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Daniel Braun
Sent: Thursday, September 29, 2005 5:50 PM
To: Multiple recipients of list OB-GYN-L
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
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R. Daniel Braun
Kinky for Governor
