The NEW ENGLAND JOURNAL of MEDICINE CASE RECORDS of the MASSACHUSETT GENERAL HOSPITAL Founded by Richard C. Cabot Eric S.Rosenberg,M..,Editor Nancy Lee Harris, M.D., Editor Jo-Anne O. Shepard, M.D., Associate Editor Alice M. Cort, M.D., Associate Editor Sally H. Ebeling, Assistant Editor Emily K. McDonald, Assistant Editor Case 16-2016: A 31-Year-Old Pregnant Woman with Fever Dwight J. Rouse, M. D., Thomas W. Keimig, M.., Laura E. Riley, M.D., Alyssa R. Letourneau, M. D., M.P. H . and Mia Y. Platt, M.D., Ph.D. Xueping Yu and Jiming Zhang 2016.06.16
Xueping Yu and Jiming Zhang 2016.06.16
Presentation of case A 31-year-old primigravid woman Dichorionic twins At 35 weeks of gestation ° Complicated by iron 胎盘 羊膜囊2 胎膜隔 胎体2 deficiency anemia and 羊膜囊1 胎体1 yperemesIs 船胎盘2 Fever
Presenta(on of case • A 31-year-old primigravid woman • Dichorionic twins • At 35 weeks of gesta(on • Complicated by irondeficiency anemia and hyperemesis • Fever
Previous medical history() The sickle cell trait, gastroesophageal reflux disease, exercise-induced asthma dysmenorrhea, a stress fracture of her left tibia clostridium difficile infection after clindamycin use and pancreatitis ° Positive for rubella- specific antibodⅰes Negative for human immunodeficiency virus (HIV) and hepatitis b virus surface antigen (HBSAg)
Previous medical history(I) • The sickle cell trait, gastroesophageal reflux disease, exercise-induced asthma, dysmenorrhea, a stress fracture of her leJ (bia, clostridium difficile infec(on aJer clindamycin use and pancrea((s • Posi(ve for rubella-specific an(bodies • Nega(ve for human immunodeficiency virus (HIV) and hepa((s B virus surface an(gen (HBsAg)
Previous medical history(ll) She did not smoke tobacco drink alcohol or use illicit drugs She did not eat lunch meat or soft cheeses during pregnancy but noted that she consumed wellboiled hot dogs and frequently ate commercialbrand hummus Her father had had deep venous thromboses her husband did not carry the sicklecell trait Current medications were ursodiol iron polysaccharide, a prenatal vitamin, doxylamine for sleep, ranitidine, and an albuter
Previous medical history(II) • She did not smoke tobacco, drink alcohol, or use illicit drugs • She did not eat lunch meat or soJ cheeses during pregnancy but noted that she consumed wellboiled hot dogs and frequently ate commercialbrand hummus • Her father had had deep venous thromboses • her husband did not carry the sicklecell trait • Current medica(ons were ursodiol, iron polysaccharide, a prenatal vitamin, doxylamine for sleep, rani(dine, and an albuter
History of present illness o Approximately 3 weeks before this evaluation mild pruritus of the palms and soles Sixteen days before this evaluation at 32 weeks 5 days of gestation) afebrile no visible rash fetal activity both fetal hearts were heard on auscultation Laboratory test results are shown in Table 1. a spot urinalysis revealed trace protein a diagnosis of cholestasis of pregnancy was made and ursodiol was administered
• Approximately 3 weeks before this evalua(on – mild pruritus of the palms and soles • Sixteen days before this evalua(on (at 32 weeks 5 days of gesta(on) – afebrile, no visible rash, fetal ac(vity – both fetal hearts were heard on ausculta(on. – Laboratory test results are shown in Table 1. A spot urinalysis revealed trace protein. A diagnosis of cholestasis of pregnancy was made, and ursodiol was administered. History of present illness(I)
History of present illness(ll) Four days laterlat 33 weeks 2 days of gestation) Persistent itching, nausea, and occasional vomiting, along with a new pruritic rash on her abdomen Fetal well-being were reassuring The patient returned home
History of present illness(II) • Four days later(at 33 weeks 2 days of gesta(on) – Persistent itching, nausea, and occasional vomi(ng, along with a new pruri(c rash on her abdomen – Fetal well-being were reassuring • The pa(ent returned home
History of present illness(lll) This evaluation On arrival Nausea, decreased appetite, frequent urination (which was unchanged from baseline), subjective fevers, and chills Contractions that had occurred during the previous 2 days and had resolved spontaneously No bleeding, dysuria, or loss of fluid
History of present illness(III) This evalua(on • On arrival – Nausea, decreased appe(te, frequent urina(on (which was unchanged from baseline), subjec(ve fevers, and chills – Contrac(ons that had occurred during the previous 2 days and had resolved spontaneously – No bleeding, dysuria, or loss of fluid
History of present illness(lll) This evaluation Physical examination Temperature was381℃ Blood pressure 120/71 mm Hg Pulse 66 beats/min Respiratory rate 22 breaths/ min Abdomen was soft and nontender Two fetal heart rates were 140 and 150 beats/ min, with accelerations and moderate variability no decelerations were noted
History of present illness(III) This evalua(on • Physical examinaBon – Temperature was 38.1℃ – Blood pressure 120/71 mm Hg – Pulse 66 beats/min – Respiratory rate 22 breaths/min – Abdomen was soJ and nontender – Two fetal heart rates were 140 and 150 beats/ min, with accelera(ons and moderate variability; no decelera(ons were noted
History of present illness(lll) This evaluation Laboratory data(o) Table 1. Laboratory Data. 1 Day arter Reference Range, 16 Days before On This This Evaluation, Variable Adults This Evaluation Evaluation on Admission Hematocrit(%) 36.046.0 31.2 30.1 (women) Hemoglobin(g/di) 12.016.0 10.1 10.1 (women) White-cell count (per mm) 4500-11,000 4940 5940 Differential count(%) Neutrophils 40 76.9 72.5 Lymphocytes 22-44 16.6 190 Monocytes 4-11 4.9 Eosinophils 0.2 Basophils 0-3 1.0 0.7 Platelet count(per mm) 150,000-400,000 209,000 205,000 Protein(g/dl) Total 6.08.3 6.6 6.4 Albumin 3.3-5.0 Globulin 1.9-4.1 3.1 3.2
History of present illness(III) This evalua(on Laboratory Data(I)
History of present illness(lll) This evaluation Treatment protocols a urine culture was obtained Acetaminophen was administered, and the infusion of intravenous f luids and fetal monitoring were continued The fetal heart patterns remained reassuring and the patient reported increased fetal movement She was discharged home later that evening and advised to monitor her temperature, to return in 2 days for an evaluation Induction of labor was scheduled for 5 days after this evaluation
History of present illness(III) This evalua(on • Treatment protocols – A urine culture was obtained – Acetaminophen was administered, and the infusion of intravenous f luids and fetal monitoring were con(nued – The fetal heart pa_erns remained reassuring, and the pa(ent reported increased fetal movement – She was discharged home later that evening and advised to monitor her temperature, to return in 2 days for an evalua(on – Induc(on of labor was scheduled for 5 days aJer this evalua(on
