SECTION II: CASE STUDY : (70pts Total)
Each question has the point allocation to portions of the question indicated in brackets. Bullet points and figures are acceptable and HIGHLY encouraged.
A 37-year old woman is pregnant and has come in for a weekly check-up in the 32nd week of pregnancy. She presents with new symptoms after an already complicated pregnancy. Starting at 6weeks into the pregnancy the patient had developed hyperemesis gravidarum (HG), which continued through to week 24. During that early period the patient lost 25lb of weight and was intravenously rehydrated 5 times. The patient had also been showing the presence of large amounts of ketones (>80 mg/dL) in the urine in the latter part of this time, especially before the last IV rehydration. At the 20 week anatomical ultrasound scan there was concern that the fetus was at a smaller size than expected for gestational age. The mother was monitored more frequently to ensure that the fetus was growing appropriately. The mother underwent a routine test for gestational diabetes at 28 weeks which had come back positive, and was linked to her HG. The diabetes was being controlled with diet and insulin injections (4units) once a day in the morning when her glucose level was hardest to regulate.
At this 32 week check-up the patient mentions that in the last week she has had headaches, nausea, abdominal pain, and shortness of breath. She has noticeable and significant swelling around the face and hands, as well as the ankles, and has gained 4lbs in weight in a week. The urine test showed the presence of protein, and her BP was 150/100. A 24h urine sample was taken, and her BP re-measured after 6hrs. It was found that her urine contained 400mg of protein, and her second BP reading was 155/112.
The patient is immediately admitted, as she is showing signs of pre-eclampsia and kept on bed rest and given antihypertensives. After a few days her symptoms appeared to be worsening as her BP was increasing (to 164/124), and biophysical profiles revealed that the level of amniotic fluid was low. The mother was given corticosteroids and magnesium sulfate. 7 days after admission labor was induced despite there being no effacement or ripening of the cervix, and magnesium sulfate administration was continued. The baby was born 12 hours later. The newborn was born at 3lb 10oz, which is below the expected birthweight for 33 weeks but not within the definition of IUGR.
QUESTIONS:
THE HYPEREMESIS GRAVIDARUM: 11 pts
1. What is the definition of hyperemesis gravidarum? (1pt)
2. What is the maternal glucose sparing effect? (2pts)
3. During this period the patient lost considerable weight and had high levels of ketones in the urine.
a) What does the high urine ketones indicate about metabolism in the patient? (2pts)
b) What is the link between the ketones, weight loss, and small fetal size in those early months? (2pts)
4. The HG would also have other effects:
a) Would the patient be metabolically acidotic or alkalotic and why? (2pts)
b) Why would she require significant IV rehydration, and how would that affect her blood pressure? (2pts)
THE GESTATIONAL DIABETES: 13pts
5. Discuss:
a) carbohydrate digestion and absorption from the GI tract (3pts)
b) How insulin mediates glucose entry into the cell (3pts)
c) what gestational diabetes (GD) is and its cause (2pts)
d) why the HG and lack of glucose absorption from the GI tract contributed to the GD (2pts)
e) What is achieved through diet control and insulin injections? (2pts)
f) Uncontrolled GD can produce a macrosomic baby. How is this possible? (1pt)
THE PRE-ECLAMPSIA: 29pts
6. Pre-eclampsia is thought to be initiated by the maternal immune system attacking the placenta.
a) Upon implantation, how is the presence of the fetus hidden from the maternal immune system? (2pts)
b) How are the innate and adaptive maternal immune responses initiated in the formation of pre-eclampsia? (3pts)
c) Discuss how the endometrial lining is developed and maintained prior to implantation. (3pts)
d) Explain how a shallow implantation could be an issue in developing pre-eclampsia. (2pts)
7. Explain the formation of the edema in the patient. In your answer you should discuss:
a) the normal movement of fluid from the blood to the interstitial space, and then into the lymphatic capillaries. (4pts)
b) how this mechanism is altered here (2pts)
c) how it relates to rapid weight gain. (2pts)
8. How is the hypertension involved in the headaches experienced by the patient? (2pt)
9. Explain the proteinuria, describing:
a) how is urine formed (5pts)
b) how/why is protein present. (2pts)
10. Suggest reasons for the nausea and abdominal pain in the patient (provide one reason for each). (2pts)
LABOR AND DELIVERY: 17pts
11. What is the reasoning behind the administration of magnesium sulfate? (3pts)
12. Why is there a need to administer corticosteroids? (2pts)
13. Briefly describe the stages of labor and the role of oxytocin. (4pts)
14. Why is delivery of the fetus the only ‘cure’ for the pre-eclampsia and the gestational diabetes? (2pts)
15. What potential complication(s) can occur for the fetus with prolonged hypoxia and acidosis? (2pts)
16. For the mother, why is it vital for all fetal material (placenta, amniotic sac etc) to be delivered in the afterbirth? (2pts)
17. What are some of the risks to the well-being of the mother in terms of the possible complications/issues/events that can happen if the pre-eclampsia is not addressed (include the ultimate risk)? (2pts)