The critical pregnant patient: A field of competence not only obstetric.

Sir,

We present an extremely interesting case that let us reflect on the importance and difficulty of a correct diagnostic approach to the critical pregnant patient. A pregnant 39-year-old woman at 34th week of gestation complained of mild fever, expectoration and cough for several days. She suffered from diabetes type 1 in insulin pump therapy, and the pregnancy was at risk for mild preeclampsia. Antipyretic and empirical antibiotic therapy had been performed at home but the clinical condition worsened; therefore, she was admitted to an emergency unit. On admission, the patient was agitated and confused, her mucous membranes were dehydrated, but no sign of meningeal irritation was detected. Blood pressure was 160/110 mmHg and the body temperature 38.2°C. Laboratory examination blood revealed leukocytosis due to increased neutrophils, raised levels of C-reactive protein and hyperglycemia (420 mg/dl). Blood gas revealed a metabolic acidosis while chest radiography showed a hot bed of right lung. Based on these data, it was formulated an initial diagnosis of diabetic ketoacidosis, thus the therapy (Labetalol, empirical antibiotic and insulin therapy, hydration, Respiratory Distress Syndrome [RDS] prophylaxis) was immediately started. However, the patient's clinical condition worsened with the onset of seizures; therefore, the patient was sedated and intubated. A lumbar puncture was performed, and cerebrospinal fluid (CSF) analysis revealed a pleocytosis with predominantly polinuclear (60%) and mononuclear cells (40%). Search for gram and antigens bacterial agglutination was negative. A brain magnetic resonance (MR) scan with coronal fluid revealed a hyperintensity on the left side of temporal lobe identified as a tumor by the radiologist. Given the presence of fever, antiviral and steroid therapy by acyclovir and dexamethasone was started on the advice of the expert in infectious diseases. After a few days, polymerase chain reaction (PCR) testing of the CSF was positive for herpes simplex virus type 2 (HSV-2); therefore, cesarean section was performed under general anesthesia. No complications arose during the procedure, and a preterm but healthy infant was delivered. The mother's clinical condition improved gradually and she was discharged from the intensive critical unit after 14 days. This clinical case allows us to make some useful considerations concerning the diagnostic difficulties of certain diseases in obstetric emergency department. The diagnostic time is extremely limited in emergency conditions; therefore, the diagnosis is generally directed toward the most common diseases. Therefore, the possibility of mistake increases in these situations as in our case where all signs and symptoms seemed to direct perfectly toward a diagnosis of uncompensated diabetic ketoacidosis. However, the diagnosis is even more difficult in the critical pregnant woman because generally is directed to exclude the most common obstetric emergencies as eclampsia, Hemolysis Elevated Liver Enzimes Low Platelets (HELLP) syndrome, etc.. Indeed, the most telltale sign (seizures)-that in normal situations directs the diagnosis toward a neurological problem[1] – was misinterpreted for the concomitant presence of the pre-eclamptic syndrome that led us to hypothesize an obstetrical disease such as eclampsia.[2] Moreover, even imaging helped us to hypothesize a cerebral tumor. Fortunately, the clinical sense led us to exclude no hypothesis and to perform prophylactic antiviral therapy. This case has a great didactic validity. First, the rarity of the event needs to be emphasized. Very few cases of encephalitis by HSV-2 primary infections in pregnancy are reported in the literature.[3-5] Second, this case also shows how the pregnancy status may confound the normal diagnostic workup because the gynecologist usually evaluates the patient from the obstetrical point of view whereas the non-specialist physician tends to consider other medical conditions. In these critical cases, the teamwork is fundamental because the different knowledge in various fields of medicine can be integrated for a faster and accurate diagnosis.