Transcript Journal Club

NYU Medical Grand Rounds
Clinical Vignette
Demetrios Tzimas, PGY 2
October 27, 2010
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
• 33 year old G3P0020 female at 28 weeks
gestation with dichorionic twins, admitted for
steroid administration due to 34% growth
discordance.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• The patient’s HPI begins 10 years prior to
admission, when she had a spontaneous first
trimester abortion. 8 years prior to admission,
she had an ectopic pregnancy. She was
diagnosed with lupus the year of admission.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•At the time of diagnosis, she presented with
photosensitivity, lymphopenia, autoimmune
hemolytic anemia, and antinuclear antibody
positivity.
•She met 4 of the 11 diagnostic criteria for SLE,
but tested negative for antiphospholipid
syndrome.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•Her pregnancy was uncomplicated until the day of
admission, when she saw her physician for a
routine prenatal visit.
•In the office, ultrasonography demonstrated a
34% growth discordance between the fetuses.
•She was admitted for steroid administration to
improve fetal lung maturity.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
•Past Medical History:
•Hypothyroidism
•Systemic Lupus Erythematosus
•Past Surgical History:
•Tonsillectomy
•Social History:
•Is married and lives with her spouse in New York City.
•Works as a certified public accountant for an accounting firm in
Manhattan.
•Denies ever using tobacco or drugs, and drinks socially but not
since she has been pregnant.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
•Family History:
•Mother - Hypertension
•Father- Type II Diabetes Mellitus
•Allergies:
•No Known Drug Allergies
•Medications:
•Levothyroxine sodium 125mcg daily
•Prednisone 20mg daily
•Azathioprine 50mg twice daily
•Folic Acid daily
•Prenatal Vitamins daily
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
•General: Patient appears of stated age, in no
acute distress.
•Vital Signs: T: 98.3 BP: 140/90 HR: 75 RR: 12
O2 sat: 100% on room air
•Soft, non-tender, gravid abdomen
•Remainder of physical exam was normal
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
•Complete Blood Count: within normal limits
•Basic Metabolic panel: within normal limits
•Hepatic panel: within normal limits
•Urinalysis: negative for protein
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Working Diagnosis
• 34% growth discordance between dichorionic
twin fetuses of unclear etiology
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 1:
– Betamethasone was administered
intramuscularly.
– The patient remained asymptomatic, but was
not discharged as her systolic blood
pressures were labile, ranging between 130s
to 160s.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 2-5:
– The patient was started on oral
antihypertensives.
– Intravenous hydralazine was later added to her
regimen as her pressures remained difficult to
control.
– A urinalysis revealed 30mg of protein. A 24-hour
urine revealed over 3g of protein at that time.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Revised Working Diagnosis
• Preeclampsia
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 6-11:
– The patient remained asymptomatic, but with
continued labile blood pressures requiring
intermittent intravenous medications.
• Hospital Day 12-15:
– The patient began to feel contractions, and
terbutaline was instituted for tocolysis.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 16:
– Ultrasonography demonstrated resolved
discordance between the size of the fetuses.
• Hospital Day 17-26:
– The patient continued to be hypertensive with
persistence of proteinuria, and worsening of
her protein to creatinine ratio.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 27:
– The patient complained of headaches
throughout the late evening with continued
hypertension with systolic blood pressures in
the 170s.
• Hospital Day 28:
– Due to worsening symptoms, the patient
underwent a caesarian section at 32 weeks
gestation. She gave birth to two viable
children.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 33:
– The patient’s proteinuria had resolved and
blood pressures normalized. She was
discharged home on her previous medication
regimen.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
• Severe preeclampsia requiring caesarian
section, secondary to a high predisposition
from systemic lupus erythematosus.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS