OB-GYN-L Messages for September, 2005: Re: Interesting case

Re: Interesting case

From:

Terrence.Jones@kp.org

Thu Sep 29 16:57:29 2005

Think the mention of pheo is 'close' in proximity at least -- nml LFT's except for elevated LDH, accomp by HTN and RUQP makes me think partial renal infarction? She's not in A Fib with an occult stenotic mitral valve? Thrombophilia with 4 prior nml AGA term preg's seems a bit unlikely. /tj

"R. Daniel Braun" <rd.braun@gmail.com> Sent by: ob-gyn-l@obgyn.net 09/29/2005 09:49 AM Please respond to ob-gyn-l

To: Multiple recipients of list OB-GYN-L <ob-gyn-l@dns.obgyn.net> cc: Subject: Interesting case

I want to present this as an unknown and see if anybody can get the real diagnosis. 26 Y/O G5 P 4004 LMP 2-9-05 EDC 11-16-05 confirmed by 23 week US. All of her prior pregnancies were NSVD's of FT appropriate weight babies at term and without complications. On 9-19-05 at 31 wks 4 days BP was 124/90 and urine protein was 1+, it had been trace 3 weeks earlier. In the triage area, her BP varied from 120-150/ 84-102. She was admitted to hospital for observation and multiple labs which were all normal except for uric acid of 8.6 and LDH of 648. She was kept on Bed Rest with Bathroom privileges and closely monitored.24 hr Urine protein was 450 mg/24 hours. EFW by US was 1330 gms. Betamethazone was given over 24 hours startin on 9-25-05. She did well without incident or change until 16:40 hrs on 9-28-05,(33 weeks gestation) when the resident was called to see her for severe RUQ pain. BP was 168/97 T 96.0 and she was exquisitely tender in RUQ and epigastrium, there was no rebound noted. She was transferred to L&D, Liver function tests and CBC were obtained. LFT's were normal, except for LDH of 636. Hgb was 14, up from 13.8, 3 days before; platelets wer 247K up from 186K, 3 days before. Magnesium Sulfate was started and she was observed. At 20:25 hrs, she was feeling fine with no pain at all. BP was 120/84. Urine output was 250cc/hr since 17:00 hrs. On 9-29-05 at 00:10 hrs, she de3veloped a recurrence of her pain. BP 140/ 80. Again exquisitely tender with no rebound. Pain is such that patient is writhing in the bed. She had had 3 episodes of emesis over the last 6 hours. Fetal monitor was reassuring. Normal reflexes. LDH now 1107. Diferential includes Cholecystitis, severe pre-eclampsia, and Gastric upset. She was given Morphine Sulfate for the pain and it went away again, only to return at 03:00 hours. Exam remains the same. At this time it was felt that she should be delivered by C/S through a vertical incision because of the possibility of Liver Capsule rupture. She was crossmatched for several units of blood (8). The provisional diagnosis at this time was atypical severe pre-eclampsia. Is there anyone there who wouldn't have delivered her at this point ? She was delivered of 3# 6 oz. 1532 gm apgar 9/9 male. It was noted that there was no hemoperitoneum and the uterine incision was closed.

This is where I am going to stop and see what you all think we found with our abdominal exploration.

Dan

-- R. Daniel Braun Kinky for Governor

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Think the mention of pheo is 'close' in proximity at least --  nml LFT's except for elevated LDH, accomp by HTN and RUQP makes me think partial renal infarction? She's not in A Fib with an occult stenotic mitral valve? Thrombophilia with 4 prior nml AGA term preg's seems a bit unlikely.   /tj   <table width0%> <tr valign=top> <td> <td>"R. Daniel Braun" <rd.braun@gmail.com> Sent by: ob-gyn-l@obgyn.net 09/29/2005 09:49 AM Please respond to ob-gyn-l <td>                To:        Multiple recipients of list OB-GYN-L <ob-gyn-l@dns.obgyn.net>         cc:                 Subject:        Interesting case</table> I want to present this as an unknown and see if anybody can get the real diagnosis. 26 Y/O G5 P 4004 LMP 2-9-05 EDC 11-16-05 confirmed by 23 week US. All of her prior pregnancies were NSVD's of FT appropriate weight babies at term and without complications. On 9-19-05 at 31 wks 4 days BP was 124/90 and urine protein was 1+, it had been trace 3 weeks earlier. In the triage area, her BP varied from 120-150/ 84-102. She was admitted to hospital for observation and multiple labs which were all normal except for uric acid of  8.6 and LDH of 648. She was kept on Bed Rest with Bathroom privileges and closely monitored.24 hr Urine protein was 450 mg/24 hours. EFW by US was 1330 gms. Betamethazone was given over 24 hours startin on 9-25-05. She did well without incident or change until 16:40 hrs on 9-28-05,(33 weeks gestation) when the resident was called to see her for severe RUQ pain. BP was 168/97 T 96.0 and she was exquisitely tender in RUQ and epigastrium, there was no rebound noted. She was transferred to L&D, Liver function tests and CBC were obtained. LFT's were normal, except for LDH of 636. Hgb was 14, up from 13.8, 3 days before; platelets wer 247K up from 186K, 3 days before. Magnesium Sulfate was started and she was observed. At 20:25 hrs, she was feeling fine with no pain at all. BP was 120/84. Urine output was 250cc/hr since 17:00 hrs. On 9-29-05 at 00:10 hrs, she de3veloped a recurrence of her pain. BP 140/ 80. Again exquisitely tender with no rebound. Pain is such that patient is writhing in the bed. She had had 3 episodes of emesis over  the last 6 hours. Fetal monitor was reassuring. Normal reflexes. LDH now 1107. Diferential includes Cholecystitis, severe pre-eclampsia, and Gastric upset. She was given Morphine Sulfate for the pain and it went away again, only to return at 03:00 hours. Exam remains the same. At this time it was felt that she should be delivered by C/S through a vertical incision because of the possibility of Liver Capsule rupture. She was crossmatched for several units of blood (8). The provisional diagnosis at this time was atypical severe pre-eclampsia. Is there anyone there who wouldn't have delivered her at this point ? She was delivered of 3# 6 oz. 1532 gm apgar 9/9 male. It was noted that there was no hemoperitoneum and the uterine incision was closed.   This is where I am going to stop and see what you all think we found with our abdominal exploration.   Dan -- R. Daniel Braun       Kinky for Governor

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