Case of Jaundice complicating Pregnancy with SOL Brain
Presentor : Dr. Pio James
Designation : Fellow, HRP and Perinatology
Hospital : Fernandez Hospital, Hyderabad
Date of Presentation : 09.10.2012
Case
Mrs X, 23 yrs, G3 P2L2 with 33 wks gestation
Self referred, DOA – 13/09/2012
History of presenting illness:
Fever/ cough – 1-2 days
Vomiting / yellowish discolouration of urine – 4 days
Pedal edema -10days
Loss of appetite
Evaluated – T.bil – 12.1, SGPT- 130,
History
G3 P2 L2,
1st – FTND, F, 1.6 kg, 2008
2nd – FTND, F,1.2 kg, 2009
3rd – natural conception
EDD – 03/11/2012 POG – 33wks, DCDA twins
1ST and 2nd trimesters – uneventful
NT, TIFFA - Normal On Iron & Calcium; fully immunised
History
ANC investigation: 23/6/2012
Hb- 10.5, RBS – 80, TSH – 0.68,
TC – 9000, PLT – 1.8lak, CUE – N, AB+
Gynec history: cycles regular
Medical/surgical history: not contributing
Family history: both parents DM/HTN
General Physical Examination
Conscious and coherent but drowsy
Mod built and nourished
Pallor -, Icterus ++, pedal edema ++
RR-18, PR-88,SpO2- 99,Temp-99F, 130/80-90 mm Hg
Reflexes – N, No flapping tremors
No bleeding or oozing site, petechiae +
Catheterised – 30 ml dark concentrated urine
Chest: b/l bronchial breath sounds/ course crepts+
CVS: S1 S2 heard
Abdomen: soft, nontender,liver/spleen not palpable, BS present
Obstetric Exam
Uterus 36 wks
Multiple fetal parts
Not tense, not tender
Both fetuses cephalic in presentation
Both Fetal heart sounds present
Vaginal exam:
Cx fully effaced, 4cm, membranes+, vertex -1, pelvis
adequate
Investigations
Urine Alb, GRBS,HVS, CBC, Coagulation profile, LFT,
RFT, ABG, electrolytes, hepatitis viral markers,
leptospira IgM, dengue IgM serology, smear for
malarial parasite, parasight F and V
Investigations13 14 15 16 17 18 19 20 21
HB 7.2 8.1 9.1 8.6 7.2 6.6 6.6 10
TC 10,500 16,500 13,900 14,200 13,300 13,500
PLT 32000 53000 56000 55000 54000 46000 71000 54000 66000
T.BLR 12.3 11.6 10.6 9.3 18.3
D.BLR 9.4 8.9 7.3 7.4 14.0
SGPT 158 82 68
CREAT 3.2 3.3 3.6 3.2 2.6 2.0 1.8 1.7 1.8
BU 147 169 113
BUN 64 79 53
INR 1.52 1.4 1.1 1.5
APTT 49 40 31
NA+ 136 127 130 130 133 136 134
K+ 5.4 4.2 3.9 3.3 3.2 4.2 5.4 5.4
Investigations
Urine alb – 4 +
GRBS – 40
Uric acid – 14.2
LDH – 1884
Alkpo4 – 315
T.Protein – 4.6
S.Alb- 2.4. A/G -1.1
S. fibrinogen - <70
FDP – 800
D- Dimer - positive
ABG – metabolic acidosis
Lactate – Normal
Ammonia – 64mcg/dl (13-09-
12 ); 109 (14-09-12 ); 72 (16-
09-12)
Provisional Diagnosis
G3P2L2, POG- 33wks, DCDA twins in preterm labour
( active phase)
Jaundice complicating pregnancy
Cause: Severe Preeclampsia with ? AFLP/ HELLP
- /+ sepsis
MODS
– Acute hepatic dysfunction
– DIC+ALI+AKI+ hepatic encephalopathy
Management
Multidisciplinary ICU care
Gastroenterologist’s consult
Stabilise mother
Procure blood products
Correct coagulopathy
Augment labour & delivery
Organ supportive and protective care
Course in the Hospital
ICU monitoring
Propped up,
02 - 5lt/mt, levolin
nebulisation
Central line – IJV,
TED stockings
IVF – 50ml/hr (MVI)
GRBS 2nd hourly - 25%
dextrose 6 hourly
Course in the Hospital
Antibiotics – Ceftriaxone, Metronidazole
Inj Vit k 10mg IV
Hepatic encephalopathy regimen – Syp
lactulose, becelac, hepamerz
Blood products – FFP-6, PRP-4, Cryo-12
Inj Fentanyl - labour pains
Avoided – NSAIDS, paracetamol, pethidine,
aminoglycosides
Delivery Details
Oxytocin augmentation and ARM
Preterm twin vaginal delivery in ICU
T1 – 1.36 kg, f, 7/8/9,14/09/2012, 13.05 hrs
T2 – 1.48 kg, m, 7/8/9,14/09/2012, 13.15 hrs
Active mgt of 3rd stage with prostodin and oxytocin;
no PPH
Perineum intact
Continued ICU care
0 – PND (14.09.2012)
2 x tonic clonic convulsions – ECLAMPSIA
(9 hrs and 14 hrs after delivery)
Started magnesium sulphate
Pulmonary edema – frusemide 20mg twice daily for
2days
Raised BP 160/101mmHg – labetolol
O/E : sleepy but easily arousable, vitals stable, flap+
Course in the Hospital PND 1- 413 14 15 16 17 18 19 20 21
HB 7.2 8.1 9.1 8.6 7.2 6.6 6.6 10
TC 10,500 16,500 13,900 14,200 13,300 13,500
PLT 32000 53000 56000 55000 54000 46000 71000 54000 66000
T.BLR 12.3 11.6 10.6 9.3 18.3
SGPT 158 82 68
CREAT 3.2 3.3 3.6 3.2 2.6 2.0 1.8 1.7 1.8
BU 147 169 113
BUN 64 79 53
AMO 64 109 72
INR 1.52 1.4 1.1 1.5
APTT 49 40 31
NA+ 136 127 130 130 133 136 134
K+ 5.4 4.2 3.9 3.3 3.2 4.2 5.4 5.4
PND 1 – 4
Supportive measures continued
Ambulant, oral feeds
Diuresing well
General condition improved
Lab parameters- no significant improvement
36 blood products transfused
Shifted to step down ICU
PND – 5 (19.05.2012) - SD ICU D1
Hb – 6.6 Temp – 101 F C/o cough Shifted to ICU
O/E:
Conscious, coherent, drowsy,
puffiness of Lt side face, partial ptosis lt eye, periorbital
edema
PR-110, BP- 110/80, spo2 – 98%
P/A : ascitis+, BS sluggish, diffusely tender
Chest – rhonchi+/b/l reduced air entry at bases, CVS – N
? SBP ( spontaneous bacterial peritonitis
PND – 5 (19.05.2012) - SD ICU D1
Management :
HVS, urine c/s, blood culture, urine for candida
Started imipinem
2 units PRBC
Investigations
S. Amylase – 81, S. Lipase - 169
Fractional NA+ excretion – 8.46%
HVS – scanty growth of E.coli-Esbl (13, 19)
Urine c/s – E.coli – no fungal elements
Blood culture – negative
Leptospira, Dengue – negative
Hepatitis viral markers – negative
USG abd : borderline hepatomegaly, b/l pleural
effusion, pericholecystic edema.
PND – 6
Lt complete ptosis, 3rd & 7th cranial nerve palsy
Lt pupil 4mm, rt pupil 2mm, periorbital edema
Drowsy
Lt ptosis
Involvement of 3rd and 7th cranial nerves
LMN type of facial nerve palsy
Anisocoria Right eye Left eye
MRI / MRV
MRI – SPACE OCCUPYING LESION MRV NEGATIVE FOR CSVT
MR SPECTROSCOPY
STRONG POSSIBILITY OF LOW GRADE GLIOMA
Differential Diagnosis
Glioma / Fungal pathology
Management:
?Craniotomy/ endoscopic sinus biopsy
? TTP
– ? plasmapheresis
Neurosurgeon’s consult
Dexamethasone 8mg IV twice daily, mannitol
Rapid deterioration in general condition- dysarthria,
dysphagia ( IX cranial nerve involvement),
worsening drowsiness
Cola colored urine
Deepening jaundice
Patient was transferred to other hospital for care
under neurophysician at her family’s request, where
she succumbed after 2 days
Diagnosis
G3P2L2, POG- 33wks, DCDA twins in preterm labour
Jaundice complicating pregnancy
Cause: Preeclampsia with ? AFLP/ HELLP - /+ Sepsis
?Postpartum eclampsia/ Seizure sec: to SOL
Intracranial SOL - ? Glioma / Fungal pathology
MODS – ALI/AKI/DIC/ Hepatic encephalopathy
Maternal death