1. NYU Medical Grand Rounds Clinical Vignette Demetrios Tzimas, PGY 2 October 27, 2010 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

2. 33 year old G3P0020 female at 28 weeks gestation with dichorionic twins, admitted for steroid administration due to 34% growth discordance. Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

3. The patient’s HPI begins 10 years prior to admission, when she had a spontaneous first trimester abortion. 8 years prior to admission, she had an ectopic pregnancy. She was diagnosed with lupus the year of admission. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

4. At the time of diagnosis, she presented with photosensitivity, lymphopenia, autoimmune hemolytic anemia, and antinuclear antibody positivity. She met 4 of the 11 diagnostic criteria for SLE, but tested negative for antiphospholipid syndrome. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

5. Her pregnancy was uncomplicated until the day of admission, when she saw her physician for a routine prenatal visit. In the office, ultrasonography demonstrated a 34% growth discordance between the fetuses. She was admitted for steroid administration to improve fetal lung maturity. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

6. Additional History Past Medical History: Hypothyroidism Systemic Lupus Erythematosus Past Surgical History: Tonsillectomy Social History: Is married and lives with her spouse in New York City. Works as a certified public accountant for an accounting firm in Manhattan. Denies ever using tobacco or drugs, and drinks socially but not since she has been pregnant. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

7. Additional History Family History: Mother - Hypertension Father- Type II Diabetes Mellitus Allergies: No Known Drug Allergies Medications: Levothyroxine sodium 125mcg daily Prednisone 20mg daily Azathioprine 50mg twice daily Folic Acid daily Prenatal Vitamins daily U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

8. Physical Examination General: Patient appears of stated age, in no acute distress. Vital Signs: T: 98.3 BP: 140/90 HR: 75 RR: 12 O2 sat: 100% on room air Soft, non-tender, gravid abdomen Remainder of physical exam was normal U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

9. Laboratory Findings Complete Blood Count: within normal limits Basic Metabolic panel: within normal limits Hepatic panel: within normal limits Urinalysis: negative for protein U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

10. 34% growth discordance between dichorionic twin fetuses of unclear etiology Working Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

11. Hospital Day 1: –Betamethasone was administered intramuscularly. –The patient remained asymptomatic, but was not discharged as her systolic blood pressures were labile, ranging between 130s to 160s. Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

12. Hospital Day 2-5: –The patient was started on oral antihypertensives. –Intravenous hydralazine was later added to her regimen as her pressures remained difficult to control. –A urinalysis revealed 30mg of protein. A 24-hour urine revealed over 3g of protein at that time. Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

13. Preeclampsia Revised Working Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

14. Hospital Day 6-11: –The patient remained asymptomatic, but with continued labile blood pressures requiring intermittent intravenous medications. Hospital Day 12-15: –The patient began to feel contractions, and terbutaline was instituted for tocolysis. Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

15. Hospital Day 16: –Ultrasonography demonstrated resolved discordance between the size of the fetuses. Hospital Day 17-26: –The patient continued to be hypertensive with persistence of proteinuria, and worsening of her protein to creatinine ratio. Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

16. Hospital Day 27: –The patient complained of headaches throughout the late evening with continued hypertension with systolic blood pressures in the 170s. Hospital Day 28: –Due to worsening symptoms, the patient underwent a caesarian section at 32 weeks gestation. She gave birth to two viable children. Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

17. Hospital Day 33: –The patient’s proteinuria had resolved and blood pressures normalized. She was discharged home on her previous medication regimen. Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

18. Severe preeclampsia requiring caesarian section, secondary to a high predisposition from systemic lupus erythematosus. Final Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS