Interesting case - HELLP?

Ms. H is 8 days postpartum. She had an uneventful pregnancy with no complications. Her history is positive for mitral valve prolapsed. She came in today because she has developed an itchy rash on her arms and legs. She also states that she has pain in her RUQ when she takes a deep breath. Her BP is 163/107; repeat 158/118. HR 90; repeat 96. She is afebrile. On exam, she has a macular popular scabby rash on all four extremities. She has bilateral pitting lower leg and pedal edema. Her lung sounds are clear; heart rate is regular with no abnormal sounds. Patient complained of pain with palpation to RUQ. Liver palpable ~2 cm below rib cage; unable to palpate spleen. Bowel sounds + in all 4 quads.

Abnormal Labs:
Lactate dehydrogenase 245 (108-212)
Serum uric acid 6.2 (2.3-5.6)
Bilirubin 0.1 (0.2-1.0)
RBC 3.07 (4.0-5.2)
Hgb 9.1 (12-16)
Hct 27.8 (35-46)
Platelets normal at 379
LFTs WNL

Plan:
BP checks x 5days in clinic or at CVS/Walgreen’s; come to clinic if over 160/110
Atarax for itch
Hydrocortisone cream for rash
Adalac CC for elevated BP

I found this case interesting because my first thought was HELLP; however, the labs did not support this diagnosis, although the enlarged liver and RUQ pain can be symptoms of HELLP. I was surprised to see the normal LFTs. The HTN could indicate pre-eclampsia. My preceptor stated that the edema is not unusual post partum because of all the IV fluids administered during labor (3-4 liters). As far as the rash goes, I don’t think it was related to the other symptoms. There are many causes for elevated lactate dehydrogenase including hemolytic anemia, infectious mononucleosis, and liver disease but I couldn’t find anything to indicate that this elevation could be a result of having given birth 8 days ago. Obviously, my preceptor was more comfortable than me in treating this woman conservatively. The enlarged liver still bothers me.

INTERESTING ISSUE-Susan Frisbie-13 June 2010

Twenty-nine year old, G3P3003, Caucasian female presents for six week postpartum appointment. The interesting piece is she is a surrogate mother for a civilian couple. The gametes were fertilized outside the womb, in vitro. She came alone to the postpartum appointment because her husband is deployed. However, he did come for the delivery. Do you wonder what her depression scale score was? It was a three and she was in good spirits. She chose to breastfeed the baby while in the hospital and I thought it was a little odd. The baby left the hospital with the adopted parents. The patient receives almost daily texts with photos of the baby. This is her first time being a surrogate mother and she states she would do it again. She and her husband are happy and have two children of their own. Thoughts that come to my mind….. Tricare will not pay for in vitro but I bet the prenatal care is covered. So is it legal for an active duty member to be a surrogate? If the DoD is aware of the intent for surrogacy will Tricare cover the cost of prenatal care and the delivery? Also found it interesting that Tricare will not cover surrogacy as an infertility option.

Amniocentesis or Not???

Amniocentesis or NOT?

One day I had the opportunity to spend the morning with a Genetics Counselor. We had a 42-year old patient present to the clinic with her spouse. She has had 8 miscarriages in the past (with 3 being in the 2nd trimester). She is now 18 weeks pregnant again and been told that her quad screen came back positive for Trisomy 18. So now we have a few issues here. The woman is AMA and she now has a positive Quad Screen and she also has a family history of miscarriages to include her sister and mother. The Genetics counselor explained to her that the reasons for all the miscarriages were more likely due to genetics/chromosomal abnormalities. The patient had a ROB prior to arriving to her appointment with the genetics counselor and was never told of her Quad Screen results until her appt with us. The patient denied any reason to believe what the genetic counselor was saying to be true. The Genetics Counselor recommended the patient receive an US as well as Amniocentesis. The counselor told the patient and her husband that the benefits of her going through with it. She also talked to the patient about the risks, which included miscarriage. The patient, concerned, began to speak about going through with it, when the spouse interrupted and stated that he definitely did not want any counseling to be done. He mentioned that they have gone through a lot with these past 8 miscarriages and have even sought treatment with the infertility clinic in Virginia and also having a cervical cerclage to ensure that she could maintain the pregnancy in case that was the issue for all her miscarriages. Both parents agreed not to do any further testing to include refusal of an Ultrasound. The patient stated that she believed that her God would provide for them a healthy baby boy and that she did not need to be followed up. I felt as if the genetic counselor could have been a little more sympathetic as well as informative to the patient. The patient was scared upon entry to the office and had no idea why she was even referred to the Genetic Counselors Office. So there was a lack of communication on some providers part. Then she enters this office and “boom” all of this information is thrown at her. If I were in the patients shoes, I would be extremely overwhelmed and would find it hard to maintain my composure. Here I am ecstatic about finally having a baby. Convinced that I am having this happy baby boy only to find out that I might be having a baby with Trisomy 18… Sad…..:o(