This patient presented with symptoms of difficulty breathing, lower limb swelling, decreased urine output, and pallor. Her labs showed kidney dysfunction with elevated creatinine and liver enzymes. Her history of abruptio placenta and recent pregnancy termination suggested HELLP syndrome. A kidney biopsy was considered but the patient refused. Her kidney function and labs gradually improved with aggressive fluid management and medications.
2. • A30- year -old female was referred from
Elmania University Hospital for OPINION with
chief complaints
• Difficulty of breathing
• Swelling of both lower limb
• Decrease urine out put
• Sever pallor
• 10 days ago
3. Personal history
• Patient named Shimaa Gamal Faez
Married since 10 years ,has 2 off
spring youngest 7 years old,house
wife ,no special hapits of medical
importance.
4. Past history
No similar condition
No history of drug intake
• No history surgical operation
except c.s.
6. Obstetric history
• She is G3 P2 .abortion occur at 7th
month of last pregnancy as
diagnosed by abruptiou placenta
resulting in haematoma and
termination of pregnancy due to
intrauterin fetal death by C. S.
7. PRESENT HISTORY
• The Condition started by dyspnea which
increasded gradually,progressed course
associated with vomting and heart burn 2week
ago . There is no respose for ttt ,she became
fatigued and abdominal pain.. On Abdominal
ultrasound examintion found abruptio placenta
and intra uterin fetal death which leading to
terminatin of prgnacy by C.S. ,lab investigation
show elevation of seum creatinine ,liver enzymes
and sever anemia,she also was olgiuric ,no
hypertension ,no diabetus melletus
8. General examination
• Patient is consious ,alert ,oriention to place
time person,orthopenic
• Blood pressure 130/90
• RR=20
• pulse=80
• Temperature 37
9. Local exaination
• HEAD NECK: congseted vein ,no neck
swelling
• Chest vesicular breathing with decrease bilateral air
entry and diffuse crepitation.
• Heart normal S1 & S2 no murmurs or added sound
• Abdomen lax & soft ,C.S.scar
• NOtenderness & no organomegally
• Lower limbs bilateral LL pitting odema below
knee,intact peripheral pulsation
14. TMA
• Consist of
• thrombocytopenia
• Microangiohemolytic anemia
• Microvascular thrombosis
• LAB of TMA
• Sever thrombocytopenia-anemia
• Reticulocytosis
• Elevated LDH
• Normal liver enzyme
• Creatinine elevation in renal involvement
• Treatment
• Urgent empirical plasmapharesis
15. HELLP Syndrom.
Hemolysis
.elevated liver enzyme
.low platelets with hypertensive disorder of pregnancy
.though to be a sever form of pre eclamptic liver
dysfunction but it can occure in normotensive as well
.Symptoms
Abdominal pain
Nausea and vomting
With or with out jaundice
16. HELLP SYNDROME con.
Diagnosis
Hemolysis
Serum LDH>600u/l
Characterstic peripherial blood smear
Elvated liver enzyme serum aminotrans ferases >70
Low platelets <100
Majority ocuring of pregnancy in 3rd trimester
Management
Close monitor of patient
End pregnancy
Steroids
Prophylaxsis anti biotic
17. Acute tubular necrosis
• Most common cause of AKI
• 1-olgiuric (2-4weeks)—a-ischemic b-toxic
• 2-polyuric (3-4)day
• 3-post diuretic
• Investigation no biopsy needed
• Urine :granular cast due to dilatation of healthy
nephron
• Sonar normal
• Blood urea ,creatinine increase,Hb% decrease,k
and po4 increase, ca++decreae
19. FURTHER INVESTIGATION DONE
• LDH =1533
• VIROLOGY HCV –ve,HBV -VE
• ANTI DS DNA -VE
• C3,C4 NORMAL
• ANA -VE
• Blood film( lieshman stain):
• blood film shows marked variation in size and shape of RBCs
some cells show central pallor,few fragmented
cell(shistocytes)are seen, WBCs show leucocytosis with absolute
neurophilia,mature segmented cell with some toxic granulation
,platelets are seen with normal granularity and no
aggregations,manual platelets cout :110.000/cmmfollow up is
recommeneded,exclude microagiopathic anemias??
21. HOSPITAL COURSE
• The patient has been admitted to nephrology
• departement on 9/03/2018
• Fluid ,blood trans fusion and antibiotic were intiated
• Follow up on regular haemodialysis
on 10/3 lasix 40mg /8hour ,and solupred 20mg 3x1
on 11/3 STOP previousS AB and add.cefipim 1gm iv /24,levofloxacin
500mh iv /24hour,
on 11/3 add aldomet 250 mg 1x3 0n 14/3 add alkapresss 10mg 1x1
on 29/3 partial improvement occur
• During this period decision was taken to do renal biopy
but patient refuse , …patient was discharged on 2/4 with
follow up in out patient clinic on with creatinine2.7,Hb =8.2 plt=84
• Solurpred 20 1x2
• Alkapress 10tab
• Rantidine 150 tab
• Motilium syrup
23. Fluid chart of patient during ttt• oliguric
• 1)10/3 input 600out put 150
• 11/3 input 450 out 200
• 12/3input 1300 out put 400
• 13/3 intake 500 out 150
• 14/3 input 800 out put 700
• 15/3input 700 out 500
• 16/3 in put 400 out put 500
• 17/3 input 400 out 600
• 18/3 input 200 out put 600
• 20/3 input 550 out put 1250
• 22/3 input 1600 out 1600
• 23/3 input 1800 out put 2000
• 24/3 input 1900 out put 2300
• 25/3 input 2200 out put 2500
• 26/3 input 2000 out put 2500
• 27/3 input 3650 out put 5000
• 28/3 input 3300 out put 4500
• 29/3 input 1300 out put 1600
• 31/3 input 1050 out put 1700
• 1/4 input 2300 out put 1500