Patient name: ak

DOB: 8/3/1988
Age:34
Gender: Female

Chief complaint:
Referral from FMU for PET

History of presenting illness:

ak is a 34 yrs. old female G3P0 A known case of lupus and HTN on medications. She is 28
weeks pregnant (assisted by IVF) at 3/3/23 she had an appointment at the FMU in Tawam, and
the test showed that she is having a symmetrical IUGR. The Doctor advised her to undergo a
PET assessment to make sure nothing goes wrong, due to her chronic medical conditions which
put her at high-risk pregnancy and its complications. On 4/3/23 she was admitted, denied any
symptoms of visual disturbance, headache, and epigastric pain. PET assessment was done it
showed worsening PET profile with laboratory changes suggesting HELLP syndrome, which
required immediate termination since the fetus doesn’t meet the criteria of viability.

Review of symptoms:
Constitutional: No fever, No chills, No sweats, headache on and off – decreased activity
Eye: No double vision, No visual disturbances.
Ear/Nose/Mouth/Throat: No decreased hearing, No ear
pain. Respiratory: No shortness of breath, No cough.
Cardiovascular: No palpitations, No tachycardia, No peripheral edema, No syncope.
Gastrointestinal: No Nausea, No diarrhea, No constipation, No heartburn, No change in
bowel habits, No epigastric pain
Genitourinary: No hematuria, no dysuria, no abnormal vaginal discharge
Hematology/Lymphatics: No bruising tendency.
Endocrine: No excessive thirst. No polyuria, no
polydipsia Immunologic: No recurrent infections
Integumentary: No rash,No petechiae, No
pruritus. Neurologic: Alert and oriented to time
and place Psychiatric: No anxiety, No
depression.

Ob hx
- All her pregnancies were assisted by IVF
- 1st pregnancy  therapeutic abortion at 20 wks., due to placental insufficiency
- 2nd pregnancy had spontaneous miscarriage in the 1st trimester + underwent D&C

Past gynecological history:

 LMP: 16/6/2022
 Menarche at age 11
 Regular cycles (last for 5-6 days)
 Does not use any form of contraceptive
  Previous pap smears were -ve

Past medical history

- Lupus
- HTN

Drugs and allergies:

- No known allergies
- Imuran 100 mg
- Hydroxychloroquine 200 BID
- Prednisolone 5mg daily
- Aspirin 150 mg
- Clexane 40mg daily
- Crinine vaginal gel
- Duphaston
- Labetalol 100 mg

BD Surgical history:

- Surgical: left kidney resection in 2009 at 20 Years of age and thyroid procedure in the
childhood.
-
Lifestyle history:
 Nonsmoker
 Stress?
 Doesn’t consume alcohol

Family history:
 No cases of autoimmune diseases in the family (Thyroid/DM/lupus) etc.
 Mother has HTN

Social history:
 Married to 1st degree relative
 Employe

d Physical

exam:

General: I couldn’t do the PE * pt. was discussed by the doctors that the preg should be
terminated*
- Pt was crying
- Had puffy face and LL edema

Vital signs:
 Temperature: 36.46C
 Peripheral pulse rate: 79bpm
 Respiratory rate: 19 br/min
  Systolic blood pressure: 130
 Diastolic blood pressure: 90
 Oxygen saturation % 100

Differential diagnosis:

- HELLP syndrome
- Pre-eclampsia
- Lupus flareup
- HUS
- Hepatitis C

Dx should be based on (Hx + PE +Labs)

Hx  we should look for risk factors that increases the risk of her developing preg complications

- Previous miscarriage + termination

- Lupus + Chronic HTN
- Single kidney
- Age > 30
- Obese

The most imp thing her is to be aware if she is having PET or not and if yes to manage it
Ask if there are any warning signs of PET: epigastric pain – lower limb edema- dizziness-visual disturbance -
vaginal bleeding-oliguria-Vomiting -decrease fetal movement

PE General + Focused (Abdominal and PV)

- General examination  Shock/anemia/seizures/
- Consent monitoring to vitals  may deteriorate rapidly
- PV  Closed Os – no bleeding

Investigations  are divided into maternal and

fetal Maternal
- CBC  to check Hct/Hbg/ WBC  is there any change in the
- LFT
- Coagulation profile
- Kidney function
test Fetal 
- US (growth assessment /liquor)
- Assessment of the wellbeing

Test Rationale Results

CBC with differential To rule out anemia and WBC: 6.0 x10^9/L
infections.
RBC: 4.54 x10^12/L

Hgb: 130 g/L

Hct: 0.37 L/L

MCV: 81.5 fL

MCH: 28.6 pg

MCHC: 351 g/L

Neutrophil #: 3.97 x10^9/L

Lymphocyte #: 1.21 x10^9/L

Monocyte #: 0.80 x10^9/L

Eosinophil #: 0.03 x10^9/L

Basophil #: 0.02 x10^9/L

Coagulation profile To rule out Platelets: 123 x10^9/L
thrombophilia.
PT: 10.0 sec

INR: 0.91

APTT: 34.9 sec

Electrolytes, urea, and creatine To check kidney Sodium: 138 mmol/L
function and electrolyte
imbalances. Potassium: 4.0 mmol/L

Chloride: 112 mmol/L

CO2: 17 mmol/L

Creatinine: 44 micromol/L

Urea: 3.90 mmol/L

 Protein/creatinine ratio: 0.72
g/g Creat
Liver function tests To check liver enzymes. Total protein: 55 g/L

Albumin level: 19 g/L

Bilirubin Total: 4.2

micromol/L

Bilirubin Direct: 2.0

micromol/L

LDH: 395 IU/L

Alkaline phosphatase: 148

IU/L

AST: 64 IU/L

ALT: 54 IU/L
Urine chemistry and Urinalysis To rule out proteinuria Creatinine: 4.27 mmol/L
and hematuria.
Protein: 0.35 g/L

Albumin/creatine: 24.33
mg/mmol

Albumin: 264 mg/L

Color: Yellow

Urine specific gravity: 1.015

Urine pH: 7.0

Leukocyte esterase: Negative

Nitrite: Negative

Protein: 1+

Glucose: Negative mmol/L

Ketones: Negative
 Urobilinogen: Normal

Blood: Negative

Interpretation
- Low plts  thrombocytopenia
- LDH is high  hemolysis
- Abnormal kidney fxn  early sign of AKI
- Elevated liver enzymes

US of the fetus
- Severe IUGR
Umbilical artery Doppler  showed absent end diastolic Flow
Management

- This all conclude from (Hx + PE+ labs) that most likely she is
having HELLP, and higher complications may develop due to
her age, medical condition, single kidney this all put her on
higher risk of developing complications
- In term of the fetus conditions no gain of weight severe IUGR +
doesn’t meet the criteria of viability (400g) therefore they need
to terminate the preg * risk of IUFD if it was not terminated*
- Was given misoprostol 3 doses 200mcg vaginally
- Follow up post – induction of labor – with rheumatologist and nephrologist

Extra --- > pts with medical conditions that can cause high bP should be monitored
much more often
- Education them about s/s of pre -eclampsia + the importance often miniating
strict control
- Antiplatelet agents  aspirin should be started from the dx of preg
- If she had HTN prior preg she should change the
medication (and take a med that is not teratogenic)
- https://www.nice.org.uk/guidance/ng133/chapter/recommendations