Hypertension in pregnancy - Management

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Who is at high risk of developing pre-eclampsia? Women are at high risk of pre-eclampsia if they have:

One of the following high risk factors:

o o o

A history of hypertensive disease during a previous pregnancy. Chronic kidney disease. Autoimmune disease, such as systemic lupus erythematosus or

antiphospholipid syndrome.

o o o o o o o o o o

Type 1 or type 2 diabetes. Chronic hypertension. Thrombophilia. Two or more of the following moderate risk factors: First pregnancy. Aged 40 years or older. Pregnancy interval of more than 10 years. Body mass index (BMI) of 35 kg/m2 or greater at the first visit. Family history of pre-eclampsia. Multiple pregnancy.

Hypertension in pregnancy - Management

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How do I manage women with new proteinuria without hypertension at less than 20 weeks' gestation?

If the woman is 20 weeks' gestation or less and is found to have proteinuria but is not hypertensive:

Consider possible urinary tract infection (UTI):

If a woman has symptoms of a UTI, or urinary dipstick test is positive for nitrite,

or is positive for both leukocyte esterase and blood, make a working diagnosis of UTI and manage appropriately. Urine should be sent for culture and sensitivity.

For detailed information on the diagnosis and management of UTI in pregnancy,

see the CKS topic on Urinary tract infection (lower) - women.

If there is no evidence of a UTI and the woman has 1+ protein or more on repeat

dipstick testing, consider underlying medical conditions and assess for chronic kidney disease. For more information, see the CKS topic on Chronic kidney disease - not diabetic. How do I manage women with new proteinuria without hypertension after 20 weeks' gestation? If the woman is over 20 weeks' gestation and has new proteinuria but no hypertension:

If she has symptoms of pre-eclampsia, arrange same-day hospital assessment. If there are no symptoms of pre-eclampsia:
Consider possible urinary tract infection (UTI).

If there is 1+ protein: if the woman has symptoms of a UTI, or the

dipstick test is positive for nitrite or is positive for both leukocyte esterase and blood, make a working diagnosis of UTI and manage appropriately. Urine should be sent for culture and sensitivity. Ensure follow up within 1 week and reassess. For detailed information on the diagnosis and management of UTI, see the CKS topic on Urinary tract infection (lower) - women.

If there is 2+ protein or more on dipstick testing: even if the woman

has symptoms of a UTI or the dipstick test is positive for nitrite, or is positive for both leukocyte esterase and blood, seek same day specialist advice.

If there is no evidence of a UTI:

If there is 1+ protein on dipstick testing of urine, review 1 week later. If

proteinuria is persistent, seek specialist advice.

If there is 2+ protein or more on dipstick testing, seek same day

specialist advice.

Symptoms of pre-eclampsia

o o

Symptoms of pre-eclampsia
Severe headaches (increasing frequency unrelieved by regular analgesics). Vision problems, such as blurred vision, flashing lights, double vision, or floating

spots.

o o o o

Persistent new epigastric pain or pain in the right upper quadrant. Vomiting. Breathlessness. Sudden swelling of the face, hands, or feet.

Basis for recommendation

Admitting to hospital if there is proteinuria and symptoms of pre-

eclampsia, even if the woman is not hypertensive

The Pre-eclampsia Community Guideline (PRECOG) development group

reviewed the available evidence and concluded that proteinuria may be the first clinical indication of pre-eclampsia [PRECOG, 2004b]. Therefore, if the woman has symptoms suggestive of pre-eclampsia and proteinuria, then she should be assumed to have preeclampsia until proven otherwise.

Considering possible urinary tract infection (UTI)

It is good clinical practice to consider possible UTI in a woman who is pregnant

and has a positive dipstick test for protein. However, although protein may occur in the urine of women with a UTI, the presence of protein does not independently predict a UTI

[Little et al, 2009]. For detailed information on the diagnosis of UTI, see the CKS topic on Urinary tract infection (lower) - women.

Reassessment of normotensive women with 1+ protein who are well

within 1 week, and seeking specialist advice if there is persistent proteinuria

The recommendation to re-assess in 1 week is based on expert advice from

PRECOG [PRECOG, 2004a].

PRECOG does not give specific advice on what action to take if a woman has

persistent 1+ protein and is otherwise well [PRECOG, 2004a]. However, there is evidence that significant proteinuria is predictive of developing pre-eclampsia and poor pregnancy outcomes, and national guidelines advise that the presence of proteinuria should alert the healthcare professional to the need for increased surveillance [National Collaborating Centre for Women's and Children's Health, 2008]. In the absence of guidance to inform management, CKS recommends seeking specialist advice if proteinuria persists, as specialist assessment and increased monitoring may be necessary.

Seeking same day specialist advice if there is 2+ proteinuria

PRECOG recommends that all women with 2+ protein or more on dipstick

testing who are over 20 weeks' gestation should have early assessment in secondary care, as this may indicate impending pre-eclampsia or an underlying medical problem [PRECOG, 2004a]. Many of the CKS expert reviewers advised that all women with 2+ protein or more on dipstick testing should have hospital assessment within 48 hours regardless of whether or not a urinary tract infection may be the cause. Therefore CKS recommends that sameday specialist advice should be obtained.

Quantification of proteinuria by a 24-hour urine collection or spot

albumin:creatinine ratio

CKS has not recommended that GPs initiate a 24-hour collection of urine or spot

albumin:creatinine ratio for quantification of protein, as this will usually be initiated in secondary care. GPs should note that:

The National Institute for Health and Clinical Excellence (NICE)

recommends that a 24-hour urine collection or a spot urinary protein:creatinine ratio are the only reliable methods for quantification of proteinuria in women at risk of preeclampsia [National Collaborating Centre for Women's and Children's Health, 2010].

Hypertension in pregnancy - Management

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How do I assess a woman with chronic hypertension? Take a history.

Length of time that the woman has had known hypertension and her level of

control.

o o

Past and current medication. Problems in previous pregnancies, their management, and the outcome of these

pregnancies.

Consider whether investigation is required for possible secondary causes

of hypertension. For more information, see the section on Secondary hypertension in the CKS topic on Hypertension - not diabetic.

Perform a dipstick urine for proteinuria at presentation and at each

antenatal visit. Use an automated dipstick if available.

Ask about symptoms of pre-eclampsia at each review after 20 weeks'

gestation.

o o
spots.

Severe headaches (increasing frequency unrelieved by regular analgesics). Vision problems, such as blurred vision, flashing lights, double vision, or floating

o o o o

Persistent new epigastric pain or pain in the right upper quadrant. Vomiting. Breathlessness. Sudden swelling of the face, hands, or feet.

Basis for recommendation Take a history and assess if investigation for secondary causes is required

CKS has based these recommendations on accepted clinical practice.

Dipstick urine for proteinuria

o o

Proteinuria in women with chronic hypertension may be:

Due to underlying renal disease. Due to the development of pre-eclampsia if it is new and occurs after 20 weeks'

gestation.

The National Institute for Health and Clinical Excellence (NICE) recommends the

use of automated dipstick testing in secondary care. Evidence from a meta analysis of six trials and a prospective study showed that visual dipstick analysis of urine with a 1+ threshold is not accurate at detecting clinically significant proteinuria. Its use in clinical decision making is therefore limited. Accuracy is improved by using an automated dipstick device. Primary care clinicians should use automated dipsticks if they have access to them. Assessing for symptoms of pre-eclampsia

This recommendation is based on expert advice [National Collaborating Centre for

Women's and Children's Health, 2010] and three narrative reviews [Sadovsky, 2002; Duley et al, 2006; Young et al, 2010]. Women with chronic hypertension are at increased risk of pre-eclampsia [National Collaborating Centre for Women's and Children's Health, 2010]. How should I manage a woman with chronic hypertension? Advise the woman that:

She should restrict her dietary intake of salt (sodium). For more information,

see the section on Lifestyle advice in the CKS topic on Hypertension - not diabetic.

o o

Bed rest is not recommended. She will require regular monitoring of her blood pressure throughout her

pregnancy, and is likely to require more frequent antenatal checkups than usual.

The aim of treatment is to adequately control her blood pressure throughout her

pregnancy.

For uncomplicated hypertension, keep the blood pressure less than

150/100 mmHg (but diastolic pressure no less than 80 mmHg).

If there is evidence of target-organ damage (for example kidney

disease), keep the blood pressure less than 140/90 mmHg.

Warn about symptoms of pre-eclampsia and that she should seek immediate

advice if she develops any symptoms after 20 weeks' gestation (including during the postpartum period).

Prescribe aspirin 75 mg daily from 12 weeks' gestation. Explain that this is

believed to help prevent the development of pre-eclampsia.

Seek specialist advice before prescribing aspirin if blood pressure is

uncontrolled.

If she is taking an angiotensin-converting enzyme (ACE) inhibitor or

angiotensin-II receptor antagonist (AIIRA), stop this immediately and prescribe an alternative treatment if necessary.

Explain that there is an increased risk of congenital abnormalities if these drugs

are taken during pregnancy.

Refer the woman to a specialist in hypertensive disorders if the woman has

secondary hypertension, or a renal physician, an endocrinologist, or a specialist in connective tissue disease as appropriate.

Otherwise, refer the woman to an obstetric physician.

While the woman is waiting to see a specialist, continue her usual

antihypertensive treatment (unless she is taking an ACE inhibitor or AIIRA).

o o o

If the woman is not currently taking antihypertensive treatment: If her blood pressure is high, discuss management with a specialist. If her blood pressure is normal (which may be because of the

physiological drop in blood pressure that occurs in early pregnancy), monitor her blood pressure regularly.

If the woman develops proteinuria after 20 weeks' gestation then her care

becomes that of a woman with pre-eclampsia.

Advising about symptoms of pre-eclampsia

This recommendation is based on expert advice from NICE and three narrative

reviews [Sadovsky, 2002; Duley et al, 2006; Young et al, 2010]. Women with chronic hypertension are at increased risk of pre-eclampsia [National Collaborating Centre for Women's and Children's Health, 2010].

A key recommendation from the 1998 Confidential Enquiry into Maternal Deaths

that is accepted good clinical practice is that all women should receive antenatal education so that they are aware of the symptoms associated with pre-eclampsia (such as headache or epigastric pain), its importance, and the need to obtain medical advice [DH, 1998]. Aspirin to prevent pre-eclampsia

NICE concluded that there is evidence from a meta-analysis that aspirin is effective

in reducing the risk of pre-eclampsia, including in women who have chronic hypertension [National Collaborating Centre for Women's and Children's Health, 2010].

Some CKS expert reviewers warned against prescribing aspirin to women with

uncontrolled blood pressure. CKS recommends that in such women, it is best to seek specialist advice about whether or not to prescribe aspirin. Stopping angiotensin-converting enzyme (ACE) inhibitors or angiotensin-II receptor antagonists (AIIRA)

There is limited evidence regarding the use of ACE inhibitors or AIIRAs during

pregnancy. Studies suggest that ACE inhibitors are associated with congenital malformations, intrauterine growth retardation, and premature delivery, and that AIIRAs are associated with congenital malformations.

NICE states that there is sufficient concern, despite the relatively poor quality of the

studies, to recommend avoiding ACE inhibitors and AIIRAs during pregnancy [National Collaborating Centre for Women's and Children's Health, 2010]. Chlorothiazide is also possibly teratogenic but is not prescribable in the UK

NICE noted a possible association with congenital abnormalities, neonatal

thrombocytopenia, neonatal hypoglycaemia and hypovolaemia, and possible maternal

electrolyte imbalance [National Collaborating Centre for Women's and Children's Health, 2010]. Other antihypertensive drugs during pregnancy

NICE reviewed studies of other antihypertensive drugs and found:

No obvious association with congenital abnormalities for the following drugs:

methyldopa, labetalol, atenolol, metoprolol, oxprenolol, pindolol, prazosin, nifedipine, verapamil, bendroflumethiazide, furosemide, and hydralazine. No or very little information about other antihypertensive drugs is available.

Antihypertensives reduce the risk of severe hypertension but not of proteinuria.

From the limited available evidence, it is not possible to determine the best antihypertensive treatment for pregnant women with chronic hypertension.

Hypertension in pregnancy - Management

How should I assess a woman with new hypertension after 20 weeks' gestation? Check urine for protein (subsequent frequency of monitoring will be

determined by secondary care). If available, use automated dipstick testing.

Ask about symptoms of pre-eclampsia at presentation and each

subsequent antenatal check.

o o
spots.

Severe headaches (increasing frequency unrelieved by regular analgesics). Vision problems, such as blurred vision, flashing lights, double vision, or floating

o o o o

Persistent new epigastric pain or pain in the right upper quadrant. Vomiting. Breathlessness. Sudden swelling of the face, hands, or feet.

Basis for recommendation Testing for proteinuria by dipstick estimation

This is based on expert advice in the National Institute for Health and Clinical

Excellence (NICE) guideline Antenatal care: routine care for the healthy pregnant woman [NICE, 2008b] which recommends testing for protein at each antenatal visit. This is particularly important in women with new hypertension who are at an increased risk of pre-eclampsia [National Collaborating Centre for Women's and Children's Health, 2010]. Rarely, pre-eclampsia may present atypically without proteinuria [Sibai et al, 1993].

There is good evidence from a systematic review and a subsequent prospective

study that automated dipstick testing is more accurate than visually read dipstick testing [National Collaborating Centre for Women's and Children's Health, 2010]. Assessing for symptoms of pre-eclampsia

This recommendation is based on expert advice from NICE [National Collaborating

Centre for Women's and Children's Health, 2010] and three narrative reviews [Sadovsky, 2002; Duley et al, 2006; Young et al, 2010]. Women with new hypertension are at increased risk of pre-eclampsia [National Collaborating Centre for Women's and Children's Health, 2010]. How should I manage a woman with new hypertension after 20 weeks' gestation? If urine is negative for protein:

Admit immediately if the woman has severe hypertension (blood

pressure 160/110 mmHg or higher) or if she has symptoms of pre-eclampsia.

Otherwise, discuss with the local maternity unit to arrange urgent assessment.

If urine is positive for protein (1+ protein or more on automated dipstick

testing, or a trace or more on visual dipstick testing):

Discuss immediately with the local maternity unit, to arrange urgent assessment

or admission.

Basis for recommendation Management of gestational hypertension (new hypertension presenting at 20 weeks' gestation or more without proteinuria)

These recommendations are based on expert opinion from the National Institute for

Health and Clinical Excellence (NICE) [National Collaborating Centre for Women's and Children's Health, 2010], which recommends:

That all women with gestational hypertension should be offered an integrated

package of care that may include hospital admission, regular measurement of blood pressure, testing for proteinuria, and relevant blood tests.

Admission to hospital if blood pressure is 160/110 mmHg or greater.

Expert assessment is also recommended as pre-eclampsia may present atypically;

20% of women with atypical eclampsia have minimal or absent proteinuria [Young et al, 2010]. Management of pre-eclampsia

These recommendations are based on expert opinion from NICE [National

Collaborating Centre for Women's and Children's Health, 2010], which recommends:

That all women with pre-eclampsia should be offered immediate admission and

an integrated package of care, regular measurements of blood pressure, testing for proteinuria, and relevant blood tests.

How will gestational hypertension be managed in secondary care? The following is a summary of secondary care management recommended by the National Institute for Health and Clinical Excellence (NICE).

Women with severe hypertension will be admitted.

Blood pressure will be measured four times a day. The woman will be kept in

hospital until her blood pressure is 159/109 mmHg or lower.

Blood will be taken to test for kidney function, electrolytes, full blood count,

transaminases and bilirubin on presentation.

Urine will be tested for protein using automated dipsticks or urinary

protein:creatinine ratio.

o o

Antihypertensive medication will be prescribed: Labetalol is the first choice.

Methyldopa and nifedipine are alternatives after consideration of the

adverse effect profile for the mother and the fetus.

o o

Follow up Once blood pressure has fallen to 159/109 mmHg or lower, women will

be followed up in outpatients/an early pregnancy assessment centre with twice-weekly blood pressure monitoring; twice-weekly automated dipstick testing for protein: and once-weekly blood tests for urea and electrolytes, full blood count, transaminases, and bilirubin.

Birth before 37 weeks will only be offered to women with refractory

severe hypertension after a course of antenatal steroids (if required) has been completed.

Women with moderate hypertension will be managed and followed up in

an outpatient setting or at a pregnancy assessment centre.

Blood will be taken for urea and electrolytes, full blood count, transaminases,

and bilirubin, if not already done by the GP on presentation.

o o o

Antihypertensive medication will be prescribed: Labetalol is the first choice. Methyldopa and nifedipine are alternatives after consideration of the

adverse effect profile for the mother and the fetus.

o o

Follow up Will be in outpatients/a pregnancy assessment unit with twice-weekly

blood pressure monitoring, and twice-weekly testing of urine for protein using automated dipsticks or urinary protein:creatinine ratio.

o
proteinuria.

Further blood tests will not be performed unless the woman develops

Women with mild hypertension will be managed and followed up in an

outpatient setting or at a pregnancy assessment centre.

o o

Blood tests other than those done for routine antenatal care will not be needed. Monitoring will be as follows:

If presenting before 32 weeks, or if at high risk of pre-eclampsia, the

woman will have blood pressure monitoring and testing of urine for protein using automated dipsticks or urinary protein:creatinine ratio twice a week.

If presenting after 32 weeks and not at high risk of pre-eclampsia, the

woman will have blood pressure and urine checked for protein using automated dipsticks or urinary protein:creatinine ratio not more often than once per week.

Bed rest in hospital is not recommended as a treatment for gestational

hypertension.

Aspirin 75 mg daily will be prescribed until the birth of the baby only if the

woman has either:

o o

One or more high risk factors for pre-eclampsia. Two or more for moderate risk factors for pre-eclampsia.

Anaemia - iron deficiency - Management

What are the clinical features of iron deficiency anaemia? What are the symptoms? Symptoms associated with iron deficiency anaemia will depend on how quickly the

anaemia develops. For example, people with chronic, slow blood loss may be able to tolerate very low levels of haemoglobin with few symptoms.

o o o o o o

Symptoms commonly include fatigue, dyspnoea, and palpitations. Less common symptoms include:
Headache. Tinnitus. Taste disturbance. Pruritus. Pica (abnormal dietary cravings, e.g. ice, clay). Sore tongue.

Dysphagia (in association with oesophageal web which occurs in Patterson-

Brown-Kelly or Plummer-Vinson syndromes).

Otherwise healthy people with slow-onset anaemia may present with fatigue and

dyspnoea on exertion as their only symptoms.

Serious symptoms such as angina, marked ankle oedema, or dyspnoea at rest are

unlikely at haemoglobin concentrations of more than 7 g/dL unless there is additional heart or lung pathology. Angina may occur if there is pre-existing coronary artery disease. What are the signs? There may be no signs, even if the person has severe anaemia. Pallor may be observed even with mild anaemia: Less commonly:

o o o o

Atrophic glossitis. Angular cheilosis (ulceration of the corners of the mouth). Nail changes, such as longitudinal ridging and koilonychia (spoon-shaped nails). Tachycardia, murmurs, cardiac enlargement, and heart failure may occur if

anaemia is severe (haemoglobin < 8 g/dL).

What investigations should I do to confirm anaemia?

o o
anaemia):

Check a full blood count (see Interpreting a full blood count). For people with a low haemoglobin and low mean cell volume (i.e. microcytic

o
ferritin levels).

For a non-pregnant person, check the ferritin level (see Interpreting

For a pregnant woman, consider checking ferritin levels. Microcytic

anaemia in this group is highly likely to be due to iron deficiency and ferritin results may be less reliable in pregnancy.

It is less clear in which groups of people vitamin B12 and folate levels should

also be checked, and when this should be done. Consider particularly if the person is anaemic and:

o o

The anaemia is normocytic with a low or normal ferritin level. There is an inadequate response to iron supplements in proven iron

deficiency anaemia and no reason for this (e.g. poor compliance) is apparent.

Vitamin B12 or folate deficiency is suspected (e.g. dietary deficiency,

malabsorption, lack of folate supplementation in pregnancy).

o
anaemia).

The person is in an older age group (more at risk of pernicious

For more information on testing for vitamin B12 or folate levels, and

interpretation of the results, see the CKS topic on Anaemia - B12 and folate deficiency.

Orientation Feedback for Eclampsia; Fetal Distress

In evaluating case performance, the domains of diagnosis (including physical examination and appropriate diagnostic tests), therapy, monitoring, timing, sequencing, and location are considered. In this case, a 25-year-old woman at 38 weeks gestation comes to the emergency department after suffering a seizure with loss of consciousness about 10 minutes earlier. From the chief complaint, the differential diagnosis is broad; however, the comprehensive history narrows it. The patient is gravida 1, para 0, has been receiving routine prenatal care. The pregnancy has been uncomplicated so far. She has had a severe headache for the past 3 days, and her feet have appeared swollen during the past 2 to 3 weeks. She has never had a seizure, and there is no history of hypertension or renal or neurologic disease. The patient is conscious but appears confused. Physical examination shows tachycardia, a low-grade fever, and elevated blood pressure. Cardiovascular examination shows a loud S4 and bounding central and peripheral pulses. There is a grade 2/6 systolic ejection murmur at the left sternal border without radiation. There is marked vasospasm on funduscopic examination with normal disc margins and a minor tongue laceration. Abdominal examination shows a gravid uterus with a fundal height of 37 cm. Estimated fetal weight is 2700 g (6 lb). The fetus is cephalic by palpation with a fetal heart rate of 144 beats/min, showing signs of compromise. Genital examination reveals an edematous vulva. The cervix is dilated to 1 cm and 50% effaced. Extremities/spine examination shows 4+ pitting edema in both lower extremities to the midthigh region. Neurologic/psychiatric examination shows that the patient is conscious but oriented to person and place only. Deep tendon reflexes are 4+ with bilateral clonus at the ankles. The remainder

of the physical examination is unremarkable. The patient's illness, at this point, would seem most consistent with a neurologic or cardiovascular abnormality, possibly pregnancy-associated. In this pregnant patient, the new onset of seizure, elevated blood pressure, lower extremity edema, and hyperactive reflexes are highly suggestive of the diagnosis of eclampsia. The computer-based case simulation database contains thousands of possible tests and treatments. Therefore, it is not feasible to list every action that might affect an examinee's score. The following descriptions are meant to serve as examples of actions that would add to, subtract from, or have no effect on an examinee's score for this case. An optimal, efficient approach would include performing a complete or targeted physical examination (including skin, HEENT/neck, chest/lung, cardiovascular, abdominal, genital, extremities, and neurologic/psychologic examinations) and ordering a complete blood count (CBC) to rule out hemolysis. Stabilizing the patient with intravenous (IV) magnesium sulfate to prevent another seizure, plus an IV optimal antihypertensive (hydralazine or betablockers) to reduce blood pressure, is important. Once the patients condition is stabilized, it is imperative to deliver the fetus quickly either by stimulating contractions (using oxytocin, misoprostol, dinoprostone, or alprostadil), by performing a cesarean delivery, or by consulting obstetrics/gynecology. The fetal heart rate should be watched until delivery by ordering a fetal monitor. Some measure of patients urine output is also indicated. The diagnostic workup should also include a urinalysis and blood tests for the following: serum creatinine or blood urea nitrogen (basic metabolic profile or complete metabolic profile) to assess kidney function; electrolytes to check sodium and potassium levels; liver enzymes; PT/PTT; and platelet count to rule out disseminated intravascular coagulation. In this acute presentation, timing is critically important. An optimal approach would include completing the above diagnostic and management actions as quickly as possible (ie, during the first hour of simulated time). Examples of additional tests, treatments, or actions that could be ordered but would be neither useful nor harmful to the patient include: Arterial blood gases or Pulse oximetry Fibrin breakdown products Thrombin time, plasma Appropriate isotonic intravenous fluids Head CT Suboptimal management of this case would include: ordering a peripheral smear instead of a complete blood count to rule out hemolysis; administering intramuscular or IV phenobarbital or benzodiazepine instead of IV magnesium sulfate; administering any IV antihypertensive other than IV hydralazine or an IV beta blocker; stimulating contractions using carboprost; failing to monitor the patients urine output; or a delay in diagnosis or treatment. Examples of poor management would include failure to order a neurologic/psychiatric examination, failure to administer an antihypertensive agent, failure to monitor the fetus or mother after delivery, or administering a suboptimal seizure medication (phenobarbital).

Examples of invasive and noninvasive actions that would subject the patient to unnecessary discomfort or risk, or would add no useful information to that available through safer or less invasive means, include: Changing the location to the outpatient office or sending the patient home Mifepristone

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Case Report
Table 1 Image Tools A 37-yr-old woman (gravida, 2; para, 1) with a history of Cesarean section delivery 16 yr earlier presented at 28 weeks gestational age with complete placenta previa, possible placenta accreta, and worsening dyspnea. Although the patient complained of dyspnea with moderate exertion before pregnancy (class II symptoms, New York Heart Association Functional Classification system; table 1), she was now unable to lie flat and even became dyspneic when speaking (class IV). Her symptoms improved with heart rate control using 25 mg metoprolol orally twice daily. Physical examination revealed an arterial blood pressure of 101/59 mmHg, a regular heart rate of 107 beats/min, and a respiratory rate of 22 breaths/min. There were diastolic and holosystolic apical murmurs, 2:6 and 3:6, respectively. The patient's lungs were clear to auscultation bilaterally, and she had mild pedal edema. Electrocardiogram showed sinus tachycardia and left atrial enlargement. Preoperative transthoracic echocardiogram revealed moderate to severe mitral stenosis, moderate to severe mitral regurgitation, and moderate pulmonary hypertension with estimated pulmonary artery systolic pressure of 54 mmHg. There was moderate tricuspid regurgitation. Left and right ventricular systolic function were normal. The patient was admitted to the hospital for observation and management. Multidisciplinary meetings were held to discuss her management and included cardiology, high-risk obstetrics, and cardiac surgery, as well as cardiac and obstetric anesthesiology. Multiple studies have shown that vaginal delivery is well tolerated in most patients with valvular heart disease.5 Cesarean section is usually performed for obstetrical indications only. Because our patient had placenta previa, an elective repeat Cesarean section was planned at 36 weeks gestational age in a cardiac operating room with cardiac surgery and cardiopulmonary bypass capabilities on standby. As prophylaxis against acid aspiration, 30 ml sodium bicitrate was administered orally in the holding area. While American Society of Anesthesiologists standard monitors were placed, the patient was positioned in the left uterine displacement position. Fetal heart rate monitoring was performed by one of the obstetricians from the time of entry into the operating room until surgical site preparation. A left radial arterial catheter was placed. Because of the patient's preexisting pulmonary hypertension, the pulmonary artery was catheterized via the right internal jugular vein. The patient's initial systemic arterial blood pressure was 125/65 (mean 76) mmHg. Her heart rate was 105 beats/min. Initial pulmonary pressures were 90/50 (mean 62) mmHg. Central venous pressure was 14 mmHg with a prominent V wave. Although thermodilution cardiac output was not measured because of

tricuspid regurgitation, initial calculated mixed venous oxygen saturation was 34%. Remifentanil (0.2 g kg1 min1) was started to attenuate the sympathetic response to laryngoscopy and intubation. General anesthesia was induced with etomidate, and succinylcholine was used for paralysis, which was administered in a rapid sequence fashion. Maintenance of anesthesia consisted of a remifentanil infusion (0.050.1 g kg1 min1), a low level of isoflurane (less than 0.5 minimum alveolar concentration), and vecuronium for muscle paralysis. Higher doses of inhalational agents were avoided to prevent uterine atony. Depth of anesthesia was monitored using bispectral index (Aspect Medical Systems, Norwood, MA) and values from 4060 were maintained during the intraoperative period. The patient was ventilated using 100% oxygen. To optimize pulmonary vascular resistance, vigilant attention was paid to maintaining normocarbia. Image Tools Additional monitoring consisted of transesophageal echocardiogram. In the midesophageal four-chamber view, characteristic features of RHD are seen (fig. 1A). Mitral valve leaflets were thickened and calcified with decreased mobility. Some calcification of the mitral valve annulus was seen as well. The addition of color flow doppler showed turbulence of antegrade flow through the stenotic valve in addition to severe regurgitation (fig. 1B). The midesophageal mitral commissural view demonstrated commissural fusion (fig. 2). Transmitral blood flow velocity using continuous-wave Doppler is presented in figure 3. The mean gradient across the mitral valve was 16 mmHg. Pressure half-time measurement was 154 ms, which corresponded to an estimated mitral valve area of 1.4 cm2. Threedimensional ultrasound reconstruction of the mitral valve, viewed from the atrial side (surgeon's perspective), is presented in figure 4. The mitral valve is severely retracted with significant commissural fusion. Cesarean section was performed without complications. Apgar scores of the neonate were 4 at 1 min and 9 at 5 min. The baby required assisted ventilation for approximately 1 min. After delivery, 40 U oxytocin was administered intravenously in 2 h. No significant changes in arterial or pulmonary pressures, or in transesophageal echocardiographic examination, occurred during the procedure. At the conclusion of the procedure, the patient was extubated. She was initially monitored in the operating room after extubation to ensure normocarbia and stable pulmonary artery pressures. She was then transferred to the cardiac care unit for postoperative monitoring. Mixed venous oxygen saturation improved to 54% within 4 h after Cesarean section. The patient was discharged from the cardiac care unit on postoperative day 1 and from the hospital on postoperative day 5. She underwent mitral valve repair and tricuspid valve annuloplasty 4 months later. Case Scenario 1:- A 26 yr old pregnant female presented with chief complaints of increasing breathlessness (gradually progressive, on exertion, non seasonal, grade 2 severity) since 1 yr. She also had amenorrhea since 8 months; cough x 1 month and 2 episodes of acute respiratory distress in midnight during the past 1 month. On general examination PR was 82/min (Anacrotic & low volume), BP-110/70 mm Hg. Cardiac examination revealed apex beat of taping character, loud S1, opening snap and a mid diastolic murmur of grade 4 intensity in mitral area. Lab investigations were within normal

limits. ECHO findings revealed moderate calcific mitral stenosis (MS) with mild regurgitation (MR), mitral valve area of 1.0 cm2, pressure gradient across mitral valve of 18 mmHg, ejection fraction- 52%. 1. Which of the following statement is incorrect regarding valvular heart diseases in pregnancy:

Rheumatoid arthritis can lead to MS Spinal anaesthesia is contraindicated in severe MS Delivery should always be via elective caesarean section Pulmonary hypertension is usually well tolerated

2. ECG findings in this case is suggestive of

P-Pulmonale with Rt. ventricular Hypertrophy P-Pulmonale with Lt. Ventricular Hypertrophy M-mitrale with Rt. Ventricular Hypertrophy M-mitrale with Lt. Ventricular Hypertrophy

3. The severity of MS is graded by the following factors except:

Mean pressure gradient >10 mmHg Pulmonary artery pressure > 50 mmHg Presence of atrial thrombus Mitral valve area < 1cm square

4. Pulmonary edema can occur in severe MS due to all the following except:

cardiac output during atrial fibrillation Tachycardia Trendelenburg position SVR

5. Which of the following statement is correct regarding the perioperative anaesthetic management of MS?

Ephedrine is preferable to phenylephrine for control of intraoperative hypotension Ketamine is a preferred inducing agent due to its favourable effects on SVR Liberal use of IV fluids may maintain blood volume and prevent hypotension Atracurium should be best avoided while choosing a muscle relaxant

6. Treatment of atrial fibrillation in severe MS may include all of the following except:

Calcium channel blockers Cardioversion Diuretic Digoxin

Case Scenario 2: A 38 years male adult was admitted in emergency department with altered consciousness and history of increasing shortness of breath. He had a past history of chest pain (angina) 6 months back, one episode of syncope 2 months back and easy fatigability and dyspnoea on routine daily activities. On auscultation, a pan-systolic murmur was audible at left sternal border radiating to neck. Heart rate was 96 beats per min, blood pressure was 162/90 mmHg and respiratory rate was 26 breaths per min. Electrocardiogram revealed left ventricular hypertrophy while Doppler examination demonstrated severe aortic stenosis (AS) with a gradient of 70 mm Hg, moderate aortic incompetence (AI) and mild mitral regurgitation (MR). 7. Which of the following is not a predominant symptom of AS?

Paroxysmal nocturnal dyspnoea Angina Dyspnoea Syncope

8. Which of the following is incorrect regarding premedication for patients with valvular heart disease?

Premedication prevents any undesirable HR during induction in AS Afterload due to sympathetic stimulation does not affect regurgitant volume in AI CO2 levels due to narcotic-induced hypoventilation can pulmonary pressures in MS/MR Any SVR can compromise forward left ventricular output in MR

9. Which is the most sensitive modality to assess perioperative cardiac functions/ischemia in this lesion?

Electrocardiography. Transesophageal Echocardiography Transthoracic Echocardiography Pulmonary artery catheter

10. Special considerations pertinent to perioperative management of AS include all except:

Hypotension may lead to myocardial ischemia and cardiac arrest Bradycardia is favourable as it increases stroke volume. Regional anaesthesia should be administered very cautiously. Tachycardia is undesirable as it decreases coronary perfusion.

11. All of the following are the complications associated with AS except:

Sudden death Myocardial infarction Aortic insufficiency Atrial fibrillation

Case Scenario 1:- A 26 yr old pregnant female presented with chief complaints of increasing breathlessness (gradually progressive, on exertion, non seasonal, grade 2 severity) since 1 yr. She also had amenorrhea since 8 months; cough x 1 month and 2 episodes of acute respiratory distress in midnight during the past 1 month. On general examination PR was 82/min (Anacrotic & low volume), BP-110/70 mm Hg. Cardiac examination revealed apex beat of taping character, loud S1, opening snap and a mid diastolic murmur of grade 4 intensity in mitral area. Lab investigations were within normal limits. ECHO findings revealed moderate calcific mitral stenosis (MS) with mild regurgitation (MR), mitral valve area of 1.0 cm2, pressure gradient across mitral valve of 18 mmHg, ejection fraction- 52%. 1. Which of the following statement is incorrect regarding valvular heart diseases in pregnancy:

Rheumatoid arthritis can lead to MS Spinal anaesthesia is contraindicated in severe MS Delivery should always be via elective caesarean section Pulmonary hypertension is usually well tolerated

2. ECG findings in this case is suggestive of

P-Pulmonale with Rt. ventricular Hypertrophy P-Pulmonale with Lt. Ventricular Hypertrophy M-mitrale with Rt. Ventricular Hypertrophy M-mitrale with Lt. Ventricular Hypertrophy

3. The severity of MS is graded by the following factors except:

Mean pressure gradient >10 mmHg Pulmonary artery pressure > 50 mmHg Presence of atrial thrombus Mitral valve area < 1cm square

4. Pulmonary edema can occur in severe MS due to all the following except:

cardiac output during atrial fibrillation Tachycardia Trendelenburg position SVR

5. Which of the following statement is correct regarding the perioperative anaesthetic management of MS?

Ephedrine is preferable to phenylephrine for control of intraoperative hypotension Ketamine is a preferred inducing agent due to its favourable effects on SVR Liberal use of IV fluids may maintain blood volume and prevent hypotension Atracurium should be best avoided while choosing a muscle relaxant

6. Treatment of atrial fibrillation in severe MS may include all of the following except:

Calcium channel blockers Cardioversion Diuretic Digoxin

Case Scenario 2: A 38 years male adult was admitted in emergency department with altered consciousness and history of increasing shortness of breath. He had a past history of chest pain (angina) 6 months back, one episode of syncope 2 months back and easy fatigability and dyspnoea on routine daily activities. On auscultation, a pan-systolic murmur was audible at left sternal border radiating to neck. Heart rate was 96 beats per min, blood pressure was 162/90 mmHg and respiratory rate was 26 breaths per min. Electrocardiogram revealed left ventricular hypertrophy while Doppler examination demonstrated severe aortic stenosis (AS) with a gradient of 70 mm Hg, moderate aortic incompetence (AI) and mild mitral regurgitation (MR). 7. Which of the following is not a predominant symptom of AS?

Paroxysmal nocturnal dyspnoea Angina Dyspnoea Syncope

8. Which of the following is incorrect regarding premedication for patients with valvular heart disease?

Premedication prevents any undesirable HR during induction in AS Afterload due to sympathetic stimulation does not affect regurgitant volume in AI CO2 levels due to narcotic-induced hypoventilation can pulmonary pressures in MS/MR Any SVR can compromise forward left ventricular output in MR

9. Which is the most sensitive modality to assess perioperative cardiac functions/ischemia in this lesion?

Electrocardiography. Transesophageal Echocardiography Transthoracic Echocardiography Pulmonary artery catheter

10. Special considerations pertinent to perioperative management of AS include all except:

Hypotension may lead to myocardial ischemia and cardiac arrest Bradycardia is favourable as it increases stroke volume. Regional anaesthesia should be administered very cautiously. Tachycardia is undesirable as it decreases coronary perfusion.

11. All of the following are the complications associated with AS except:

Sudden death Myocardial infarction Aortic insufficiency Atrial fibrillation

CASE Life on the line

A 32-year-old woman in the 24th week of her fourth pregnancy arrives at the emergency department complaining of cough and congestion, shortness of breath, and swelling in her face, hands, and feet. The swelling has become worse over the past 2 weeks, and she had several episodes of bloody vomiting the day before her visit. The patient says she has not experienced any leakage of fluid, vaginal bleeding, or contractions. She reports good fetal movement. The patients medical history is unremarkable, but a review of systems reveals a 15-lb weight loss over the past 2 weeks, racing heart, worsening edema and shortness of breath, and diarrhea.

Physical findings include exophthalmia and an enlarged thyroid with a nodule on the right side, as well as bilateral rales, tachycardia, tremor, and increased deep tendon reflexes. There is no evidence of fetal cardiac failure or goiter. A computed tomography (CT) scan of the mother shows bilateral pleural effusions indicative of highoutput cardiac failure. Thyroid ultrasonography (US) reveals a diffusely enlarged thyroid gland with a right-sided mass. The thyroid-stimulating hormone (TSH) level is undetectable. Fetal heart rate is in the 160s, with normal variability and occasional variable deceleration. Fetal US is consistent with the estimated gestational age and shows adequate amniotic fluid and no gross fetal anomalies. What is the likely diagnosis? This is a classic example of undiagnosed hyperthyroidism in pregnancy manifesting as thyroid storm. As the case illustrates, uncontrolled hyperthyroidism in pregnancy poses a significant challenge for the obstetrician. The condition can cause miscarriage, preterm delivery, intrauterine growth restriction, preeclampsia, andat its most dangerousthyroid storm.1 Thyroid storm is a life-threatening emergency, and treatment must be initiated even before hyperthyroidism is confirmed by thyroid function testing.2 The good news is that these complications can be successfully avoided with adequate control of thyroid function.

Bleeding During Pregnancy

CASE STUDY 1
Patient A is a woman, 24 years of age, gravida three para two, who reported she believes she is about 7 weeks pregnant. Three days previous, she noted some pink vaginal spotting. She presented with painless, dark red vaginal spotting. Patient A reported her last intercourse was more than a week ago. She denied any itching, burning, or malodorous discharge prior to the onset of her symptoms. She denied fever but thinks she had been having chills. Some nausea was reported but no vomiting. She did have a positive home pregnancy test 1 month ago. She denied uterine cramping, but admitted to some mild upper abdominal cramping. The patient complained of suprapubic pain after urination. The pain occurred after each voiding. The pain did not localize elsewhere and lasted for just a few minutes. Patient A reported some frequency, but attributed this to her pregnancy. Bowel function has been normal. She was appropriately concerned, as her previous pregnancies were uncomplicated. During the previous 6 months, Patient A has been diagnosed and treated for gonorrhea once and chlamydia twice. Follow-up testing was negative. Patient A has also been treated for recurrent lower urinary tract infection and bacterial vaginosis during the same period of time. The differential diagnosis for Patient A includes: Urinary tract infection Lower genital tract infection Threatened abortion Ectopic pregnancy Normal pregnancy Examination revealed normal external genitalia. The vagina was pink with moderate amounts of maroon-colored watery discharge noted. The cervix was pink and appeared closed. No exudate or lesions were noted on the cervix. Cultures for gonorrhea and chlamydia were obtained. Bimanual examination revealed a nontender uterus, anteverted, enlarged to a 6- to 7-week gestational size. No masses were appreciated. The uterus was normal shape and configuration. The cervix was long and closed.

Cervical motion tenderness was absent. Adnexa were slightly tender to palpation, without mass. Rectal examination was confirmatory. Urinalysis in the office revealed 10 to 20 WBCs per high-powered field, 20 to 30 RBCs, no bacteria, moderate epithelial cells, and some casts. A urine sample was forwarded to the lab for culture and sensitivity. The routine pregnancy laboratory tests were obtained, and an ultrasound exam was ordered. Laboratory findings revealed that Patient A is Rh negative with a negative antibody screen. She was offered RhoGAM per protocol and accepted. Her hemoglobin was 12.4, with the remainder of her lab work within normal limits. Her quantitative beta hCG was 14,283 mIU/mL. With an hCG that high, one would expect to be able to identify a fetus or products of conception on ultrasound. The radiologist immediately called to report that Patient A's ultrasound demonstrated a thickened endometrium and a slightly enlarged uterus measuring 9 cm x 6 cm x 8 cm. No gestational sac was noted. The left adnexa revealed a significantly increased vascularity adjacent to the left ovary. The right ovary was normal, with several small follicles. Ectopic pregnancy was suspected. The hCG levels were borderline for the administration of methotrexate. With the uncertainty of the location of the gestation and the question of the patient's ability to return for close follow-up, the patient was prepared for surgery. At the time of diagnostic laparoscopy, a 4 cm x 5 cm cornual pregnancy was noted on the left side. The tubes and ovaries were normal bilaterally. The left cornua was removed in its entirety to the level of the endometrium; however, the endometrium was not entered. Cornual pregnancies implant in the area where the fallopian tube enters the uterus. Approximately 1% to 5% of ectopic pregnancies occur in the cornua [35,81,91,92]. The uterine muscle surrounding the cornua permits the pregnancy to grow to a more advanced age, often 12 to 16 weeks, before rupture. Because this area is so vascular, ruptured cornual pregnancies can result in a profuse, rapid, and fatal hemorrhage. This patient's cornual pregnancy was not ruptured at the time of identification, and her postoperative recovery was normal. Urine culture done at the time of the office visit was negative. However, the chlamydia culture was positive, and the patient was treated according to CDC guidelines [137]. Because additional pregnancies were desired, the patient was started on hormone contraception and advised not to conceive for at least 1 year after her surgery in an effort to allow the uterine incision site to completely heal.

CASE STUDY 2
Patient R is 38 years of age, gravida 4 para 2, who had a spontaneous abortion 8 months previous. She presented at 15 weeks gestation. Her initial obstetric appointment was completed at 11 weeks gestation. No fetal heart tones were auscultated. Because the patient had a definite last menstrual period and the uterine size was appropriate at the time of the examination, no ultrasound was performed. Plans were made to schedule an ultrasound at 20 to 22 weeks gestation for complete evaluation secondary to a family history of cardiac anomaly. Laboratory results from her first appointment were as follows: Hemoglobin (Hgb): 12.2 Hematocrit (Hct): 36% WBC: 8,200 Platelets: 172,000 Blood type: B Rh: Positive Antibody screen: Negative Venereal disease research test: Negative Hepatitis B (HbsAg): Negative HIV: Negative

 Urine culture: Negative Urinalysis: Within normal limits; protein and glucose negative Pap smear: Normal Gonorrhea culture: Negative Chlamydia culture: Negative Rubella: Immune Physical examination at the time of her first examination revealed a height of 65 inches, weight 212 lbs, and pulse 80 beats/minute. Her blood pressure was 114/72 mm Hg. Uterine size was measured to be 10 to 12 weeks gestation; cervix was noted to be long and closed. The patient returned with complaints of brown spotting "off and on" for several days, headache, fatigue, nausea, vomiting, and swelling in her legs. She had been unable to keep food or fluids down for 24 hours. Her second exam reported a weight of 222 lbs, pulse of 86 beats/minute, and blood pressure of 162/94 mm Hg. Fundal height was recorded as 20 cm, and no fetal heart tones were monitored. Urinalysis (dipped) revealed 1+ protein and negative glucose with large ketones. Mucous membranes are dry, and the patient appears pale. Pitting edema in the calves is noted. The differential diagnosis for Patient R includes: Pre-eclampsia Multiple gestation Hyperemesis Molar pregnancy Partial molar pregnancy An ultrasound exam was ordered and revealed no fetus, but the presence of characteristic grape-like clusters in the uterus and the diagnosis of complete hydatiform molar pregnancy was made. The patient was referred to an obstetrician for evacuation and management of this pregnancy. Because diagnosis was made before surgical evacuation of the uterus, a chest x-ray was performed preoperatively. It was within normal limits. CBC, platelet count, PT, PTT, liver function tests, and renal function tests were obtained. An hCG level was also obtained for baseline. Blood type and Rh type were known from her prenatal work-up. The patient did not require RhoGAM.

CASE STUDY 3
Patient C is a married female, 22 years of age, gravida 1 para 0, at 7 weeks gestation according to her last menstrual period. This is a planned and welcome pregnancy. She called the office with complaints of bright red bleeding, lighter than a menstrual period but requiring sanitary pad protection. She also reported intermittent cramping. She denied lightheadedness, dizziness, nausea, vomiting, or focal pain. Although she had not experienced any nausea or vomiting, she reported continued breast tenderness. On arrival in the office, her vital signs were obtained. Her height was 65 inches; weight 142 lbs; blood pressure 112/68 mm Hg; pulse 76 beats/minute. She appeared to be in some discomfort from the cramping, but her color was good and she was able to answer questions without difficulty. Upon questioning, she denied any trauma, recent intercourse, or changes in discharge preceding the onset of bleeding. Her last Pap smear was done 4 months previous and was normal. Routine cervical cultures at the time were negative for chlamydia and gonorrhea. Pelvic examination reveals the following: External genitalia: A small amount of dark red blood is noted at the vaginal introitus. No lesion, trauma, or lacerations are noted. Vagina: Pink, a small amount of dark red, mucousy blood is noted in the vaginal vault. No trauma or lacerations are visible.

Cervix: Appears closed, pink without exudates or lesion. A small amount of dark blood is noted coming from the cervical os. Bimanual exam indicated a 7- to 8-week gestation-sized, anteverted uterus, mildly tender to palpation. No adnexal masses were appreciated; the cervix felt closed. The results of laboratory studies indicated: Blood type: A Rh: Positive Antibody screen: Negative CBC: Within normal limits hCG: 2400 mIU/mL An ultrasound examination was performed. An intrauterine pregnancy was noted, with a fetus and fetal cardiac activity of 136 beats per minute. A normal gestational sac was seen consistent with a pregnancy of 7 weeks 2 days. The placenta was low lying but did not cover the cervical os. No subchorionic hemorrhage was apparent. The differential diagnosis for Patient C includes: Normal pregnancy Threatened abortion Because the patient continued to bleed, a repeat quantitative beta hCG in 48 hours was ordered. When bleeding is light, it is also appropriate to repeat the ultrasound exam in 2 weeks to follow growth and viability. The patient was educated about the warning signs and symptoms of spontaneous abortion. She was encouraged to call with changes in symptoms, including bleeding saturating more than a pad an hour, passage of clots, severe cramping, lightheadedness, dizziness, fever, chills, or any other symptoms that make her uncomfortable. Two days later, the patient returned to have her hCG repeated. She was accompanied to the office by her husband. Her repeat hCG was 1500 mIU/mL. She continued to bleed lightly but had not saturated a pad an hour. She denied fever, chills, or passing any clots. Her vital signs remained stable, and she was afebrile. The pelvic exam was unchanged from 2 days previous, with the exception of the bimanual examination. Palpation of the uterus was more uncomfortable for the patient than noted in the previous exam. Patient C and her husband were told that the falling hCG levels indicate a pregnancy loss or miscarriage. Definitive diagnosis was made when the ultrasound revealed intrauterine fetal death, no fetal cardiac activity, and a collapsing gestational sac. A diagnosis of incomplete abortion or abortion in progress was made. The options of care were discussed with the patient and her husband. They were offered the choices of expectant management, medical management, or surgical evacuation of the uterus. This couple chose expectant management and were sent home with instructions to call if the bleeding saturated a pad an hour, the bleeding became foul smelling, or if she developed fever or chills. Vaginal abstinence was encouraged. The patient was instructed in NSAID pain relief measures but was asked to call if additional pain control is needed. Plans were made for a follow-up telephone call later that week, and the couple was encouraged to call with any questions or concerns. A follow-up appointment was scheduled in 2 weeks, at which time hCG levels could be measured if indicated, birth control provided, and the patient's grief response assessed.

Bleeding During Pregnancy

CASE STUDY 1
Patient A is a woman, 24 years of age, gravida three para two, who reported she believes she is about 7 weeks pregnant. Three days previous, she noted some pink vaginal spotting. She presented with painless, dark red vaginal spotting. Patient A

reported her last intercourse was more than a week ago. She denied any itching, burning, or malodorous discharge prior to the onset of her symptoms. She denied fever but thinks she had been having chills. Some nausea was reported but no vomiting. She did have a positive home pregnancy test 1 month ago. She denied uterine cramping, but admitted to some mild upper abdominal cramping. The patient complained of suprapubic pain after urination. The pain occurred after each voiding. The pain did not localize elsewhere and lasted for just a few minutes. Patient A reported some frequency, but attributed this to her pregnancy. Bowel function has been normal. She was appropriately concerned, as her previous pregnancies were uncomplicated. During the previous 6 months, Patient A has been diagnosed and treated for gonorrhea once and chlamydia twice. Follow-up testing was negative. Patient A has also been treated for recurrent lower urinary tract infection and bacterial vaginosis during the same period of time. The differential diagnosis for Patient A includes: Urinary tract infection Lower genital tract infection Threatened abortion Ectopic pregnancy Normal pregnancy Examination revealed normal external genitalia. The vagina was pink with moderate amounts of maroon-colored watery discharge noted. The cervix was pink and appeared closed. No exudate or lesions were noted on the cervix. Cultures for gonorrhea and chlamydia were obtained. Bimanual examination revealed a nontender uterus, anteverted, enlarged to a 6- to 7-week gestational size. No masses were appreciated. The uterus was normal shape and configuration. The cervix was long and closed. Cervical motion tenderness was absent. Adnexa were slightly tender to palpation, without mass. Rectal examination was confirmatory. Urinalysis in the office revealed 10 to 20 WBCs per high-powered field, 20 to 30 RBCs, no bacteria, moderate epithelial cells, and some casts. A urine sample was forwarded to the lab for culture and sensitivity. The routine pregnancy laboratory tests were obtained, and an ultrasound exam was ordered. Laboratory findings revealed that Patient A is Rh negative with a negative antibody screen. She was offered RhoGAM per protocol and accepted. Her hemoglobin was 12.4, with the remainder of her lab work within normal limits. Her quantitative beta hCG was 14,283 mIU/mL. With an hCG that high, one would expect to be able to identify a fetus or products of conception on ultrasound. The radiologist immediately called to report that Patient A's ultrasound demonstrated a thickened endometrium and a slightly enlarged uterus measuring 9 cm x 6 cm x 8 cm. No gestational sac was noted. The left adnexa revealed a significantly increased vascularity adjacent to the left ovary. The right ovary was normal, with several small follicles. Ectopic pregnancy was suspected. The hCG levels were borderline for the administration of methotrexate. With the uncertainty of the location of the gestation and the question of the patient's ability to return for close follow-up, the patient was prepared for surgery. At the time of diagnostic laparoscopy, a 4 cm x 5 cm cornual pregnancy was noted on the left side. The tubes and ovaries were normal bilaterally. The left cornua was removed in its entirety to the level of the endometrium; however, the endometrium was not entered. Cornual pregnancies implant in the area where the fallopian tube enters the uterus. Approximately 1% to 5% of ectopic pregnancies occur in the cornua [35,81,91,92]. The uterine muscle surrounding the cornua permits the pregnancy to grow to a more advanced age, often 12 to 16 weeks, before rupture. Because this area is so vascular, ruptured cornual pregnancies can result in a profuse, rapid, and fatal hemorrhage. This patient's cornual pregnancy was not ruptured at the time of identification, and her postoperative recovery was normal. Urine culture done at the time of the office visit

was negative. However, the chlamydia culture was positive, and the patient was treated according to CDC guidelines [137]. Because additional pregnancies were desired, the patient was started on hormone contraception and advised not to conceive for at least 1 year after her surgery in an effort to allow the uterine incision site to completely heal.

CASE STUDY 2
Patient R is 38 years of age, gravida 4 para 2, who had a spontaneous abortion 8 months previous. She presented at 15 weeks gestation. Her initial obstetric appointment was completed at 11 weeks gestation. No fetal heart tones were auscultated. Because the patient had a definite last menstrual period and the uterine size was appropriate at the time of the examination, no ultrasound was performed. Plans were made to schedule an ultrasound at 20 to 22 weeks gestation for complete evaluation secondary to a family history of cardiac anomaly. Laboratory results from her first appointment were as follows: Hemoglobin (Hgb): 12.2 Hematocrit (Hct): 36% WBC: 8,200 Platelets: 172,000 Blood type: B Rh: Positive Antibody screen: Negative Venereal disease research test: Negative Hepatitis B (HbsAg): Negative HIV: Negative Urine culture: Negative Urinalysis: Within normal limits; protein and glucose negative Pap smear: Normal Gonorrhea culture: Negative Chlamydia culture: Negative Rubella: Immune Physical examination at the time of her first examination revealed a height of 65 inches, weight 212 lbs, and pulse 80 beats/minute. Her blood pressure was 114/72 mm Hg. Uterine size was measured to be 10 to 12 weeks gestation; cervix was noted to be long and closed. The patient returned with complaints of brown spotting "off and on" for several days, headache, fatigue, nausea, vomiting, and swelling in her legs. She had been unable to keep food or fluids down for 24 hours. Her second exam reported a weight of 222 lbs, pulse of 86 beats/minute, and blood pressure of 162/94 mm Hg. Fundal height was recorded as 20 cm, and no fetal heart tones were monitored. Urinalysis (dipped) revealed 1+ protein and negative glucose with large ketones. Mucous membranes are dry, and the patient appears pale. Pitting edema in the calves is noted. The differential diagnosis for Patient R includes: Pre-eclampsia Multiple gestation Hyperemesis Molar pregnancy Partial molar pregnancy An ultrasound exam was ordered and revealed no fetus, but the presence of characteristic grape-like clusters in the uterus and the diagnosis of complete hydatiform molar pregnancy was made. The patient was referred to an obstetrician for evacuation and management of this pregnancy. Because diagnosis was made before surgical evacuation of the uterus, a

chest x-ray was performed preoperatively. It was within normal limits. CBC, platelet count, PT, PTT, liver function tests, and renal function tests were obtained. An hCG level was also obtained for baseline. Blood type and Rh type were known from her prenatal work-up. The patient did not require RhoGAM.

CASE STUDY 3
Patient C is a married female, 22 years of age, gravida 1 para 0, at 7 weeks gestation according to her last menstrual period. This is a planned and welcome pregnancy. She called the office with complaints of bright red bleeding, lighter than a menstrual period but requiring sanitary pad protection. She also reported intermittent cramping. She denied lightheadedness, dizziness, nausea, vomiting, or focal pain. Although she had not experienced any nausea or vomiting, she reported continued breast tenderness. On arrival in the office, her vital signs were obtained. Her height was 65 inches; weight 142 lbs; blood pressure 112/68 mm Hg; pulse 76 beats/minute. She appeared to be in some discomfort from the cramping, but her color was good and she was able to answer questions without difficulty. Upon questioning, she denied any trauma, recent intercourse, or changes in discharge preceding the onset of bleeding. Her last Pap smear was done 4 months previous and was normal. Routine cervical cultures at the time were negative for chlamydia and gonorrhea. Pelvic examination reveals the following: External genitalia: A small amount of dark red blood is noted at the vaginal introitus. No lesion, trauma, or lacerations are noted. Vagina: Pink, a small amount of dark red, mucousy blood is noted in the vaginal vault. No trauma or lacerations are visible. Cervix: Appears closed, pink without exudates or lesion. A small amount of dark blood is noted coming from the cervical os. Bimanual exam indicated a 7- to 8-week gestation-sized, anteverted uterus, mildly tender to palpation. No adnexal masses were appreciated; the cervix felt closed. The results of laboratory studies indicated: Blood type: A Rh: Positive Antibody screen: Negative CBC: Within normal limits hCG: 2400 mIU/mL An ultrasound examination was performed. An intrauterine pregnancy was noted, with a fetus and fetal cardiac activity of 136 beats per minute. A normal gestational sac was seen consistent with a pregnancy of 7 weeks 2 days. The placenta was low lying but did not cover the cervical os. No subchorionic hemorrhage was apparent. The differential diagnosis for Patient C includes: Normal pregnancy Threatened abortion Because the patient continued to bleed, a repeat quantitative beta hCG in 48 hours was ordered. When bleeding is light, it is also appropriate to repeat the ultrasound exam in 2 weeks to follow growth and viability. The patient was educated about the warning signs and symptoms of spontaneous abortion. She was encouraged to call with changes in symptoms, including bleeding saturating more than a pad an hour, passage of clots, severe cramping, lightheadedness, dizziness, fever, chills, or any other symptoms that make her uncomfortable. Two days later, the patient returned to have her hCG repeated. She was accompanied to the office by her husband. Her repeat hCG was 1500 mIU/mL. She continued to bleed lightly but had not saturated a pad an hour. She denied fever, chills, or passing any clots. Her vital signs remained stable, and she was afebrile.

The pelvic exam was unchanged from 2 days previous, with the exception of the bimanual examination. Palpation of the uterus was more uncomfortable for the patient than noted in the previous exam. Patient C and her husband were told that the falling hCG levels indicate a pregnancy loss or miscarriage. Definitive diagnosis was made when the ultrasound revealed intrauterine fetal death, no fetal cardiac activity, and a collapsing gestational sac. A diagnosis of incomplete abortion or abortion in progress was made. The options of care were discussed with the patient and her husband. They were offered the choices of expectant management, medical management, or surgical evacuation of the uterus. This couple chose expectant management and were sent home with instructions to call if the bleeding saturated a pad an hour, the bleeding became foul smelling, or if she developed fever or chills. Vaginal abstinence was encouraged. The patient was instructed in NSAID pain relief measures but was asked to call if additional pain control is needed. Plans were made for a follow-up telephone call later that week, and the couple was encouraged to call with any questions or concerns. A follow-up appointment was scheduled in 2 weeks, at which time hCG levels could be measured if indicated, birth control provided, and the patient's grief response assessed.

Case scenario 1 Manisha, a 16-year-old unmarried girl from a poor urban area comes to your clinic. She is accompanied by her mother. She joins you in the consulting room alone, and is obviously upset. After some initial discussion she tells you that she is two months pregnant and wants a termination. She is doing well at school and is hoping to become a nurse. The baby was conceived when she was forced to have sex by the boy that she was going out with, but she has no intention of having a long-term relationship with him any more. If she has the baby her parents will throw her out of the house and she will be forced to leave school. She tells you that she has already found someone who will provide an abortion near where she lives, but she is scared to go there because a friend of hers recently went to this person for an abortion and became very sick afterwards, and died. (Note: termination of pregnancy is legal in the country, but unmarried girls under 18 years require parental consent).