Clinical Pearls

When no chorionic villi are found on uterine curettage of a pregnant woman, the most likely etiology is ectopic pregnancy.

Methotrexate inhibits DNA synthesis due to its interference with folate metabolism.

A relative contraindication to methotrexate use is an ectopic pregnancy larger than 3.5 cm or the presence of fetal cardiac activity in the tube.

REFERENCES

Mishell DR. Ectopic pregnancy. In: Stenchever MA, Droegemueller W. Herbst AL. Mishell DR, eds. Comprehensive gynecology, 4th ed. St. Louis: Mosby-Year Book. 2001:443478. Nelson AL, DeUgarte CM. Gambone JC. Ectopic pregnancy. In: Hacker NF, Moore JG, Gambone JC, eds. Essentials of obstetrics and gynecology, 4th ed. Philadelphia: Saunders. 2004:325-333.

An 18-year-old G2 PI at 35 weeks' gestation has a history of Graves' disease and is undergoing treatment with oral propylthiouracil (PTU). She states that over the last day, she has been feeling as though her "heart is pounding." She also complains of nervousness, sweating, and diarrhea. On examination, her blood pressure is 150/110, heart rate 140 bpm, respiratory rate 25/min, and temperature I00.8°F. The patient appears anxious, disoriented, and somewhat confused. The thyroid gland is mildly tender and enlarged. Cardiac examination reveals tachycardia with a grade III/VI systolic murmur. The fetal heart rate tracing shows a baseline in the 160-bpm range without decelerations. Deep tendon reflexes are 4+ with clonus. Her leukocyte count is 20,000/mm3.

+ What is the most likely diagnosis?

^ What is the best management for this condition?

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