Another OB disaster

[Planktonmd]

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This is my OB case today on call:
20 Y/O G1 P0 35 weeks pregnant with no prenatal care.
Arrives to OB in active labor.
She mentions that she is feeling weak, has generalized muscle pain, has very dark urine and nausea.
Lab results show: WBC = 26000, Platelets = 300,000
AST and ALT elevated in the 400- 500 range, Alk phos 350, Direct bilirubine 9.
Fibrinogen = 80 (low).
PT= 19, PTT = 39
Blood sugar = 34
Blood gas shows metabolic acidosis (BE= -10)
Blood pressure is not elevated.
What now?

 

[Jeff05]

2 big IVs.
a-line
GA for C/S.

 

[Planktonmd]

I forgot to mention that the creatinine is 3.5 and the urine output is very low.

 

[urge]

pre eclampsia, or sepsis. Seems like a section

 

[Noyac]

This is my OB case today on call:
20 Y/O G1 P0 35 weeks pregnant with no prenatal care.
Arrives to OB in active labor.
She mentions that she is feeling weak, has generalized muscle pain, has very dark urine and nausea.
Lab results show: WBC = 26000, Platelets = 300,000
AST and ALT elevated in the 400- 500 range, Alk phos 350, Direct bilirubine 9.
Fibrinogen = 80 (low).
PT= 19, PTT = 39
Blood sugar = 34
Blood gas shows metabolic acidosis (BE= -10)
Blood pressure is not elevated.
What now?

Any rash?
ETOH use?
Any other history?

I'm thinking some form of liver disease (duh), myositis, autoimmune disease.

How about giving some steroids, vitamin K, fluids and glucose?

Is there any need for c/s now?

 

[Planktonmd]

Any rash?
ETOH use?
Any other history?

I'm thinking some form of liver disease (duh), myositis, autoimmune disease.

How about giving some steroids, vitamin K, fluids and glucose?

Is there any need for c/s now?

No rash, no ETOH abuse, Tox screen negative and serum acetaminophen normal.

 

[urge]

Sounds like liver failure. Was she hypotensive? Febrile? What's her hepatitis status? Could she have hepatitis E (or D, I don't really remember the letter)?

 

[Strength&Speed]

she may have an element of liver failure, but I don't see how that would cause her associated symptoms. preeclampsia, sepsis, or cholelithiasis with ascending infection. an autoimmune problem could cause the muscle weakness and liver problems, but I think it would be relatively uncommon to cause such a severe, acute picture by itself.

 

[deleted9493]

Could be a big hepatic thrombosis...Budd-Chiari type scenario. What does the WBC differential roughly look like?

 

[Planktonmd]

WBC 26000 80% neutrophils 4% bands.
Liver ultrasound does not show biliary etiology.
She is not hypotensive and not in shock.

 

[Bougie]

Sounds like early acute fatty liver of pregnancy because of the low fibrinogen, renal insufficiency, myalgias, and transaminitis. Stabilize (volume, art line, 2 fat IVs, glucose, type and cross) and deliver by GA. Likely evolving coagulopathy rules out neuraxial technique in my book. Have OB look at liver and pancreas while in the abdomen (possible associated necrotizing pancreatitis). Serial labs postop with hepatology consult. Will get better after placenta is in the trash. Any of her family members have similar issues during pregnancy?

 

[Planktonmd]

Sounds like early acute fatty liver of pregnancy because of the low fibrinogen, renal insufficiency, myalgias, and transaminitis. Stabilize (volume, art line, 2 fat IVs, glucose, type and cross) and deliver by GA. Likely evolving coagulopathy rules out neuraxial technique in my book. Have OB look at liver and pancreas while in the abdomen (possible associated necrotizing pancreatitis). Serial labs postop with hepatology consult. Will get better after placenta is in the trash. Any of her family members have similar issues during pregnancy?

BINGO 😀

Exactly, We gave FFP and did a C section under GA.
She is in the ICU still in renal failure but the liver seems to be getting slightly better.
The coagulopathy seems to improve slightly.

 

[Strength&Speed]

BINGO 😀

Exactly, We gave FFP and did a C section under GA.
She is in the ICU still in renal failure but the liver seems to be getting slightly better.
The coagulopathy seems to improve slightly.

acute fatty liver of pregnancy? causing renal failure? through volume depletion or is there another mechanism i'm missing...

i'm not an ob person...is acute fatty liver of pregnancy associated with preeclampsia and HELLP?

 

[Bougie]

It is a nasty side road on the preeclampsia, eclampsia, HELLP pathway.

Kidney dysfunction early is due to beta oxidation of fats in the kidney and late renal insufficiency is probably due to hepatorenal syndrome. It's thought to be a defect in mitochondrial fatty acid metabolism instigated by an unknown factor produced by the placenta. It's hereditary.

Here's a good review article:
Castro, Mary A. MD; Fassett, Michael J. MD; Reynolds, Telfer B. MD; Shaw, Kathryn J. MD; Goodwin, T. Murphy MD Reversible peripartum liver failure: A new perspective on the diagnosis, treatment, and cause of acute fatty liver of pregnancy, based on 28 consecutive cases. American Journal of Obstetrics & Gynecology. 181(2):389-395, August 1999.

 

[Strength&Speed]

It is a nasty side road on the preeclampsia, eclampsia, HELLP pathway.

Kidney dysfunction early is due to beta oxidation of fats in the kidney and late renal insufficiency is probably due to hepatorenal syndrome. It's thought to be a defect in mitochondrial fatty acid metabolism instigated by an unknown factor produced by the placenta. It's hereditary.

Here's a good review article:
Castro, Mary A. MD; Fassett, Michael J. MD; Reynolds, Telfer B. MD; Shaw, Kathryn J. MD; Goodwin, T. Murphy MD Reversible peripartum liver failure: A new perspective on the diagnosis, treatment, and cause of acute fatty liver of pregnancy, based on 28 consecutive cases. American Journal of Obstetrics & Gynecology. 181(2):389-395, August 1999.

great, cool of you to do that bougie. great case plankton.

I wonder if her risk goes down with subsequent pregnancies like eclampsia. I'll check out the article.

 

[mille125]

Very interesting case



This is a case of rhabdomyolysis which explains the myofascial symptoms and dark urine. It has likely led to acute renal failure and the DIC picture. I would order a urine myoglobin, CPK, and urine hemoglobin. It is is truly rhado then you really should treat aggressively with fluid. If these studies are negative, it may by ATN. Incidentally, what was the serum potassium and phosphorus (elevated?).

What is the likely cause? Given her clinical history, it is most likely infectious (WBC at 26K). Influenza, salmonella, and legionella are notorious offenders (less likely in pregnancy). Even though she has not developed sepsis and would say that it is likely infectious.


This is not a typical picture of shock liver because you would expect transaminases in the thousands instead of the hundreds.


This is not a typical picture of preeclampsia given the absense of hypertension. I have never seen a preeclamsic patient in shock (i dont do OB). I wonder what the blood pressure would be in a preeclampsic patient in shock (would it be normal? low?).


Very good case....please keep us posted on the progress.

 

[Strength&Speed]

Very interesting case



This is a case of rhabdomyolysis which explains the myofascial symptoms and dark urine. It has likely led to acute renal failure and the DIC picture. I would order a urine myoglobin, CPK, and urine hemoglobin. It is is truly rhado then you really should treat aggressively with fluid. If these studies are negative, it may by ATN. Incidentally, what was the serum potassium and phosphorus (elevated?).

What is the likely cause? Given her clinical history, it is most likely infectious (WBC at 26K). Influenza, salmonella, and legionella are notorious offenders (less likely in pregnancy). Even though she has not developed sepsis and would say that it is likely infectious.


This is not a typical picture of shock liver because you would expect transaminases in the thousands instead of the hundreds.


This is not a typical picture of preeclampsia given the absense of hypertension. I have never seen a preeclamsic patient in shock (i dont do OB). I wonder what the blood pressure would be in a preeclampsic patient in shock (would it be normal? low?).


Very good case....please keep us posted on the progress.

they already did...acute fatty liver of pregnancy 🙂 I think the dark urine could also be caused by the elevated bilirubin...i presume that was the cause in this case...

 

[jwk]

Damn, why didn't the RRNA's pick up on that?

 

[LADoc00]

This is my OB case today on call:
20 Y/O G1 P0 35 weeks pregnant with no prenatal care.
Arrives to OB in active labor.
She mentions that she is feeling weak, has generalized muscle pain, has very dark urine and nausea.
Lab results show: WBC = 26000, Platelets = 300,000
AST and ALT elevated in the 400- 500 range, Alk phos 350, Direct bilirubine 9.
Fibrinogen = 80 (low).
PT= 19, PTT = 39
Blood sugar = 34
Blood gas shows metabolic acidosis (BE= -10)
Blood pressure is not elevated.
What now?

Okay easy one, call Pathology, stat.

Your problem was you were wasting time scanning old House and Scrubs episodes on the Dr lounge DVR looking for clues, total flub there.

 

[Planktonmd]

Very interesting case



This is a case of rhabdomyolysis which explains the myofascial symptoms and dark urine. It has likely led to acute renal failure and the DIC picture. I would order a urine myoglobin, CPK, and urine hemoglobin. It is is truly rhado then you really should treat aggressively with fluid. If these studies are negative, it may by ATN. Incidentally, what was the serum potassium and phosphorus (elevated?).

What is the likely cause? Given her clinical history, it is most likely infectious (WBC at 26K). Influenza, salmonella, and legionella are notorious offenders (less likely in pregnancy). Even though she has not developed sepsis and would say that it is likely infectious.


This is not a typical picture of shock liver because you would expect transaminases in the thousands instead of the hundreds.


This is not a typical picture of preeclampsia given the absense of hypertension. I have never seen a preeclamsic patient in shock (i dont do OB). I wonder what the blood pressure would be in a preeclampsic patient in shock (would it be normal? low?).


Very good case....please keep us posted on the progress.

The dark urine is caused by Bilirubin (her Bili was 9), no rhabdo here.
The renal failure is also part of the game and could be a form of hepatorenal syndrome.
If you read the description of fatty liver of pregnancy it fits all the symptoms this patient had and it doesn't have to be pre eclampsia, this entity does not have to be associated with pre eclampsia or HELLP.
The platelets were normal and there was no hypertension.
It's a rare case and this was the first time I have seen it, even the obstetrician hasn't seen it before although he has been practicing for 15 years.
She continues to improve in the ICU although the kidneys are not back to normal.

 

[mille125]

The dark urine is caused by Bilirubin (her Bili was 9), no rhabdo here.
The renal failure is also part of the game and could be a form of hepatorenal syndrome.
If you read the description of fatty liver of pregnancy it fits all the symptoms this patient had and it doesn't have to be pre eclampsia, this entity does not have to be associated with pre eclampsia or HELLP.
The platelets were normal and there was no hypertension.
It's a rare case and this was the first time I have seen it, even the obstetrician hasn't seen it before although he has been practicing for 15 years.
She continues to improve in the ICU although the kidneys are not back to normal.

very interesting case....thank you for sharing it.....

 

[Jalopycat]

You should present that at SOAP. Pretty cool case.