28 yo with uti

[pbruss]

28 yo G6P6 omish female 10 weeks out from spontaneous vaginal delivery at home with no prenatal care, presents at ER with "the antibiotics I got here are not working".

Since here delivery she has had diffuse and pain, nausea, fatigue, headache, and subjective fever at home. No vomiting, unusual vag bleeding, CP, SOB, vision changes, or edema. Symptoms have prigressivly gotten worse. She takes no meds, no past surgical or medical history, no family history and no recreational drugs/ETOH/tobacco. She has noticed urinary frequency but no retention, incontinence, or pain with urunation. Reports vag bleeding for first week after delivery but none since and nothing different then her previous 5 kids.

She was in your ER 3 days before for the same, was diagnosed with uti, put on bactrim, but is getting worse.

Exam - t-99.9 p-93 bp-112/74 98% on RA
Appears I'll but not toxic AAOx3
Cv-rrr no mrg
Lungs CTA bilaterally with no resp distress
Abd- moderate tenderness in RUQ, epigastrum and LUQ but does not localize to one area. Soft not distended normal bowel sounds. She does have some mild rebound with deep palpitation but no guarding.
Ext- no edema or cyanosis but does have rash on both legs just above the ankle. 10-15 scattered punctate macular dark red lesions that do not blanch. She did not remember the rash being there yesterday

Labs from pervious visit
Wbc-5.5 hg-11 plt-157
Urune dip- positive for lucocyte esterase ketones wbc protein and RBC. Negative for nitrates gkucose and pregnancy. Culture not sent.

Based on the above, what missing part of the exam would help you the most in choosing further diagnostics.

A. HEENT
B. Pelvic
C. neuro - strength, dtrs, Babinski, sensation and propreoception.
D. Visual acuity
E. Gait including Romberg

Based on your choice from above what test would you order next

A. MRI brain
B. CTA chest
C. Serum pregnancy
D. CMP
E. Renal US

[Bjs04f]

Concerned about either retained POC causing septic picture, or amniotic fluid embolism. She has vasculitic like rash with LUQ and RUQ pain for spleen/liver, possibly pyelo/glomerulonephritis picture as well. This was done in conjunction with Womack and Barkley. So Pelvic followed by CTA chest to look for emboli

[pbruss]

Solid reasoning. I am sorry but I had her labs wring. The playlet count was 126 on the first visit NOT 156. Does that change anything?

[kemple]

Neuro exam and CMP looking for kidney function. Is this HSP in/after pregnancy?

[DD]

I was thinking possible HELLP given the non-blanching rash but 10 weeks seems too far away. I'd pick CMP regardless because of the RUQ pain and rash.

[pbruss]

COrrect. This was HELLP. the answers i was looking for was HEENT and CMP. her skin and eyes were not jaundice but the bottom of her tounge was yellow - which is the first place it will show up. on her CMP her ast and alt were around 8oo each and her total billi was 5. she had an INR of 1.9 and a LDH of 500. i have read that you can get HELLP syndrome up to 12 weeks post partum. check out some of the stuff below from Up to date

DIAGNOSIS — The diagnosis of HELLP syndrome is based upon the presence of all of the laboratory abnormalities comprising its name (hemolysis with a microangiopathic blood smear, elevated liver enzymes, and low platelet count) in a pregnant woman. Thus, laboratory work-up should include [19]:

●Complete blood count with platelet count

●Peripheral smear

●Aspartate aminotransferase (AST), bilirubin

In addition, we obtain a serum creatinine concentration and urine protein to creatinine ratio.

We suggest obtaining these laboratory tests in women with new onset hypertension and/or characteristic symptoms (right upper quadrant/epigastric pain, nausea, vomiting, fatigue or malaise) in the second half of pregnancy or first postpartum week.

Pregnant/postpartum women who have some of the typical laboratory abnormalities but do not meet all of the laboratory criteria described below are considered to have partial HELLP syndrome [7].

Laboratory criteria — Precise criteria for HELLP are necessary for research purposes and for predicting maternal complications. We require the presence of all of the following criteria to diagnose HELLP (Tennessee classification) [16]:

●Microangiopathic hemolytic anemia with characteristic schistocytes (also called helmet cells) on blood smear (picture 1). Other signs suggestive of hemolysis include an elevated indirect bilirubin level and a low serum haptoglobin concentration (≤25 mg/dL).


●Platelet count ≤100,000 cells/microL


●Total bilirubin ≥1.2 mg/dL (20.52 micromol/L)


●Serum AST ≥70 IU/L. Some investigators obtain alanine aminotransferase (ALT) levels instead of, or in addition to, AST levels. An advantage of the AST is that it is a single test that reflects both hepatocellular necrosis and red cell hemolysis.


These thresholds were chosen, in part, to avoid problems related to differences in assays used to measure liver enzymes, which may result in an elevated value in one hospital that is near normal in another. We do not include elevated lactate dehydrogenase (LDH) in the laboratory criteria for HELLP syndrome because it is a nonspecific finding associated with both hemolysis and liver disease.

As discussed above, women who do not meet all of the above laboratory abnormalities are considered to have partial HELLP syndrome. However, these patients may progress to complete expression of HELLP syndrome.

There is no consensus regarding the laboratory criteria diagnostic of HELLP syndrome. A common alternative (Mississippi classification) used to define HELLP syndrome is [20,21]:

●Hemolysis documented by an increased LDH level and progressive anemia


●Hepatic dysfunction documented by an LDH level >600 IU/L, elevated liver enzymes documented by AST >40 IU/L, ALT>40 IU/L, or both


●Thrombocytopenia documented by a platelet nadir less than 150,000 cells/mm³. Thrombocytopenia is subclassified as class one HELLP syndrome: platelet nadir ≤50,000 cells/mm³, class two HELLP syndrome: platelet nadir ≤100,000 cells/mm³, or class three HELLP syndrome: platelet nadir ≤150,000 cells/mm³.

HELLP syndrome refers to a syndrome characterized by Hemolysis with a microangiopathic blood smear, Elevated Liver enzymes, and a Low Platelet count. The most common clinical presentation is abdominal pain and tenderness in the midepigastrium, right upper quadrant, or below the sternum. Many women also have nausea, vomiting, and malaise, which may be mistaken for a nonspecific viral illness or viral hepatitis, particularly if the serum aspartate aminotransferase (AST) and lactate dehydrogenase (LDH) are markedly elevated. Hypertension (blood pressure ≥140/90 mm Hg) and proteinuria are present in approximately 85 percent of cases, but it is important to remember that either or both may be absent in women with otherwise severe HELLP syndrome. Hepatic rupture is rare and is a surgical emergency; if rupture is suspected, ultrasound examination may show intra- or extra-hepatic bleeding, but hepatic complications are best characterized by magnetic resonance (MR) imaging or computed tomography (CT).

The usual times of onset
Antepartum cases. As was previously
noted, HELLP syndrome usually develops
before delivery, with the most frequent
onset being before 37 weeks’ gestation
(TABLE 4).
In the postpartum period, most cases develop
within 48 hours after delivery. Of these,
approximately 90% occur in women who
had antepartum preeclampsia that progressed
to HELLP syndrome in the postpartum
period. However, approximately
20% of postpartum cases develop more
than 48 hours after delivery.

Attachments:

HELLP_Article2.pdf (102.08 KB)

[pbruss]

abd her platlet count was 98 when i saw her

[DD]

10 weeks postpartum seems like a record! The longest I've found is 6!