Clinical Pearls

The most common cause of septic shock in pregnancy is pyelonephritis.

When dyspnea occurs in a pregnant woman who is being treated for pyelonephritis, acute respiratory distress syndrome should be considered.

Endotoxin release from gram-negative bacteria is the cause of acute respiratory distress syndrome associated with pyelonephritis.

REFERENCES

Cunningham FG. Leveno KJ. Bloom SL, Hauth JC, Gilstrap LC III, Wenstrom KD. Renal and urinary tract disorders. In: Williams obstetrics, 22nd ed. New York: McGraw-Hill. 2005:1255-1258. Gambone JC. Moore G, Koos BJ. Common medical and surgical complicating pregnancy. In: Hacker NF. Moore JG. Gambone JC, eds. Essentials of obstetrics and gynecology, 4th ed. Philadelphia: Saunders, 2004:216-246.

A 31-year-old G1 PO woman at 24 weeks' gestation complains of a 2-day history of soreness of the right calf. She states that she has been walking slightly more over the past several days. She denies a history of medical illnesses or trauma to her legs. Her family history is unremarkable. On examination, her blood pressure is 100/60, heart rate 100 bpm. respiratory rate 12/min, and she is afebrile. The neck is supple. Heart and lung examinations are normal. The abdomen is nontender and without masses. The fundal height is 23 cm, and fetal heart tones range from 140 to 150 bpm. The right calf is somewhat tender and slightly swollen. No palpable cords are present. The Homans sign is negative.

ANSWERS TO CASE 37: Deep Venous Thrombosis in Pregnancy

Summary: A 31-year-old G1 PO woman at 24 weeks' gestation, who has been walking slightly more than usual, complains of a 2-day history of right calf soreness. On examination, her heart rate is 100 bpm and respiratory rate 12/min. Heart and lung examinations are normal. The right calf is somewhat tender and slightly swollen. No palpable cords are present, and the Homans sign is negative.

^ Next step: Noninvasive assessment for deep venous thrombosis (DVT) of the right leg.

Analysis

Objectives

1. Know that pregnancy is a hypercoagulable state and predisposes to thrombosis.

2. Know that the physical examination is not an accurate method for diagnosing DVT.

3. Know the diagnostic and therapeutic measures for DVT.

Considerations

This 31-year-old woman at 24 weeks' gestation has been walking slightly more than usual and complains of calf tenderness. The right calf is mildly tender and swollen. These subtle findings are sufficient to warrant investigations for DVT. Because of the increased levels of clotting factors (predominantly fibrinogen) and the venous stasis, pregnancy produces a hypercoagulable state. The physical examination is not very sensitive or specific for assessment of DVT. The Homans sign, that is. dorsiflexion of the foot in an attempt to elicit tenderness in the patient, is a poor test and theoretically may itself cause embolization of clots. For these reasons, many experts advise against performing this test. Instead, a noninvasive test, such as Doppler flow studies of the venous system of the affected lower extremity, is an appropriate method for assessment of DVT. If the Doppler flow test confirms a thrombosis. anticoagulation with an agent such as heparin should be initiated. In a nonpregnant woman, venography would be an option, that is, injecting radiopaque dye into a vein of the foot and taking radiographic images of the venous system.

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