A 36-year-old G1P0 at 35 weeks’ gestation presents to labor and delivery reporting a several-day history of generalized malaise, anorexia, nausea, and emesis. She reports no headache, vision changes, contractions, vaginal bleeding, or leaking fluid. She reports good fetal movement, and the FHR is in the 150s with good variability and no decelerations. On physical examination, you notice that she is mildly jaundiced and appears to be a little confused. Her vital signs indicate a temperature of 37.7°C (99.9°F), pulse of 70 beats per minute, and blood pressure of 100/62 mm Hg. Laboratory data are as follows—WBC = 25,000, Hct = 42.0%, platelets = 51,000, SGOT/ PT = 287/350, glucose = 43 mg/dL, creatinine = 2.0 mg/dL, fibrinogen = 135 g/l, PT/PTT = 16/50 s, serum ammonia level = 90 mmol/L (nl = 11-35). Urinalysis is positive for 3+ protein and large ketones.
Which of the following is the most likely diagnosis?
Acute fatty liver of pregnancy is a rare complication of pregnancy. Estimates of its incidence range from 1 in 7000 to 1 in 15,000 pregnancies. At one time, it was thought to be universally fatal, but early diagnosis and prompt delivery have significantly improved the prognosis. It is thought that recessively inherited mitochondrial abnormalities of fatty acid oxidation predispose a woman to fatty liver in pregnancy. This disorder usually manifests itself late in pregnancy and is more common in nulliparous women. Typically, a patient will present with a several-day or -week history of general malaise, anorexia, nausea, emesis, and jaundice. Liver enzymes are usually not elevated above 500 U/L. Indications of liver failure are present, manifested by elevated PT/PTT, bilirubin, and ammonia levels. In addition, there is marked hypoglycemia. Low fibrinogen and platelet levels occur secondary to a consumptive coagulopathy. In cases of viral hepatitis, serum transaminase levels are usually much higher and marked hypoglycemia or elevated serum ammonia levels would not be seen. Sometimes the HELLP syndrome can initially be difficult to differentiate from acute fatty liver, but in this case the patient has a normal blood pressure. In addition, hepatic failure is not characteristic of severe preeclampsia. Hyperemesis gravidarum is characterized by nausea and vomiting unresponsive to simple therapy. It usually occurs early in the first trimester and resolves by about 16 weeks. In some cases, there can be a transient hepatic dysfunction. Intrahepatic cholestasis of pregnancy is characterized by pruritus and/or icterus. Some women develop cholestasis in the third trimester secondary to estrogen-induced changes. There is an accumulation of serum bile salts, which causes pruritus. Liver enzymes are seldom elevated above 250 U/L.
Which of the following is the recommended treatment for this patient?
Acute fatty liver resolves spontaneously after delivery. Delayed diagnosis and movement toward delivery can result in risk of coma and death from severe hepatic failure. In addition, procrastination can result in severe hemorrhage and renal failure. Bed rest and supportive therapy would be the treatment for viral hepatitis. Benadryl treatment would apply to therapy for cholestasis of pregnancy. MgSO4 therapy would be applicable to cases of the HELLP syndrome.
A 32-year-old G1P0 presents for a routine OB visit at 14 weeks’ gestation. Laboratory findings drawn at her first prenatal visit 4 weeks ago showed a platelet count of 60,000/μL. Follow up laboratory findings revealed a normal PT, PTT, and bleeding time. All her other laboratory findings were normal. During the present visit, her blood pressure is 120/70 mm Hg, she has no proteinuria on urine dip, and she reports no complaints. On taking a more in-depth history you learn that, prior to pregnancy, she had a history of occasional nose and gum bleeds, but no serious bleeding episodes. She has considered herself to be a person who just bruises easily.
ITP typically occurs in the second or third decade of life and is more common in women than in men. The diagnosis of ITP is one of exclusion, because there are no pathognomonic signs, symptoms, or diagnostic tests. Traditionally, ITP is associated with a persistent platelet count of less than 100,000/μL in the absence of splenomegaly. Most women have a history of easy bruising and nose and gum bleeds that precede pregnancy. If the platelet count is maintained above 20,000/μL, hemorrhagic episodes rarely occur. In cases of ITP, the patient produces IgG antiplatelet antibodies that increase platelet consumption in the spleen and other sites. Gestational thrombocytopenia occurs in up to 8% of pregnancies. Affected women are usually asymptomatic, have no prior history of bleeding, and usually maintain platelet counts above 70,000/μL. Platelet counts usually return to normal in about 3 months. The cause of gestational thrombocytopenia has not been clearly elucidated. HELLP syndrome is associated with thrombocytopenia, but this condition typically occurs in the third trimester and is associated with hypertension (preeclampsia). In neonatal alloimmune thrombocytopenia, there is a maternal alloimmunization to fetal platelet antigens. The mother is healthy and has a normal platelet count, but produces antibodies that cross the placenta and destroy fetal/neonatal platelets.
A 23-year-old G1P0 presents for a routine OB visit at 28 weeks’ gestation. Laboratory findings drawn at her prenatal visit 2 weeks ago reveal a 1-hour glucose test of 128 mg/dL, hemoglobin of 10.8 g/dl, and a platelet count of 80,000/μL. All her other laboratory findings were normal. During the present visit, her blood pressure is 120/70 mm Hg, and her urine dip is negative, and she has no complaints. She has no known medical problems, but does report a history of epistaxis on occasion, but no other bleeding.
What is the next step in treatment for her thrombocytopenia?
This patient is most likely to have gestational thrombocytopenia. Asymptomatic pregnant women with platelet counts above 50,000/μL do not need to be treated, because the platelet count is sufficient to prevent bleeding complications. For severely low platelet counts, therapy can include prednisone, intravenous immune globulin, and splenectomy. These therapies are typically not required to treat gestational thrombocytopenia.
A 21-year-old G2P1 at 25 weeks’ gestation presents to the emergency room with a chief complaint of shortness of breath. She reports a history of asthma, and states her peak expiratory flow rate (PEFR) with good control is usually around 400 L/min. When speaking, the patient has to stop to catch her breath between words; her PEFR is 210. An arterial blood gas is drawn and oxygen therapy is initiated. She is afebrile, and on physical examination expiratory wheezes are heard in all lung fields.
Which of the following is the most appropriate next step in her management?
Inhaled β-agonists are the primary treatment for an acute asthma exacerbation. Intravenous steroids should be given if the exacerbation is severe, if the patient is currently taking oral steroids, or if the response to bronchodilator therapy is incomplete or poor. Antibiotics are used for patients with fever, leukocytosis, or evidence of infection. A febrile patient should have a chest x-ray to rule out pneumonia. Methylxanthines are not used for acute asthma exacerbations.
Click to expand