels, and Echocardiography are often performed but are neither sensitive nor specific as diagnostic or pretest probability tools for the evaluation of suspected PE during pregnancy. PE cannot be definitively diagnosed without confirmatory imaging. The two most common modalities for imaging are lung scintigraphy (ventilation/perfusion scanning [V/Q]) and computed tomographic pulmonary angiography (CTPA). Magnetic resonance pulmonary angiography (MRPA) is not validated, and although contrast-enhanced pulmonary angiography was the gold standard, neither test is commonly used in the pregnant population.
Although only a relatively modest amount of data have been gathered, low molecular weight heparin, which does not cross the placenta, can be given once a day and does not require monitoring. Low molecular weight heparin has not been shown to increase the risk of bleeding with surgical procedures, including cesarean delivery, in a small number of patients.
A 28-year-old gravida 2 para 1 presents to the emergency department at 16 weeks gestation. She has noted the sudden onset of dyspnea, pleuritic chest pain, and mild hemoptysis. Both calves are mildly edematous and somewhat tender. A lung scan shows a high probability of pulmonary emboli.
Which one of the following would be appropriate management at this time?
Correct Answer B:
The risk of pulmonary embolism is five times higher in pregnant women than in nonpregnant women of similar age, and venous thromboembolism is a leading cause of illness and death during pregnancy. Warfarin, which readily crosses the placenta, should be avoided throughout pregnancy. It is definitely teratogenic during the first trimester, and extensive fetal abnormalities have been associated with exposure to warfarin in any trimester.
Because heparin does not cross the placenta, it is considered the safest anticoagulant to use during pregnancy. Initially, patients with venous thromboembolism during pregnancy should be managed with heparin given according to the recommendations for nonpregnant patients. These women should receive intravenous heparin for 5-10 days followed by subcutaneous heparin for the duration of the pregnancy. Warfarin can be given after delivery, since it is not present in breast milk.
The indications for placement of an inferior vena cava filter are not changed by pregnancy, and include any contraindication to anticoagulant therapy, the occurrence of heparin-induced thrombocytopenia, and recurrence of pulmonary embolism in a patient receiving adequate anticoagulant therapy.
There are no data to support the use of aspirin for treatment or prophylaxis of pulmonary embolism either during or after pregnancy.
A 32-year-old woman at 21 weeks’ gestation presents with acute shortness of breath and pleuritic chest pain. Her medical history is significant for anti-phospholid antibody syndrome.
Which of the following tests would be most helpful in confirming the diagnosis?
Correct Answer C:
With the hypercoagulable state of pregnancy combined with her history of antiphospholipid antibody syndrome, this patient most likely has developed a venous thrombosis leading to a pulmonary embolus.
Perfusion scanning alone is recommended initially, and the ventilation scan is added when perfusion defects are noted. Pulmonary angiography might be necessary if lung scan findings are of low probability or indeterminate and clinical suspicion remains high.
Note:
Several studies show no increased risk of teratogenicity in patients undergoing radiological procedures in the diagnosis of maternal venous thromboembolic disease. A complete and adequate evaluation to document the presence or absence of PE requires less than 0.005 Gy. Obtaining the appropriate diagnostic study in pregnancies is mandatory.Although the chest radiograph, electrocardiogram, and arterial blood gas are part of the routine workup of chest pain, the diagnosis is made by either a ventilation perfusion can, spiral CT scan, or pulmonary angiography. Since the thrombus may be in the pelvis, Doppler studies of the lower extremities may miss the source of emboli.
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