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