Ward Admission Discussion - Safiunisha, 38/F

1. ESTABLISHING THE DIAGNOSIS

Confirmed: Early Pregnancy

• Positive UPT (home + ER repeat) - confirmed pregnancy
• USG pending - will establish gestational age, viability, location (rule out ectopic), and fetal number (molar/multiple gestation can drive higher hCG and worse HG)

Primary Presentation: Hyperemesis Gravidarum (HG)

• Nausea and vomiting in early pregnancy (before 16 weeks)
• 4-5 episodes/day impairing daily function
• Likely weight loss (not documented yet - should be assessed)
• Dehydration state (clinically masked by fluid status - check ketones in urine)

• High hCG levels in multiple gestation or molar pregnancy (USG will clarify)
• H. pylori infection (known association with HG - may warrant testing and treatment)
• Thyroid dysfunction: HG causes transient gestational hyperthyroidism via TSH receptor stimulation by hCG (shared alpha subunit) - hence the wise order for FT3/FT4/TSH by the OBG team (Scott-Brown's Otorhinolaryngology, block 7)

2. BLOOD REPORT ANALYSIS

Anemia - Microcytic Hypochromic (MCV 59, MCH 22)

• Most common non-physiologic anemia in pregnancy
• Iron deficiency in pregnancy: low serum iron, high TIBC (>400 µg/dL), ferritin <20 µg/L is diagnostic
• Iron studies + Hb electrophoresis ordered - correct approach

• G7 obstetric history with 3 deaths (D3) is a major red flag for possible hemoglobinopathy in mother and/or partner
• Hb electrophoresis / HPLC ordered - excellent decision
• Important caveat: Concurrent IDA can mask HPLC findings in thalassemia. Iron deficiency should be corrected first, then repeat HPLC if initial result is inconclusive (Creasy & Resnik's Maternal-Fetal Medicine, p. 1333)

The "Pancytopenia" Question

1. IDA + nutritional anemia (most common, especially with repeated pregnancies and vomiting)
2. Folate/B12 deficiency - vomiting for 4 days with poor intake; check reticulocyte count and peripheral smear
3. Aplastic anemia of pregnancy - bone marrow hypoplasia can develop at any point during pregnancy, typically progressive, resolves after delivery (Creasy & Resnik's, p. 1303-1307)
4. Hypersplenism from any cause
5. Hemophagocytic syndrome triggered by infection (dengue, typhoid, viral)
6. Viral infections - parvovirus B19, dengue, CMV, EBV
7. Nutritional - severe folate deficiency in repeated pregnancies (G7!)

3. WIDAL TEST - H ANTIGEN 1:80

• This is a single sample - paired sera 2 weeks apart is needed to show a 4-fold rise
• H antigen titres persist longer after immunization and past infections; O antigen titres are more clinically relevant for active disease
• H 1:80 alone, without O antigen, and without clinical features (sustained fever pattern, rose spots, relative bradycardia) is not enough to diagnose enteric fever
• Widal has poor sensitivity and specificity, especially in endemic regions
• Current fever (2 spikes/day) + leukopenia is suspicious though - blood culture is the gold standard if enteric fever is seriously suspected

4. OBSTETRIC HISTORY - G7P4L1D3A2 (HIGH-RISK)

• 7 pregnancies (gravida 7)
• 4 full-term deliveries but only 1 living child (L1)
• 3 deaths (D3) - could be stillbirths, neonatal deaths, or early childhood deaths
• 2 abortions (A2)

• Hemoglobinopathy (thalassemia major in babies, parents are carriers)
• Rh incompatibility and alloimmunization - check indirect Coombs, blood grouping
• Antiphospholipid syndrome (recurrent losses)
• TORCH infections
• Gestational diabetes causing fetal loss

5. MANAGEMENT - ASSESSMENT OF CURRENT ORDERS

What was ordered - and why it's appropriate:

What could be added:

1. IV fluid resuscitation - Ringer's Lactate 1-2L (not explicitly mentioned but critical for HG)
2. Urine for ketones - confirm HG severity and monitor response
3. Blood culture x2 before antibiotics if enteric fever is suspected
4. Reticulocyte count - essential for pancytopenia workup
5. Peripheral blood smear - must-do alongside CBC
6. Serum ferritin, TIBC - complement iron studies
7. Serum folate + B12 - repeated pregnancies + poor intake + vomiting
8. LFT - HG can cause transient elevation; also baseline before medications
9. Indirect Coombs test (ICT) / Blood group and Rh typing - given obstetric history
10. Urine routine + microscopy - baseline, rule out UTI as fever source
11. Thiamine (Vitamin B1) supplementation - mandatory in HG to prevent Wernicke encephalopathy (B1 deficiency, bleeding diatheses in fetus). Give before IV dextrose.
12. DVT/VTE risk assessment - HG patients on IV fluids are at risk; consider LMWH if prolonged admission

6. ANTIEMETIC NOTE - ONDANSETRON PRECAUTION

• Recent studies suggest a possible association with oral cleft/cardiac defects in first trimester
• Ideally, first-line should be tried (doxylamine-pyridoxine / metoclopramide / promethazine) before ondansetron
• Since this is acute inpatient management and severity warrants it, the stat dose is clinically justified
• Avoid ondansetron + other QTc-prolonging drugs together (ROSEN's Emergency Medicine, block 32)

7. SUMMARY PROBLEM LIST

8. PENDING: USG RESULT IS THE PIVOT POINT

• Gestational age (management thresholds change)
• Viable IUP vs. ectopic? - vital before any intervention
• Molar pregnancy? - vesicular pattern = explains severe HG, no fetal parts
• Multiple gestation? - twin/triplet elevates hCG, worsens HG
• Cervical length, adnexal pathology

Bottom line for night team: Keep her NBM, start IV Ringer's Lactate, ensure thiamine is given before any IV dextrose, monitor vitals 4-hourly, get ketones on urine, send blood culture if fever persists, and ensure blood smear is examined when CBC returns. USG report will be the most consequential result tonight.

Anti-Snake Venom (ASV) - Dosing Protocol

India's "Big Four" - Polyvalent ASV covers:

1. Indian Cobra (Naja naja) - Neurotoxic
2. Common Krait (Bungarus caeruleus) - Neurotoxic
3. Russell's Viper (Daboia russelii) - Vasculotoxic/Hemotoxic (+ neurotoxic in some regions)
4. Saw-scaled Viper (Echis carinatus) - Hemotoxic

INDICATIONS FOR ASV (Do not give empirically)

• Neurotoxicity (ptosis, ophthalmoplegia, respiratory paralysis, dysphonia)
• Spontaneous systemic bleeding
• Non-clotting blood (20WBCT positive)
• Hypotension / cardiovascular toxicity
• Impaired consciousness
• Rhabdomyolysis
• WBC >20,000 or elevated serum enzymes
• Haemoglobinuria / myoglobinuria

• Swelling involving >half the bitten limb
• Rapid progression of swelling
• Known necrotic venom with digital/fascial compartment bites

Important: Test doses (skin/conjunctival) have NO predictive value for anaphylaxis and are NOT recommended.

ASV DOSING - INDIA PROTOCOL

Each vial = 10 mL reconstituted polyvalent ASV Children receive the SAME dose as adults (venom dose is independent of body weight)

Initial Dose

Repeat Doses

For Hemotoxic (Vasculotoxic) Bites:

• Reassess with 20WBCT (20-minute Whole Blood Clotting Test) at 6 hours after each dose
• If 20WBCT still >20 min (blood not clotting): repeat 5-10 vials (half to full dose) every 6 hours until coagulation is restored
• Liver cannot replace clotting factors in <6 hours - so do NOT re-dose before 6 hours

For Neurotoxic Bites (Cobra/Krait):

• Reassess at 1-2 hours
• If symptoms have worsened or not improved: give a second dose of 10 vials, then discontinue
• Once respiratory failure develops AND patient has received 20 vials total → stop ASV, assume all circulating venom is neutralized, shift to assisted ventilation
• Exception: King cobra / Australian elapids may require 50+ vials

Late Presenters (Days After Bite)

• Key question: Is there current venom activity?
• Perform 20WBCT:
  • Coagulopathy present → Give ASV
  • No coagulopathy → Treat complications (AKI etc.) without ASV
• Neurotoxic late presenters with active ptosis/respiratory symptoms → give 1 dose of 8-10 vials empirically (most venom likely bound, but worth neutralizing any free venom)

NEOSTIGMINE - For Neurotoxic Envenomation

ASV REACTION MANAGEMENT

Pre-treatment with antihistamines +/- hydrocortisone is practiced in India, though WHO notes evidence is limited.

THE 20WBCT (Bedside Monitoring Tool)

1. Draw 2-3 mL venous blood into a clean dry glass tube
2. Leave undisturbed at room temperature for 20 minutes
3. Tilt the tube:
   • Clots = normal (no significant coagulopathy)
   • Does NOT clot = defibrination syndrome → positive, give/repeat ASV

QUICK SUMMARY TABLE