Case Conference: Upper abd pain in a term pregnancy

[dchristismi]

30 yo G3P2 at about 37 weeks c/o upper abd pain and nausea. Started vaguely mid afternoon and intensified by 9 pm. Pt appears very uncomfortable. Pain worse with deep breath, radiates to back, but pt denies SOB. Denies loss of fluids, vaginal bleeding or discharge.

VS: 98.6, P 90, BP 117/60, Sat 100% RA.

FHT 150

Exam notable for Spanish-speaking only F in moderate distress, markedly gravid abdomen which is somewhat tender RUQ to R flank, but exam is challenging due to pain and the fact that she's all baby at this point.

PMH: hypothyroidism, no surgeries, has been getting routine prenatal care.

After 5 mg Morphine, 4 mg Zofran, pt still rates pain 8/10 and looks uncomfortable, so an additional 5 mg given, labs pending, and she goes to US.

US shows normal GB, 3 mm CBD, nl liver, unable to visualize pancreas, no hydronephrosis, 37 W IUP in cephalic presentation with normal placenta.

Initial labs :

WBC 7.2, Hgb 12.8, Plt 120K

Na 135, K 4.1, Cl 103, HCO3 21, BUN 7, Cr 0.5, Gluc 90

AST 115, ALT 98, Alk P 187, Alb 3.2, Tb 0.6

UA with 2-5 WBC, no blood, no protein, trace ketones, trace LE

What to do next? Differential? What else do you want to know?

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[joeDO2]

just a first yr here but i'll play along...

gastroenteritis, gallbladder disease, pancreatitis, bowel obstruction, some type of thrombosis, etc., peptic ulcer

would like to know amylase/lipase, coags, d-dimer, mri if available

 

[pinipig523]

just a first yr here but i'll play along...

gastroenteritis, gallbladder disease, pancreatitis, bowel obstruction, some type of thrombosis, etc., peptic ulcer

would like to know amylase/lipase, coags, d-dimer, mri if available

ddimer will be elevated, she's pregnant. MRI for what?

 

[pinipig523]

30 yo G3P2 at about 37 weeks c/o upper abd pain and nausea. Started vaguely mid afternoon and intensified by 9 pm. Pt appears very uncomfortable. Pain worse with deep breath, radiates to back, but pt denies SOB. Denies loss of fluids, vaginal bleeding or discharge.

VS: 98.6, P 90, BP 117/60, Sat 100% RA.

FHT 150

Exam notable for Spanish-speaking only F in moderate distress, markedly gravid abdomen which is somewhat tender RUQ to R flank, but exam is challenging due to pain and the fact that she's all baby at this point.

PMH: hypothyroidism, no surgeries, has been getting routine prenatal care.

After 5 mg Morphine, 4 mg Zofran, pt still rates pain 8/10 and looks uncomfortable, so an additional 5 mg given, labs pending, and she goes to US.

US shows normal GB, 3 mm CBD, nl liver, unable to visualize pancreas, no hydronephrosis, 37 W IUP in cephalic presentation with normal placenta.

Initial labs :

WBC 7.2, Hgb 12.8, Plt 120K

Na 135, K 4.1, Cl 103, HCO3 21, BUN 7, Cr 0.5, Gluc 90

AST 115, ALT 98, Alk P 187, Alb 3.2, Tb 0.6

UA with 2-5 WBC, no blood, no protein, trace ketones, trace LE

What to do next? Differential? What else do you want to know?

My main concerns:
1. Early preeclampsia w/o hypertension, evolving HELLP
2. Atypical PE though the VS don't show it
3. Pancreatitis - where's the lipase.
4. Atypical appy in a 3T patient - usually the appendix is pushed upwards and although the incidence is equal in preggers and nonpreggers, this may be one of them.
5. Other than that - gastro, blah blah blah.

Last BM? Passing flatus? Last meal? PO tolerant or vomiting? Billous or bloody?

I bet this is some weird diagnosis.... I can feel it....

 

[Apollyon]

MRI for appendicitis, although, at 37 weeks, CT is fine.

I just get this sneaking suspicion that this will be "atypical labor" and soon the patient will declare and go to the delivery room.

Without liver markers being out of whack, and with a normal and no stone GB on U/S, a biliary source is unlikely.

edit: I was posting after your first post, but before your second

 

[dchristismi]

Of course it's a weird diagnosis. What'd ya expect?!? Cholelithiasis?? pshaw. You know me better than that.

Lipase 30.
Dimer unreliable in pregnancy. Yes, it could be normal, but if it's high, are you going to scan her? A positive dimer boxes you into a corner.

Patient has that vague "I don't like this" look to her. I don't know how to explain this, but my gut is telling me that there's something wrong. Getting that across in a case presentation is hard.
I am a black cloud.

After 10mg Morphine, pain is tolerable and I can examine her better. Tenderness appears to be limited to RUQ and R flank, but it's mild tenderness. No rebound or any peritoneal signs that I can illicit.

BP 118/66, P 80, RR 14, 100% RA.

Felt fine this am, ate lunch, but vaguely nauseated and uncomfortable since about 1500. No vomiting or diarrhea. Pain got worse as evening progressed. It's 2200 now.
Last BM yesterday.

Next?

 

[pinipig523]

These guys are always hyper coagulable with a 10x risk for thrombosis (if I recall correctly). Where's the EKG and markers?

Good point about the MRI - I was just asking the med student what was he looking for.

I also know that there are instances in which an MRI can detect PE, not thoroughly studied and may be institution dependent.

 

[dchristismi]

She's 30, it's more abdominal/flank than chest, so cardiac was much, much lower on my differential, so didn't get EKG or enzymes.

I discussed with the OBGYN, and we decided to proceed with CT chest to r/o PE. She also wanted CT A/P, but I hoped that cuts through the liver would be enough. She also wanted me to obs her for 12 hours... which I couldn't do. But I could obs her for 3. (I'd asked the US tech to look for an appy off the record, and she's a good tech - didn't see anything suspicious.)

MRI is iffy in the middle of the night for us, and as she was term, I went with CT.
CT chest shows no PE, no dissection, no pulmonary findings, but does show a 2.3 x 3.4 cm R well circumscribed, benign-appearing R paraspinal mass.

...and then I got pulled into a crashing-septic-LOL-lactate-of-10-rescus...

But I do love it when they declare.

 

[dchristismi]

Repeat labs (3 hours after initial):

WBC: 8.1
Hbg 11.6
Plt 83K

ALT: 177
AST: 245
Alk P: 145

Anything else you want to know? The OB had two specific questions when I called with the lab results...

 

[sleepymed]

Repeat labs (3 hours after initial):

WBC: 8.1
Hbg 11.6
Plt 83K

ALT: 177
AST: 245
Alk P: 145

Anything else you want to know? The OB had two specific questions when I called with the lab results...

I would probably do coags and a DIC panel; sounds like it's concerning for HELLP

 

[dchristismi]

It is.

But there is a single physical exam finding that will give it away.
What is it?

The OB and I figured it out, and the case had a happy ending. (Well, the OB asked me to go look for it. And she had it.)

 

[WilcoWorld]

Well if you're entertaining HELLP then I guess you'll need that d-dimer now...

As for your PE finding, I'm not sure. Are you talking about papiledema, or signs of DIC like petechia or purpura?

My goodness this is humbling. I see three types of pregnant patients - previable, actively dying or crowning. The rest, including someone like this, go straight to L&D.

 

[pinipig523]

I like this... Good case!

I called it early on too!

I began to think portal vein thrombosis... Something I saw a month ago.

But back to the case, a single physical exam finding? Jaundice or scleral icterus? Maybe early signs of edema?

 

[dchristismi]

Yes, it was HELLP, but without any significant hypertension or proteinuria! It crossed my mind as soon as I saw the slightly elevated LFTs... when they doubled and her platelets and hbg dropped, it was pretty clear. (This was only 3 hours later, mind you)

I normally see the 3 groups you describe as well... but not being sure if she had something obstetric or medical or surgical made me really afraid to send her to L&D before I knew.

Shortly after we got the labs, she ended up going to L&D, and delivered a healthy baby boy. (I imagine they sectioned her, but don't know details yet.)

Simple, simple test. Something we overlook a lot. PreE and HELLP often come with neurologic issues. The OB wanted me to ask if she had blurry vision (she didn't), and check...










wait for it...








Neurologic...








Use your stethoscope bell or that thing the drug reps used to hand out... a simple tool...
(No, not a panoptic...)









I should totally make you guys look this up.

 

[WilcoWorld]

Ahh, hyperreflexia. Glad I carry a Rappaport Sprague, best reflex hammer I ever owned.

 

[dchristismi]

DING DING DING!

I actually went and dug up a real hammer rather than use my Littman, and she was hyperreflexic, bordering on clonus. Perhaps the most dramatic reaction to a simple patellar tap I've ever seen. (To the point it sort of scared the patient.)

Sort of a convoluted teaching point, but a damn cool case. Especially after reading that the infant mortality rate approaches 60%! Catching it early is key, but when all you get is RUQ pain and nausea to work with, it's a tricky diagnosis.

 

[pinipig523]

DING DING DING!

I actually went and dug up a real hammer rather than use my Littman, and she was hyperreflexic, bordering on clonus. Perhaps the most dramatic reaction to a simple patellar tap I've ever seen. (To the point it sort of scared the patient.)

Sort of a convoluted teaching point, but a damn cool case. Especially after reading that the infant mortality rate approaches 60%! Catching it early is key, but when all you get is RUQ pain and nausea to work with, it's a tricky diagnosis.

Thanks man... great case!

 

[WilcoWorld]

The fact that she wasn't hypertensive and her LFT's were normal and the CBC was normal-ish on initial labs is rather frightening.

 

[beakerdan]

Especially as a medical student, I love these kinds of threads, and wish they showed up more often in this forum.

 

[dchristismi]

Her LFTs weren't *completely* normal. But yeah, we do tend to overlook them unless they're like 500. Or 5000.

And her platelet count was *slightly* low.
The trends are impressive, though.

We repeat and trend cardiac markers; we think of the appy that's "too early to tell." Perfect example. (But yes, it scares me to think of what might have happened!)

Her BP went up a little bit - right before she left for L&D. But it might have been because I announced that she was going to have the baby - NOW.

Actually what sort of worried me is that I didn't go ahead and CT her belly... with my luck, her LFTs would have improved and I would have missed a renal artery dissection or splenic artery aneurysm, both of which were on my DDX.
There but for the Grace of God...

 

[Apollyon]

I carry a reflex hammer in my white coat. (Go me.)

Hey, even if it wasn't "active labor", the kid coming out was still "curative".

Good job! At least this patient wasn't 100 years old and had broken a hip playing tennis.

 

[TallScrubs]

Especially as a medical student, I love these kinds of threads, and wish they showed up more often in this forum.

I agree. Having recently covered DIC/HELLP in M1, this was cool to think through.

Give us more (only blood and cardiac please! we can do pulm/renal in a month or so )

 

[la gringa]

i had an EERILY similar case about 2 years ago, in my first year out of residency... terrible pain, pretty much crying.

when the lft's and bili were up, i added coags and called L&D. she went stat to the OR, even at 32 weeks...

and as far as PE r/o... if you gotta do it, YOU GOTTA DO IT. good article on the 2011 LLSA reading list about VTE in pregnancy from JAMA.

 

[WilcoWorld]

Her LFTs weren't *completely* normal. But yeah, we do tend to overlook them unless they're like 500. Or 5000.

Whoops, those numbers were so unimpressive I looked right past 'em. It would've helped if you'd made them more red.

as far as PE r/o... if you gotta do it, YOU GOTTA DO IT.

Last patient of my overnight was a 19 yo G1P0 with SOB. She carried no diagnosis of asthma, just a lot of ED/Urgent Care visits resulting in albuterol prescriptions, which usually helped. When I heard her clearly asthmatic (bilateral and symmetric prolonged expiratory) wheezing I actually said to her "that's music to my ears".

 

[pinipig523]

Her LFTs weren't *completely* normal. But yeah, we do tend to overlook them unless they're like 500. Or 5000.

And her platelet count was *slightly* low.
The trends are impressive, though.

I knew there was a high likelihood that this was early PreEclampsia/HELLP.... the numbers looked to be marginally in that direction.

 

[txterp98]

Great case. Nice job with your vigilance, rechecking...and that reminder about hyperreflexia!

Quick question....and this might just be showing how good I have it....a patient like this would've bypassed the ER and gone straight to L&D: >20 wks with abdominal pain. The part about obs for 12 hours in your ER...our obs period occurs in L&D with non-invasive fetal monitoring. In the rare cases where we have to work these patients up first...think r/o sepsis or PE....OB comes down to see them and hooks them up to non-invasive. When they're medically cleared, they go up...OB then observes for as long as they feel necessary.

Again, great job with this patient. I'm just trying to get a feel for other systems...especially ones where L&D is on premises.

 

[dchristismi]

Just to answer that last question, we have a very unusual setup, and do NOT have L&D on the premises. We have a freestanding OB hospital about 2 miles down the road. If she'd come by EMS, she might have gone to either, but she didn't know what to do.

Generally, lower abd pain at term gets a quick "not crowning" check and is shipped immediately. (We use both EMS and a courier system for non-emergent transfers)

I shot down the whole "obs 12 hours" thing because yes, that is an L&D thing and certainly didn't need to happen in my ER. BUT... and it's a big but:

If she has something medical or surgical (ie nonobstetric), or needs ICU, she needs to stay at my hospital and have OB come to her. The monitoring capabilities at the OB hospital are rather minimal, IMHO. So I needed to determine if this was gallbladder/PE/renal first. It's a very tricky situation, and it's quite possible that if she'd been sent over quickly, they OB might have missed it (being a very early presentation), and then sent her to me after clearing her obstetrically. We've had a couple of clusters when a pregnant lady was sent the wrong place, and not having OB nearby makes it tricky (hence multiple phone conversations.) She would be going over regardless - once she was "cleared" from a medical standpoint.

Tricky problem, and our system is far from ideal. I have demanded that OB come to the patient in the past (which then leaves their entire hospital uncovered sometimes, although they do have a backup system). I could have asked L&D to send a nurse over to do fetal monitoring... but didn't think of it, honestly.

Ideal? No. Work 99% of the time? Yes. Really, the vast majority of these get shipped immediately. It was just a very weird pain.