A 28-year-old pregnant female presents with nocturnal numbness in her hands. Which have woke her up from sleep for the past three months. She also has difficulty grasping objects.
What is the most likely etiology?
Correct Answer C:
Carpal tunnel syndrome is compression of the median nerve as it passes through the carpal tunnel in the wrist. Symptoms include pain and paresthesias in the median nerve distribution. Diagnosis is suggested by symptoms and signs and confirmed by nerve conduction velocity testing. Treatments include ergonomic improvements, analgesia, splinting, and sometimes corticosteroid injection or surgery.
Carpal tunnel syndrome is very common and most often occurs in women aged 30 to 50. Risk factors include RA or other wrist arthritis (sometimes the presenting manifestation), diabetes mellitus, hypothyroidism, acromegaly, amyloidosis, and pregnancy-induced edema in the carpal tunnel. Activities or jobs that require repetitive flexion and extension of the wrist may contribute. Most cases are idiopathic.
A G1P0 woman at 35 weeks gestation presents with headache and a blood pressure of 170/115 mmHg. Protein is ++ on her urine. She has normal body reflex, fetal heart 140 beats/min.
What is the most appropriate next step?
Preeclampsia is pregnancy-induced hypertension plus proteinuria. Eclampsia is unexplained generalized seizures in patients with preeclampsia. Preeclampsia and eclampsia develop between 20 weeks gestation and the end of the 1st week postpartum.
Diagnostic criteria for severe preeclampsia include at least one of the following:
When severe preeclampsia is diagnosed after 34 weeks' gestation, delivery is most appropriate. The mode of delivery should depend on severity of the disease and the likelihood of a successful induction. However, whenever possible, vaginal delivery should be attempted and cesarean section should be reserved for routine obstetric indications. In addition, women with severe preeclampsia who have non reassuring fetal status, ruptured membranes, labor, or maternal distress should be delivered regardless of gestational age.
Magnesium sulfate is the drug of choice for seizure prophylaxis in women with preeclampsia. Therapy is started at the beginning of labor or prior to cesarean section and continued 24 hours postpartum in most cases. The duration of postpartum therapy may be modified depending on the severity of the disease.
→ C-section (choice A) and inducing labor (choice B) are incorrect. While the patient is approaching term and severe pre-eclampsia warrants delivery, the patient is at risk of seizures and should first receive prophylaxis.
→ Hydralazine (choice D) and Nifedipine (choice E) are considered " conservative" management of pre-eclampsia and while there have been some reports of successful management, currently there are no recommended protocols for conservative management of patients with severe pre-eclampsia and eclampsia.The first goal of management of severe pre-eclampsia and eclampsia is prevention or control of convulsions and stabilization of the patient's basic cardiovascular status. Administration of magnesium sulfate by an established protocol is considered to be the most rapid, efficient, and safe pharmacologic approach for accomplishing this goal.
All of the following are risk factors for developing preeclampsia, except:
Correct Answer D:
Factors associated with an increased risk of developing preeclampsia:
A 20-year-old woman who is 35 weeks pregnant with her first child is admitted to the hospital because of persistent hypertension and 1+ protein on urinalysis obtained 36 hours ago. She is confined to bed awaiting further diagnostic studies for preeclampsia. Her blood pressure is now 160/100 mm Hg. She is complaining of headaches, blurred vision and epigastric pain.
At this time it is most appropriate to conclude that this patient has which of the following?
This patient has severe preeclampsia. Preeclampsia is diagnosed on the basis of her elevated blood pressure and proteinuria occurring after 20 weeks’ gestation. She has severe preeclampsia on the basis of her headaches, blurred vision, and epigastric pain. This patient requires magnesium sulfate to prevent eclampsia (seizures occurring in the setting of preeclampsia). Magnesium sulfate has been shown to be the most effective agent to use for the prevention of seizures in women with preeclampsia. She also requires delivery to arrest the disease process. Delivery is the only “cure” for preeclampsia. Bed rest pending further diagnostic studies is inappropriate because delivery is necessary to prevent a worsening of the disease process that can be fatal for mother and fetus.
You see a 23-year-old gravida 1 para 0 for her prenatal checkup at 38 weeks gestation. She complains of severe headaches and epigastric pain. She has had an uneventful pregnancy to date and had a normal prenatal examination 2 weeks ago. Her blood pressure is 140/100 mm Hg. A urinalysis shows 2+ protein; she has gained 5 lb in the last week, and has 2+ pitting edema of her legs.
The most appropriate management at this point would be:
This patient manifests a rapid onset of preeclampsia at term. The symptoms of epigastric pain and headache categorize her preeclampsia as severe. These symptoms indicate that the progress is well advanced and that convulsions are imminent. Treatment should focus on rapid control of symptoms and delivery of the infant.
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