Interesting case 10/29/09

Interesting case Interesting case 10/29/0910/29/09

BMH-GTBMH-GT

Dr.Huxford,DrBusch,Dr.Alnas, Dr.Huxford,DrBusch,Dr.Alnas, Dr.Witty,Dr.KhanDr.Witty,Dr.Khan

28 YO WF in 328 YO WF in 3rdrd trimester trimester

Presents with RUQ pain and Presents with RUQ pain and tendernesstenderness

Raised LFT Raised LFT ThrombocytopeniaThrombocytopenia EclempsiaEclempsia AnemiaAnemia Acute renal failure Acute renal failure

Events post C-section Events post C-section

Renal shut down Renal shut down Multiple IVF plus mannitol dripsMultiple IVF plus mannitol drips Magnesium sulfate dripsMagnesium sulfate drips Edema /anasarcaEdema /anasarca Pt transferred from NewAlbany to Pt transferred from NewAlbany to

BMHGTBMHGT

Situation on arrivalSituation on arrival

IntubatedIntubated Bilateral lung infiltratesBilateral lung infiltrates Wbs 32000; platelets 90,000 to Wbs 32000; platelets 90,000 to

150,000150,000 Mg 10Mg 10 Creatinine 5.7Creatinine 5.7 Hemoglobin 10Hemoglobin 10 D-dimer >20D-dimer >20 ALT 3000 down to 130; LDH 1530ALT 3000 down to 130; LDH 1530

HELLPHELLP

3 per 1000 pregnancies( 33 per 1000 pregnancies( 3rdrd trimester/postartum)trimester/postartum)

Complement activation ; endothelial injuryComplement activation ; endothelial injury Coagulation cascade activation Coagulation cascade activation LDH >600; ALT >70; PLT <50; LDH >600; ALT >70; PLT <50;

SCHISTOCYTES ON SMEAR; RENAL SCHISTOCYTES ON SMEAR; RENAL FAILURE PROTEINURIAFAILURE PROTEINURIA

Maternal mortality 1-3%Maternal mortality 1-3% Fetal mortality 10-35%Fetal mortality 10-35%

Management of HELLPManagement of HELLP

Fetal maturity ; iv steroids Fetal maturity ; iv steroids Prompt deliveryPrompt delivery Treat renal and pulmonary according to Treat renal and pulmonary according to

situation situation IV Magnesium to prevent seizuresIV Magnesium to prevent seizures Plasmaphresis if persists >72 hours post Plasmaphresis if persists >72 hours post

partumpartum DIC treatment ; platelets for DIC treatment ; platelets for

counts<20,000 or bleeding diasthesiscounts<20,000 or bleeding diasthesis

How did this patient do How did this patient do here ?here ?

Urgent Hemodialysis for volume Urgent Hemodialysis for volume overload overload

Diaysis was difficult due to Diaysis was difficult due to hemodynamic compromise ; had to use hemodynamic compromise ; had to use IV albumin ; blood transfusion ; suffered IV albumin ; blood transfusion ; suffered severe bradycardia during HDsevere bradycardia during HD

After 2 HD Rx started IV lasix drip with After 2 HD Rx started IV lasix drip with good diuresisgood diuresis

Lung infiltrates slowly improved Lung infiltrates slowly improved ADAM TS 13____ 43 %ADAM TS 13____ 43 %

Course of events Course of events

On lasix drip lung infiltrates slowly On lasix drip lung infiltrates slowly improved improved

ExtubatedExtubated Needed supports of BIPAPNeeded supports of BIPAP Fever due to lines Fever due to lines HypernatremiaHypernatremia d/c on biaxin d/c on biaxin Drug rash due to biaxin Drug rash due to biaxin

Follow up issues Follow up issues

WBC COUNT >20,000WBC COUNT >20,000 RENAL FAILURE RENAL FAILURE RASH RASH ANEMIA ANEMIA