OB case

[sevoflurane]

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32 y/o female G3P2 at 34 weeks. Presents with RLQ abd. pain which radiates to her back under her scapula. Started yesterday around 1:00pm. Progressively worse. Now she’s guarding. Tocodynamometer = not in active labor.

Other Pmhx:

Admitted 2 weeks ago for urethral abscess 3x5cm. To OR for I&D. Done under spinal. Easy spinal and smooth case.
1ppd smoker, still smoking. 🙁
On methadone.

VS:
ST at 135 bpm
172/88
98%
RR = 18
5’4” 275 lbs.
FHR 165
Afebrile

Hgb 11, plateles 390, WBC 16K


Pretend you are OB and Anesthesia all in one. How are you going to work this up/what are you going to ask for?
What is your plan peri-operatively and what are your concerns?

Med students and residents get first shot. This is actually a pretty straight forward case and not a zebra.... but I think this case has a couple of issues that are good to keep in mind when dealing with non-obstetric surgery in the pregnant patient.

 

[PMPMD]

Pretend you are OB and Anesthesia all in one.

I shudder at the thought.

DDx:
Pyelo
Cholecystitis
Appy


W/U:
RUQ U/S
MRI abd
PEC labs (HTN)

Plan:
Acute abdomen, so will need OR.
SAB would not be ideal if laparoscopy planned.
GETA with RSI (assuming airway looks OK)
Full OB monitors on, OBs in room with scalpels in hand.

 

[Depakote]

OB was a while ago and being a post-match 4th year hasn't helped that... These could sound really stupid.

What is the cost/benefit of using steroids in the setting of an acute infection when we've got a 34 weeker waiting to drop on us?


Also, that pain radiating to the back/shoulders makes me uneasy in the setting of a SBP in the 170s, smoker. Is it possible to get a look at the aorta without exposing the little one to radiation? (I'm just thinking out loud on this one... probably not too likely)

 

[PMPMD]

OB was a while ago and being a post-match 4th year hasn't helped that... These could sound really stupid.

What is the cost/benefit of using steroids in the setting of an acute infection when we've got a 34 weeker waiting to drop on us?


Also, that pain radiating to the back/shoulders makes me uneasy in the setting of a SBP in the 170s, smoker. Is it possible to get a look at the aorta without exposing the little one to radiation? (I'm just thinking out loud on this one... probably not too likely)

Given the acuity of the presentation, its unlikely that you could get more than one dose of steroids in.

You could eval her aorta with MRI to avoid radiation. Sens and spec are 98% for dissection.

 

[Monty Python]

32 y/o female G3P2 at 34 weeks. Presents with RLQ abd. pain which radiates to her back under her scapula. Started yesterday around 1:00pm. Progressively worse. Now she's guarding. Tocodynamometer = not in active labor.

Other Pmhx:

Admitted 2 weeks ago for urethral abscess 3x5cm. To OR for I&D. Done under spinal. Easy spinal and smooth case.
1ppd smoker, still smoking. 🙁
On methadone.

VS:
ST at 135 bpm
172/88
98%
RR = 18
5'4" 275 lbs.
FHR 165
Afebrile

Hgb 11, plateles 390, WBC 16K


Pretend you are OB and Anesthesia all in one. How are you going to work this up/what are you going to ask for?
What is your plan peri-operatively and what are your concerns?

Med students and residents get first shot. This is actually a pretty straight forward case and not a zebra.... but I think this case has a couple of issues that are good to keep in mind when dealing with non-obstetric surgery in the pregnant patient.

For some reason I keep focusing on that "on methadone" portion of the PMHx. Pt is still smoking, so social history is not the cleanest ... extrapolating from that, is she a current/former meth user? That, plus the radiating pain in the back, and I'm thinking AA like a previous poster stated. Anzalone, Crow, & Costalas (2002): aortic aneurysm can be found in young people after meth abuse.

A 3x5 cm abscess on the urethra makes me shudder. Ouch. If not an AA I would think perhaps a bug from the abscess managed to travel northward in her GU system.

 

[PMPMD]

Mycotic aneurysm?

Still not sure why she's having peritoneal signs.

 

[scudrunner]

If the patient is afebrile, how likely is infection? Seems like pyelonephritis, appendicitis, and peritonitis are unlikely. Was she on antibiotics? The relatively normal RR (esp for a prego) may also support looking for something other than an infection. But the elevated WBCs certainly indicate an immune response of some kind.

Her sympathetics are definitely in overdrive. How has her BP been so far in the pregnancy?

Good O2 sat... for now.

Might check the urine to look for any kidney pathology.

How about checking a D-dimer and coags? Recent surgery = not moving much lately. Pregnant = hyper-coagulable state to begin with. Both risk factors = not a good. Might be a clot somewhere...? Thrombosis to adrenals or kidney...? Maybe a mesenteric artery/other?

 

[sevoflurane]

SAB would not be ideal if laparoscopy planned.

Yep, and you are correct in getting pre-eclampsia labs (lft's, urine protein, etc.)

Any reason you wouldn't want to do it laparoscopically?

What is the cost/benefit of using steroids in the setting of an acute infection when we've got a 34 weeker waiting to drop on us?

Good thinking Depakote and you've got the coolest avatar on SDN. At 34 weeks the lungs are not ready for prime time and surgery is associated with premature labor. So steroids is something you are definitely going to consider. There is a sizeable difference in infant RDS between 34 and 36 weeks. I think it's something like 10-20% of neonates born at 34 weeks gestation get RDS. That's a big number compared to less than 5% after 36 weeks.

Would you start some mag/tocolysis as a preemptive adjunct?

 

[PMPMD]

If the patient is afebrile, how likely is infection? Seems like pyelonephritis, appendicitis, and peritonitis are unlikely. Was she on antibiotics? The relatively normal RR (esp for a prego) may also support looking for something other than an infection. But the elevated WBCs certainly indicate an immune response of some kind.

Her sympathetics are definitely in overdrive. How has her BP been so far in the pregnancy?

Good O2 sat... for now.

Might check the urine to look for any kidney pathology.

How about checking a D-dimer and coags? Recent surgery = mot moving much lately. Pregnant = hyper-coagulable state to begin with. Both risk factors = not a good. Might be a clot somewhere...? Thrombosis to adrenals or kidney...? Maybe a mesenteric artery/other?

Guarding is a sign of peritonitis.

Agree absence of fever is confounding.

Agree that mesenteric ischemia could be on the DDx, although the pain wasnt described as very severe.

 

[sevoflurane]

Given the acuity of the presentation, its unlikely that you could get more than one dose of steroids in.

You could eval her aorta with MRI to avoid radiation. Sens and spec are 98% for dissection.

No time for steroids now. Got to take care of the problem.

Say this happened at 3:00am. and you have no chance for an MRI cuz someone walked in with a box of nails and now it's busted. Say USD is of poor quality. Would a CT scan be OK? Or ex-lap her to see what's up....

 

[sevoflurane]

For some reason I keep focusing on that "on methadone" portion of the PMHx. Pt is still smoking, so social history is not the cleanest ... extrapolating from that, is she a current/former meth user? That, plus the radiating pain in the back, and I'm thinking AA like a previous poster stated. Anzalone, Crow, & Costalas (2002): aortic aneurysm can be found in young people after meth abuse.

A 3x5 cm abscess on the urethra makes me shudder. Ouch. If not an AA I would think perhaps a bug from the abscess managed to travel northward in her GU system.

Agree. Ouch + 😱

The back pain definitely worried me.... especially with her social history. 32 y/o with no teeth is always suspect in my book... I left that out though.

I am no addict specialist but does methadone have a role in methamphetamines treatment? Or are you saying she may have also been a meth user in addition to heroin/narcotics.

 

[urge]

Can't she just get antibiotics?

 

[sevoflurane]

She came into the ED, OB got consulted and then got a CT as it was the fastest way to get a diagnosis in this urgent situation.

Didn't they used to treat acute appendicitis with abx back in the day? I think I remember MilitaryMD posting a case about this.

Now that you have a CT.... what else would you look for which would help you in the management of the patient? Or proceed to the OR, SAB/GA, take out appendix and go back home to bed?

 

[sevoflurane]

If not an AA I would think perhaps a bug from the abscess managed to travel northward in her GU system.

ding, ding, ding...👍

 

[anonperson]

Agree. Ouch + 😱

The back pain definitely worried me.... especially with her social history. 32 y/o with no teeth is always suspect in my book... I left that out though.

I am no addict specialist but does methadone have a role in methamphetamines treatment? Or are you saying she may have also been a meth user in addition to heroin/narcotics.

Ob intern here:

Methadone is used for opiate/heroin addiction.

As far as this patient goes, as others have mentioned:

pre eclamptic labs (spot protein cr, lfts, uric acid, ldh)
UA/UCx
Renal U/S
CT of abdomen and pelvis (MRI would take too long)

Main worry is there is some type of abscess formed either from the GU system like you mentioned earlier or a ruptured appy. From what I understand, ruptured appys are treated non surgically initially with IV antibiotics (although I would have to defer to gen surg for that).

Laparoscopy would be pretty difficult with such a gravid uterus. Risk of injury is great at this point.

This patient is at the cut off for steroids, max is 34 weeks basically so giving her a dose would be an option. This would alter her CBC for the next day or so (WBC)

If shes not contracting tocolysis would be questionable. Plus it would increase risk of any pulmonary edema risk factors if were worried about pyelonephritis.

 

[scudrunner]

Guarding is a sign of peritonitis.

Agree absence of fever is confounding.

Agree that mesenteric ischemia could be on the DDx, although the pain wasnt described as very severe.

Yeah, and the pain would be pretty sudden if it were a clot, so I guess that doesn't really fit.

 

[Ronin2258]

One thing that gets me on mesenteric ischemia not being high: Food phobia/abdominal pain after eating, unless there is more history that needs to be asked.

Pain referred to the scapula suggests irritation of the diaphragm if memory serves. That would to me suggest the kidney on that side, likely pyelonephritis. Can't rule out hepatic abscess/cholecystitis, considering displacement of organs as the uterus grows.

One other thing to consider would be a tubo-ovarian abscess. I am not sure far up the tubes climb with the uterus to cause the referred pain, but it would be something to consider, especially with past history of urethral abscess and the high suspicion of IVDA. I also suspect the sexual history is, well, colorful to say the least.

What did UA show? Nitrates? Leuk Esterase?

 

[sevoflurane]

Ob intern here:
Laparoscopy would be pretty difficult with such a gravid uterus. Risk of injury is great at this point.

Boom!

So you look at the CT and look for the appendix... where would it be located at 34 weeks? With this obese lady her appendix was 3cm under the costal margin. Pushed way up north from the usual RLQ location. Her incision was essentially that of an open gallbladder. Her pain radiating to the back was a nasty look'n appendix in an unusual place.

This case is RSI/GETA for me unless there is an AW issue, and then it would be an intrathecal catheter dosed up slowly. Others may differ, but certainly something to keep in mind when choosing SAB vs GA... you need to get high levels in this case (and keep them there). I went in thinking spinal. Once I looked at the CT, I elected to go with plan B.

Some skilled practitioners may try and do this laparoscopically, but I see more disadvantages than advantages. A uterus that large is going to get in the way and pneumoperitoneum isn't exactly the best thing in this situation especially if your surgeon wants to go above 15 in such a small space.

Pretty routine case regarding an appy in the pregnant patient. Incidence is about 1-2:1000 of which 30% will not be true appendicitis which is considered acceptable as an acute appy with symptoms is dangerous to mom and baby if you sit on it. There is some literature on this situation.

The absence of fever was definitely confounding... but this was her presentation. She had been on abx and I don't know if this had anything to do with it.... not the first appy I've done without a fever.

 

[sevoflurane]

Great responses and ddx. 🙂

 

[PMPMD]

Thanks Sevo, this was a great teaching case. I was definitely in suspense waiting for the Dx.

 

[Monty Python]

Agree. Ouch + 😱

The back pain definitely worried me.... especially with her social history. 32 y/o with no teeth is always suspect in my book... I left that out though.

I am no addict specialist but does methadone have a role in methamphetamines treatment? Or are you saying she may have also been a meth user in addition to heroin/narcotics.

Methadone has no role in treating methamphetamine addiction. Call me cynical or jaundiced, but the mention of methadone (plus smoking) in her social history opened the door to the possibility of other undisclosed and undesirable aspects in her social history including a potential methamphetamine addiction. Methamphetamine is associated with a higher incidence of aortic aneurysms in young folks. Combine that with her back/shoulder pain and I'm thinking a dissection in progress.

Muddying the waters is her elevated HR and WBC while remaining afebrile.

 

[sevoflurane]

Thanks Sevo, this was a great teaching case. I was definitely in suspense waiting for the Dx.

Thanks for chppin' in. Have a great weekend.

 

[sevoflurane]

Methadone has no role in treating methamphetamine addiction. Call me cynical or jaundiced, but the mention of methadone (plus smoking) in her social history opened the door to the possibility of other undisclosed and undesirable aspects in her social history including a potential methamphetamine addiction. Methamphetamine is associated with a higher incidence of aortic aneurysms in young folks. Combine that with her back/shoulder pain and I'm thinking a dissection in progress.

Muddying the waters is her elevated HR and WBC while remaining afebrile.

I agree completely.

 

[Ronin2258]

Interesting Sevo.

Here is an Indian PDF discussing appendicitis and pregnancy I just found. Made for an interesting read.

http://medind.nic.in/maa/t03/i3/maat03i3p212.pdf

Acute appendicitis was treated with abx, and is still done in various parts of the world. In the US, abx are used to treat a ruptured appendix, then go in and do an interval appendectomy about 6 weeks later. Saw this route taken when I was still a surgery resident.

 

[WholeLottaGame7]

When I hear pain radiating to the scapula/shoulder, I always think free air. With pain in the RLQ, I'd first go to ruptured appy. I like the broad differential everyone's created; I'd add Fitz-Hugh-Curtis syndrome, which is inflammation of the liver capsule 2/2 PID (via peritoneal spread, I presume?). That could also present with RUQ pain.

 

[scudrunner]

Thanks Sevo, this was a great teaching case. I was definitely in suspense waiting for the Dx.

👍

 

[PMPMD]

Here's a blast from the past thread related to this topic.

http://forums.studentdoctor.net/showthread.php?t=251094