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.
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Lorraine, I spent a day in L&D triage and we had a young lady, G1PO, that we walked in from clinic to do a f/u BP check r/t protein in her urine. Her blood pressure remained WNL and her 24 hour protein stayed at 350, barely elevated. Her AST and ALT were also elevated but not too much above the high end of normal. However, the liver elevation was new. My preceptor and another midwife mentioned atypical pre-eclampsia as an explanation for not having an elevated BP. She ended going home with another 24 hour urine and a f/u on Saturday for another BP check. The potential DVT was also ruled out by doppler in Vascular. We commonly study the classic picture of disease but often labs are elevated without an easy explanation. Thanks for sharing. Susan Frisbie
ReplyDeleteRemember that pre-eclampsia and eclampsia are SNEAKY. I've had patients present with just a headache - NL BP, no edema, etc....with 4+++ reflexes.
ReplyDeleteI too am concerned about her liver. What's going on? So, did your preceptor bring her back in within a few days? I'm not used to seeing women so anemic either...even postpartum. How much did she bleed during delivery? I'm not sure how well she's "thinking" with a HCT of 27.