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Melinda Halsey is a 31 year old G-2, P-1 at 35 4/7 weeks gestation who presented yesterday with abdominal pain. Her pain started in her right flank and was intense, lasting several minutes, before easing off. This would occur every 10 minutes. When she had the pain, it was an intensity of 9/10. The pain shifted to her central lower abdomen, where it is still cramping in nature. She took her temperature at home and it was 101.2 by ear thermometer.
She’s had no trouble with urination other than her usual urinary frequency. She had three episodes of loose BMs this morning, but no BMs since then. She is hungry and would like some Pizza.
Her pregnancy has been uneventful and her previous pregnancy was also uneventful, resulting in a full term delivery. She has no significant medical or surgical history.
Her exam is significant for uterine tenderness with mild rebound. The rest of her abdomen is soft and non-tender unless palpation impacts the uterus.
Her cervix was noted to be dilated 1 cm, and 2 cm thick, with the presenting fetal head at a -2 station. There was a foul odor coming from the vagina and there was a purulent drainage present in the cervix.
When first evaluating her, the migration of her pain from the right flank to her lower midline suggested the possibility of renal stone, or possibly pyelonephritis. For that reason, we ordered a straight cathed urine specimen, which was reported as normal. This effectively ruled out both pyelonephritis and renal stone.
I ordered a CBC, primarily to assess the white blood count, which in this case was 13,500, a little high for pregnancy.
I considered appendicitis to be very unlikely in view of her enthusiastic hunger.
With the foul-smelling purulent cervical drainage and tender uterus, chorioamnionitis seemed the most likely diagnosis.
The fetal monitor tracing was normal, so we have started her on Unasyn to treat her infection, and pitocin to induce labor. For pain relief during labor, we have started an epidural anesthetic, with good results.
