Case on Medical Illness:

A 29 y/o medical clerk was seen at the ER due to nausea and vomiting with slight
epigastric pain. On history taking, she claimed to have regular menstrual cycle but been
amenorrheic for 2 months, Pregnancy test was done and it showed (+) result. Patient was then
referred to the OB department.
Past Medical History Bronchial asthma, last attack was a week ago. Self-medicate as
need with salbutamol inhaler.
(+) Family history of Bronchial asthma, both parents have DM, HPN and Coronary Artery disease.
LMP: August 5, 2017 PMP: July 7, 2017
BW: 190 lbs. Height: 5 2
Vital Signs: BP= 120/80 HR= 70/min RR= 18/min T= Afebrile

1. Compute for the age of gestation today and EDC of the patient. Identify the risk
factors present in the patient and discuss their effects.
Age of Gestation
LMP: August 5, 2017
Consultation date: October 16, 2017
August: 26 days +
September: 30 days +
October: 16 days +
Total: 72 days

AOG = (72 days) / (7 days) = 10 weeks & 2 days

Estimated Date of Delivery (EDD)

Using Naegeles rule: 8 / 5 / 17
-3 +7____
5 / 12 / 18
EDC = May 12, 2018

a. Bronchial asthma
The patient has a history and family history of bronchial asthma which causes
bronchoconstriction obstructing airways and decreases airflow. These reduce the forced
expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) ratio and the peak expiratory
flow (PEF). The work of breathing progressively increases and patients note chest tightness,
wheezing, or breathlessness. Subsequent alterations in oxygenation primarily reflect ventilation-
perfusion mismatching due to uneven distribution of airway narrowing. These changes are
generally reversible and well-tolerated by the healthy, non-pregnant individual. However, even
early asthma stages may be dangerous for the pregnant woman and her fetus. The patient is
more susceptible to hypoxia and hypoxemia due to the smaller functional residual capacity and
increased pulmonary shunting.
Effects of pregnancy on asthma:
With severe asthma at start of pregnancy, more likely to experience worsening disease
18-fold increased exacerbation risk following CS delivery compared with vaginal delivery

Effects of asthma on pregnancy:

Risk of preeclampsia, pre-term labor, low birth weight, and perinatal mortality
Life threatening complications: pneumothorax, cardiac arrhythmia, muscle fatigue with
respiratory arrest

b. Family history of diabetes mellitus

The patient in this case belongs to the average risk group: Asian, classified as obese, and
having a strong family history of DM based on the 4th International Workshop Conference on
Gestational Diabetes Recommendation. Due to this, she must undergo the 2-hr 75-gram OGTT
screening for GDM at first consult.
Maternal effects of DM

GDM class A2 is associated with unexplained stillbirth

Increased frequency of hypertension and need for caesarean delivery
Fetal effects:

Increased risk of macrosomia

Risk of shoulder dystocia and the need for CS
Increased chance of obesity and DM
Hypoglycemia after birth

c. Family history of hypertension and coronary artery disease

In a study by Ness et al in 2003, it was concluded that a strong family history of aggregate
cardiovascular risk increased the likelihood for developing preeclampsia and transient
hypertension of pregnancy. These findings support the theory that a pre-existing tendency to
cardiovascular risk, and particularly hypertension, increases a women's susceptibility to
developing hypertension in pregnancy.
d. Occupational risk
The patient is a medical clerk and so she is exposed to infectious diseases that can affect her
pregnancy such as CMV, TB and influenza. Infections have been a major cause of maternal and
fetal morbidity worldwide. The unique maternal-fetal vascular connection in some cases serves
to protect the fetus from infectious agents, whereas in other instances, it provides a conduit for
their transmission to the fetus.
 e. Obesity
To compute for her BMI, 2-4 lbs (expected weight gain during 1st trimester) is subtracted from
her current weight, 190lbs; then, using her height (52), her BMI can be obtained. In this case, the
patients BMI is computed to be 34 kg/m2 and by the WHO classification, this is obese I.
Excessive fat tissue is detrimental given that it has multifaceted endocrine and paracrine
functions. One major effect is that obesity interacts with inherited factors to cause insulin
resistance and in some cases, the metabolic syndrome (type 2 diabetes, dyslipidemia, and
hypertension). Obese women unequivocally have reproductive disadvantages which translate
into difficulty in achieving pregnancy, early and recurrent pregnancy loss, preterm delivery, and a
myriad of increased obstetrical, medical, and surgical complications with pregnancy, labor,
delivery, and the puerperium.

2. With the history of bronchial asthma attach a week ago, discuss your antenatal
management, the labor, delivery and post-partum care.

In 1/3 of the time, pregnancy improves asthma, in another third, it worsens asthma and lastly, in
the last third, there is no change. IV hydration and supplementation of oxygen by mask after ABG
extraction and are necessary. Continuous oxygen pulse oximetry and external fetal monitoring
are during labor and delivery. The choice of delivery is vaginal delivery because there is 18 times
increase exacerbation following CS delivery compared with vaginal. Pharmacologic treatment
includes beta agonist and EPI; however, these must be used with caution. Corticosteroids may
be given early to all patients. During exacerbations during pregnancy, initial treatment with beta
agonist is done, and if it results to PEFR>70% of baseline, the patient can be discharged.

3. When is the best time to screen the patient for DM according to the POGS CPG?
Discuss the follow-up screening until delivery.
Diabetes Mellitus on Pregnancy

As mentioned on POGSs Clinical Practice Guideline (2011), a universal screening for GDM
is recommended for all Filipino gravidas. The best time to screen a pregnant woman for DM is on
her first prenatal visit. All Filipino gravidas should be screened for type 2 DM (FBS, HbA1c or
RBS) as they are considered high risk by race or ethnic group.
A diagnosis of GDM is made if any one of the following plasma values are exceeded (Level
III, grade C) using 75-gm OGTT:

FBS > 92mg/dL (5.1 mmol/L) at any AOG

1 hour > 180mg/dL (10.0 mmol/L)
2 hours > 153mg/dL (8.5 mmol/L)
For Filipino pregnant women, POGS CPG Consensus Panel recommends the following cut-
off values for the diagnosis of GDM:

FBS 92mg/dL
2 hours > 140mg/dL
 A diagnosis of OVERT DM is given among women with any of the following results in their
first visit:

FBS 126 mg/dL (7 mmol/L)

RBS 200mg/dL (11.1 mmol/L)
HbA1c 6.5%
2 hour 75-g OGTT >200mg/dL (11.1 mmol/L)
A patient that has NO OTHER RISK FACTORS aside from race and the initial test is normal,
screening for GDM should be done between 24-28 weeks using a 2-hr 75-grams OGTT
If there are OTHER RISK FACTORS, screening should proceed immediately to 2-hr 75-
grams OGTT at first consult. If normal, repeat tests are to be done at 24-28 weeks and again later
at 32-34 weeks due to increasing glucose sensitivity as pregnancy progresses.

4. While on duty at the ER, she was exposed to a child with CMV infection. What are
the risks of this exposure to her pregnancy? Discuss the management.
CMV exposure and its management

Cytomegalovirus (CMV) is a virus which can be transmitted to a developing child before birth.
Usually, the infection is harmless and rarely causes illnesses. Once a person becomes infected,
the virus remains alive but usually dormant within that persons body for life.
CMV infection can be divided into two: primary and recurrent. Primary infection can cause more
serious problems in pregnancy than recurrent infection can.
Pregnant healthy women are not at special risk for CMV infection. They rarely have symptoms,
but rather their developing baby may be at risk for congenital CMV disease. The transmission
rate from a pregnant woman who contracts CMV during pregnancy to the fetus is between 30-
50% according to the Organization of Teratology Information Service (OTIS). Of those infected
babies, only 10-15% show signs of congenital CMV after primary maternal infection.
Characteristics of a CMV infection in newborn includes: low birth weight, microcephaly,
intracranial calcification, mental and motor retardation, deafness, jaundice, chorioretinitis, and
hemolytic anemia.
Diagnosis
CMV infections are rarely diagnosed due to the fact that the virus usually produces few, if
any, symptoms. However, people who have had CMV develop antibodies to the virus which
remain in their body which means that a blood sample test for the CMV antibody can be used in
diagnosing CMV infection. The virus can also be cultured from urine, throat swabs and tissue
samples specimens. However, these culture tests are usually expensive and not widely available.
In cases of CMV infection in pregnant women, there are a few ways that the fetus can be checked
for infection: (1) Amniocentesis can be done to check fetal fluids or blood for signs of infection.
Symptoms that may signify possible infection include low amniotic fluid levels, enlarged tissues
in the brain and intrauterine growth restriction. (2) Testing of the saliva, urine and blood can be
done once the baby is born. Cordocentesis and ultrasound may also be used.
 Treatment
Vaccines for CMV are still in the research and developmental stages, however there are
still some treatment options for CMV infection. One study revealed that hyperimmune globulin,
when given to pregnant women with CMV, may help in preventing the fetus from contracting the
infection. Currently there is no medication that can fully prevent symptoms and long-term effects
of CMV in infants, however, antiviral medications such as Ganciclovir and Valganciclovir may be
used to treat some aspects of congenital CMV. These may also foster brain development and
prevent the loss of hearing.

5. 2 x 3 Anterior neck mass that moves with deglutition and its evaluation, effects on
pregnancy and management.
When an adult patient presents with a neck mass, malignancy is the greatest concern. Although
differentiating benign and malignant masses can be difficult, a methodical approach will usually
result in an accurate diagnosis and appropriate treatment. Aside from neoplasm, other causes of
neck mass may be congenital anomalies, inflammatory and infectious conditions, trauma,
metabolic, idiopathic and autoimmune conditions.

Figure 1. Approach to diagnosis of an adult neck mass

Considering the findings of the anterior neck mass of the patient and following the approach to
diagnosis shown in Figure 1, the mass can be deduced to be thyroid in origin.
 Figure 2. Diagnostic tests for anterior neck mass in adult

Figure 3. Approach to an infectious/inflammatory neck mass (CXR = chest X-ray; U/S =

ultrasound; TFT = thyroid function test; FNA = fine-needle aspiration; EBV = Epstein-Barr
Virus; CT = computed tomography).
According to the approach presented in Figure 1, the mass can be a thyroid
infectious/inflammatory mass. Figure 2 and 3 shows the diagnostic test that should be done in
order to evaluate these masses in consideration.
Effect of pregnancy on the mass and vice versa
Human chorionic gonadotropin (hCG) and estrogen which are pregnancy-related
hormones may cause as increase in the thyroid hormone levels in the blood. Made by the
placenta, hCG is similar to TSH and mildly stimulates the thyroid to produce more thyroid
hormones. Estrogen on the other hand, produces higher levels of thyroid-binding globulin,
also known as thyroxine-binding globulin, a protein that transports thyroid hormone in the
blood. Thyroid hormone is critical to the normal development of the babys brain and
nervous system. During the first trimester, the fetus depends on the mothers supply of
thyroid hormone, which comes through the placenta. The babys thyroid begins to function
on its own at around 12 weeks.
Normally, the thyroid enlarges slightly in healthy women during pregnancy, although no
enough to be detected by a physical exam. A noticeably enlarged thyroid or thyroid
nodules can be a sign of thyroid disease and should be evaluated.
Uncontrolled hyperthyroidism during pregnancy can lead to: congestive heart failure,
preeclampsia, thyroid storm, miscarriage, premature birth, and low birth weight. On the
other hand, uncontrolled hypothyroidism during pregnancy may cause: anemia,
miscarriage, low birth weight, stillbirth and preeclampsia. Because thyroid hormones are
crucial to fetal brain and nervous system development, uncontrolled hypothyroidism
especially during the first trimestercan affect the babys growth and brain development.
Treatment
Benign Thyroid Mass Treatment
Observation
If the thyroid biopsy suggests that it is benign, watching the patient and the mass is often
most appropriate. It implies repeating thyroid blood tests, ultrasound and physical
examination in approximately one year. If the mass increase in size or establish
symptoms, repeat biopsy or another intervention may be indicated.
Thyroid Hormone Therapy

Prescribing thyroid hormone can lower the thyroid stimulating hormone (TSH) production
of the pituitary gland and thus decrease the stimulation to growth of thyroid tissue.
Surgery
Sometimes benign thyroid masses are managed with surgery. Potential reasons for
removing these masses include: large thyroid mass, produces excessive thyroid hormone,
have indeterminate or suspicious for cancer FNAs.
Malignant Thyroid Mass Treatment
 Almost all thyroid nodules that are malignant are treated by surgery. The options of extent
of thyroid surgery including total removal of the thyroid gland (total thyroidectomy) versus removal
of half of the thyroid gland (thyroid lobectomy).

6. On routine urinalysis, pus cells =30-40/hpf; rbc=8-10/hpf. What is your plan of

management with regards to this result?

Given that the patient has signs of significant pyuria (pus cell=30-40/hpf) and hematuria
(rbc=8-10/hpf), adding the fact that she is positive for pregnancy test, we make a diagnosis of
acute cystitis in pregnancy.
Treatment of acute cystitis in pregnancy should be instituted immediately to prevent the spread
of the infection to the kidney. Since E. coli remains to be the most common organism isolated,
antibiotics to which this organism is most sensitive and which are safe during pregnancy should
be used (e.g. Nitrofurantoin, Amoxicillin-clavulanate, Cephalosporins). A 7-day course is
recommended. TMP-SMX and fluoroquinolones are contraindicated during pregnancy due to its
teratogenic effect. Post-treatment urine culture should be obtained to confirm eradication of
bacteriuria and resolution of infection in pregnant women
7. On her 28 weeks AOG, she complained of initial dysuria. Painful vesicular lesions
were noted in the labia majora and peri-urethral area. What is your impression?
Discuss your differential. Give the management.
Salient features:

28 weeks AOG
Dysuria
Painful vesicular lesions in labia majora and peri-urethral area
Initial Impression: Sexually Transmitted Disease (STD)
Differential Diagnosis:

Chancroid
Rule In Rule Out
Painful lesions in genitals Characteristic of lesion is
nonindurated ulcers
(+) dysuria
Ruled Out

Syphilis
Rule In Rule Out
Presence of lesion in the genital Lesions are painless
area (+) dysuria
Ruled Out

Herpes Type 2 Infection

Rule In Rule Out
Painful vesicular lesions in genitals
 (+) dysuria
Ruled Out

Final Diagnosis: Type 2 Herpes simplex virus Infection

Management:
Antiviral therapy with acyclovir, famciclovir, or valacyclovir has been used for treatment of
first-episode genital herpes. Oral or parenteral preparations attenuate clinical infection and the
viral shedding duration. For intense discomfort, oral analgesics and topical anesthetics may
provide some relief, and urinary retention is treated with an indwelling bladder catheter. Acyclovir
appears to be safe for use in pregnant women. The manufacturers of acyclovir and valacyclovir,
in cooperation with the Centers for Disease Control and Prevention, maintained a registry of
outcomes following exposure to these drugs during pregnancy through 1999. More than 700
neonates exposed during the first trimester were evaluated, and no increased adverse effects
were found. At this time, there are insufficient data with famciclovir exposure, although a
pregnancy registry is being maintained.

Reference:
Clinical Practice Guideline on Diabetes Mellitus in Pregnancy (2011). Philippine
Obstetrical and Gynecological Society (Foundation), Inc.
Komal PS, Mestman JH. Graves hyperthyroidism and pregnancy: a clinical update.
Endocrine Practice.2010;16(1):118129.
Organization of Teratology Information Specialists. (2014). Cytomegalovirus (CMV) and
pregnancy. Retrieved from: http://www.mothertobaby.org/files/Cytomegalovirus.pdf. Retrieved
on: October 28, 2017
Thandar, M.A. & Jonas N.E. (May 2004). An Approach to Neck Mass. CME Volume 22.
No. 5. Retrieved from: https://www.ajol.info/index.php/cme/article/viewFile/43974/27491.
Retrieved on: October 28, 2017;
Williams Obstetrics. 24th Edition. Sexually Transmitted Diseases. Chapter 65, pp. 1265-
1276. McGraw Hill. 2014.