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From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of R. Daniel
Braun
Sent: Thursday, September 29, 2005 11:50 AM
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
--
R. Daniel Braun
Kinky for Governor
