ILA.

03
April 30, 2018
CASE 3 INTEGRATED LEARNING ACTIVITY
Group 3 and 7
3B 2019

CASE PRESENTATION  Increased LDH

A 24-year old G3P2, 35 week pregnant was admitted as an emergency case Course in the ER
complaining of dizziness and easy fatigability. During the first trimester of  Received PRBCs
pregnancy, she had episodes of vomiting. She has history of anencephaly  Thrombocytopenia
and has history of hypothyroidism. On admission, she was pale, but had no  Hypersegmented neutrophils on  No response to pulse
jaundice. Her hemoglobin was 4.9 gm/dL. MCV was 82.30, MCH was PBS methylprednisone
29.80pg, reticulocyte was 0.18%, LDH was 5175 U/L.  Decreased serum vitamin B12
 Improvement on platelet, Hgb
She received 3 units of packed red blood cells on admission. Three days and retic count on
after admission, her platelet dropped from 40,000 to 27,000/cu mm. she cyanocobalamine injection
received pulse methylprednisone for 3 days but showed no response. One week later
Peripheral smear showed hypersegmented neutrophils. Serum vitamin  Epigastric pain radiating to RLQ
B12 was 31.9 pmol/L. Cyanocobalamin injection was started and showed  Nausea and vomiting
marked improvement in platelet count 260,000/cu mm. hemoglobin and
Physical Exam (1 week later)
reticulocyte count increased to 11.7gm/dL and 10.9% respectively 10 days
 (+) Iliopsoas sign
after cobalamin injection.
 (+) Rovsing’s sign
 (+) Obturator sign
She was eventually discharged. However, one week later, she developed
epigastric pain radiationg to the right lower quadrant with nausea and Laboratory findings (1 week later)
vomiting. Physical examination findings showed (+) iliopsoas sign, (+)  Increased WBC count
Rovsing’s sign, (+) obturator sign. White blood cell count was 18,000 with  Increased neutrophils
95% segmenters.
Approach to Diagnosis of the Medical Condition
Learning Objectives Group 7
1. Discuss the diagnosis and differential diagnosis of the medical
condition
2. Explain the mechanism for the following clinical manifestations:
2.1 dyspnea and easy fatigability
2.2 pallor
3. Explain the mechanism for the following laboratory findings:
3.1 low haemoglobin
3.2 low platelet count
3.3 high serum LDH level
3.4 hypersegmented neutrophil
4. Discuss the role of vitamin B12 administration in the case
5. Discuss the diagnosis and differential diagnosis of the surgical
condition
6. Describe the effect of both the medical and surgical conditions on the
following:
6.1 pregnancy
6.2 newborn

Salient Features
Pertinent Positives Pertinent Negatives
General Data
 24 y/o
 G3P2
 35 weeks pregnant
Chief Complaint
 Dizziness and easy fatigability
History
 1st tri: Episodes of vomiting
 Hx of anencephaly
 Hx of hypothyroidism
Physical Examination
 Pale  No jaundice
Laboratory Findings
 Decreased Hgb
 Normocytic
 Normochromic
 Decreased reticulocytes

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Group 3

Working Diagnosis of the Medical Condition

Group 3
G3P2, 35 weeks AOG, Not in
labor, with Hypothyroid induced
Megaloblastic anemia of
pregnancy secondary to
Cobalamin deficiency, to consider
Folate deficiency
Group 7
G3P2, Pregnancy Uterine,
35 weeks AOG, Not in labor
with Vitamin B12 Deficiency
Anemia

Mechanisms for the Clinical Manifestations

In cobalamin deficiency, the methionine synthase reaction cannot occur,
N5-methytetrahydrofolate accumulates and the other C-1 donor forms of
tetrahydrofolate cannot be formed. The methionine synthesis from
homocysteine ceases allowing the trapping of the folate pool as N5-
methylTHF, diminishing levels of N5, N10-methylenetetrahydrofolate. N5,
N10 methyleneTHF is required for the methylation of dUMP to dTMP. Thus
in its deficiency, the thymidylate synthase reaction is slowed and dTMP
levels drops and hence DNA synthesis is also slowed down due to
nonavaliabilty of deoxyribunocleotides. Inadequate dTMP restricts DNA
but not RNA synthesis leading to large erythroid cells with small nuclei

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containing a high ratio of RNA to DNA that are removed from the
circulation, thus a decrease in the circulating red blood cells.
destruction of immature and abnormal erythroid precursors and high
content of LDH in megaloblasts of patients with megaloblastosis is
considered to be the most likely source of the raised serum enzyme
activity. Also, megaloblastic anemia can manifest with low value of
hemoglobin in association with disproportionally greater increase in total
serum LDH level

Role of Vitamin B12

Because there is eventually a marked decrease in RBCs, there is also a
decrease in oxygen in the blood or hypoxemia and then impaired oxygen
delivery to the tissues or hypoxia which is manifested by pallor. With the
presence of hypoxemia, chemoreceptors in the carotid bodies and medulla
are activated leading to an increase in ventilation producing breathing
discomfort.
• Normal daily requirement increases from 2 ug to 3 ug in pregnancy
• The increased daily requirement of vitamin B12 can be met by a diet
which contains animal product
• Since some patients have underlying diseases (such as
malabsorption and/or pernicious anemia), oral vitamin B12
supplements might not be effective
• Cyanocobalamin given IM reverses the anemia of the patient
• Standard treatment plan: 1000 ug IM 3 times/week for 2 weeks

The central processing in the brain compares the afferent and efferent
signals and dyspnea results when a mismatch occurs between the Approach to Diagnosis of the Surgical Condition
need for ventilation is not being met by the physical breathing. The Group 3
afferent receptors allow the brain to assess whether the motor commands
to the ventilator muscles are effective, meeting the required demands of
airway pressure, air flow and lung movement. When these respond
inappropriately to the command, the intensity of dyspnea increases. The
sensory cortex is simultaneously activated when motor signals are sent to
the chest wall, resulting in the conscious sensation of muscular effort
and breathlessness manifested as easy fatigability.

Mechanisms for the Lab Findings

Since more than 70% of patient with this condition were operated on with a
preoperative diagnosis of acute appendicitis, we’ve also considered cecal
diverticulitisone of our differentials.

Because dyspoiesis affects all cell lines, reticulocytopenia and, during later
stages leukopenia and thrombocytopenia develop. The mechanism of
thrombocytopenia is ineffective platelet production. Megakaryocyte
numbers are normal or increased in the marrow however platelet survival
is normal or slightly shortened. As impairment of normal DNA synthesis
leads to abnormal granulopoiesis, a frequently observed morphologic  Most frequent non-obstetric condition requiring surgery is
feature is the presence of hypersegmented neutrophils, which is a much appendicitis that occurs about 1 in every 1500 pregnancies
more specific feature of megaloblastic change than is macrocytosis.
 Pregnancy makes the diagnosis of appendicitis difficult because some
of the signs and symptoms in appendicitis can accompany a normal
Elevation of lactate dehydrogenase activity (often exceeding 1000
pregnancy such as nausea, vomiting, and leukocytosis
units) found in megaloblastosis. The very high rate of intramedullary

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 The diagnosis can be made using and ultrasound with 80% accuracy; Effects of Vitamin B12 Deficiency to Maternal and Fetal Heatlh
however, it decreases to 30% when the appendix perforates B12 Deficiency:
 PE  Methyl-malonyl CoA accumulation  NTDs
o Rebound tenderness, pain on percussion, rigidity, guarding, (+)  Insufficient Methionine and THF  NTDs
Rovsing sign, (+) Obturator sign, (+) Psoas sign  Homocysteine accumulation
o Infertility
Group7 o Recurrent Fetal loss
o Preeclampsia
o Preterm birth
o Low birth weight
o IUGR
o Cardiovascular symptoms
o Reduced physical and mental performances
o Fatigue

Premature labor:
- Uterine contractions, usually pain in the hypogastric area, of
sufficient frequency and intensity to cause effacement and
dilation of cervix
Round Ligament Pain Syndrome
- Sudden shooting pain lower abdomen that extends to the groin
especially when performing sudden movements
Ovarian Torsion
- Misdiagnosed as appendicitis or preterm labor as about 80% of
the cases are found on the right side
Ureterolithiasis
- Usually encountered during pregnancy when it passes stones
from the kidney especially when due to nephrolithiasis
Pyelonephritis
- UTIs, which is common during pregnancy, and asymptomatic
bacteuria, it can lead to the development of cystitis or
pyelonephritis
Acute Appendicitis
- Persistent abdominal pain and tenderness : findings
- Right lower quadrant pain : most frequent, although pain
migrates upward with appendiceal displacement

Working Diagnosis of the Surgical Condition

Group 3 Group 7
G3P2, 36 weeks AOG, Not in G3P2, Pregnancy Uterine, 36
labor, with Acute Appendicitis weeks AOG, Not in labor with
Acute Appendicitis

 Delay in surgery by >24hrs increases risk of perforation

 Management: Effects Acute Appendicitis to Maternal and Fetal Health
o (Group 3): Acute Appendicitis
 Surgical exploration and the subsequent removal of the - Most common cause of an acute surgical abdomen in
inflamed appendix
pregnancy.
 Prior the exploration, Antibiotics is given usually with 2nd
generation cephalosporin or a 3rd generation penicillin o Perforation
o (Group 7): Laparotomy  Can cause widespread Pus and Fecal soiling of intra-
 Diagnosis Relatively Certain: abdominal cavity
 Appendectomy through Transverse incision over  Can cause severe sepsis & a critically ill patient
point of maximal tenderness  Peritonitis
 Diagnosis Less Certain:  May cause Premature uterine contraction
 Vertical incision at lower midline o May lead to Preterm labor

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 Preterm labor is common in 1st & 3rd

trimesters
 It is highest in the 1st week following
surgery (suggests that both
appendicitis and surgical
complications lead to preterm
contractions)
 Increases risk of Fetal loss
 3 – 5% : without perforation
 36% : with perforation
- Maternal Mortality
o Rates are much lower, ranging from 0 – 2%.
o The prognosis for women who undergo appendectomy
during pregnancy is generally good
- Other complications:
o Ileus and Respiratory infections
- Non-perforated appendicitis can quickly progress to
appendicular rupture which is associated with early
delivery, miscarriage, and fetal loss
- Potential effects of pneuomoperitoneum and
pneumoamnion on fetal physiology
- Induce cardiovascular depression on the fetus

LET’S GO BATCH 2019! 100% PROMOTION!

#2019KAKAYANIN

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 ILA.03
April 30, 2018
CASE 3 INTEGRATED LEARNING ACTIVITY
Group 3 and 7
3B 2019

QUESTION & ANSWER PORTION

 1.5 Increase in Hgb every 1 packed RBC – Doc Ang
 “Effect of methylprednisone to fetus?” – Dr. Dr.
o “No effect because it does not pass the placenta” – Dr. Teh
 “Effect of anemia to mother?” – Dr. Martin
o “Uterine atony”
 Most appropriate surgical incision for this case is low mid vertical incision (para diretso CS if may complications) (kasi umakyat si
appendix) – Dr. Turingan

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