STA

Bakhytbek Zhalmagambetov
 case
CC: Patient female 26 y.o. was admitted due to worsening condition
(thrombocytopenia 354,000 -> 166,000, oliguria, ALT, AST rise) after cesarean
section
HPI: Patient had a pregnancy complicated with pre-eclampsia(headache,
persisting hypertension after 20 week of gestation{150/90}, proteinuria),
emergent C-section was done on 37 weeks of gestation and she was admitted
one day postoperative to ICU with abovementioned condition.
PMH: Denies TB, HIV, Hepatitis B,C. Blood transfusion in 1980 due to labor.
FH/SH: Patient works as a manager. Never smoked, never used alcohol.
Married, lives in a comfortable housing. No DM, hypertension in parents, and
siblings
Denies allergy for medications, spore, dust
 ROS
• GENERAL: complains for weakness
• HEENT: No dysphagia, denies runny nose, no otalgia or hearing problems
• CARDIO: denies pain on exertion, no shortness of breath
• Resp: no chest pain, no shortness of breath, no wheezing
• GI: has occasional heartburns, no constipation, denies blood or mucus in
the stool
• GU: She denies dysuria, no nycturia, no frequent and small amount urea
• Neuro: denies dizziness or visual disturbances, denies gait imbalance
• Skin: denies dryness, no itching, color changes
 PE
• Vitals : BP-155/95, BMI -20,5, HR-72, RR-16
• General – on the bed, normostenic, no jaundice
• HEENT – tongue is not hypertrophied, No lympodenopathy ,hearing is preserved ,
visual fields are not decreased bilaterally
• Cardiovascular – normal S1, S2, no murmurs, no carotid bruits bilaterally, pulses are
regular, in concert. Apex beat is not deviated
• Lungs – vesicular sounds, no crackles or wheezes, no use of accessory muscles. CVT-
negative
• Abdomen – On inspection: symmetric, enlarged due to uterus size, scar from C-
section. Auscultations: decrease in bowel sounds, palpation: painful with light
palpation on peri-operational sites, abdomen a bit tender, not palpable spleen, liver,
percussion: liver 14 cm, enlarged
• GU – urethral catheter is placed
• Extremities – pitting edema on both legs , no cyanosis or clubbing fingers
• Musculo-skeletal – not performed
• Neurological – sleepiness, CN 2-12 grossly intact.
 Instrumental results
• Xray of chest: no pathologies
• EGDS surface gastritis
• US abdomen--- hepamegali, no free liquid
 Lab results (WBC, PLT, HB)
140

120

100

80

60

40

20

0
6 april 7 april 8 april 9 april 10 april 11 april 12 april
WBC PLT Hb
Lab results (total/direct bilirubin – mmol/l)
450

400

350

300

250

200

150

100

50

0
6 april 7 april 8 april 9 april 10 april 11 april 12 april
total direct
Lab results (ALT, AST – mccat/l)
8

0
6 april 7 april 8 april 9 april 10 april 11 april 12 april
ALT AST
Lab results (total protein, albumin, SRP)

97.5

70.2
65.7

53.5 55 53.3
48.4 47 46.7 46.7 48
44.96
36.2
31.7 29.37 29.5
26.1
17.3 18.44

6 APRIL 7 APRIL 8 APRIL 9 APRIL 10 APRIL 11 APRIL 12 APRIL

total protein albumin SRP
Lab results (creatinine, urea)
250

200 202.72 204.5

190

150 148.8

116.4
100 99.5

66.5
50

16.9 17.57 15.1

7.49 9.1 12.05 9.11
0
6 april 7 april 8 april 9 april 10 april 11 april 12 april
creatinine urea
Lab results (сoagulogramm) DIC???
PT (sec) INR Fibrinogen (g/l) APTT (sec)

6 April 12,0 1,11 3,45 36,2

7 April 11,0 1,01 3,36 37,7
8 April 10,0 0,92 3,31 29,7
9 April 9,6 0,88 2,68 36,1
10 April 10,9 1,01 2,67 35,5
11 April 10,7 0,99 2,2 34,1
HELLP syndrome
• HELLP syndrome is a life-threatening pregnancy complication usually
considered to be a variant of preeclampsia. Both conditions usually
occur during the later stages of pregnancy, or sometimes after
childbirth.
• H (hemolysis, which is the breaking down of red blood cells)
EL (elevated liver enzymes)
LP (low platelet count)
 Symptoms of HELLP Syndrome

The physical symptoms of HELLP Syndrome may seem at first like preeclampsia.
Pregnant women developing HELLP syndrome have reported experiencing one or
more of these symptoms:
• Headache
• Nausea/vomiting/indigestion with pain after eating
• Abdominal or chest tenderness and upper right upper side pain (from liver
distention)
• Shoulder pain or pain when breathing deeply
• Bleeding
• Changes in vision
• Swelling
 Management
1) Antibacterial therapy: cefuroxime 1,5 gr. *2 times a day
2) nimodipine 50 ml perfusor 1,0 ml/h (cerebral bleeding associated with the HELLP syndrome)
3) Gastroprotectors: omeprazole 40 mg
4) Tramadol 2 ml when pain
5) Oxitocin 5 units IM
6) Furosemide 100 mg through perfusor under diuresis control
7) Anticoagulative therapy : Sodium enaxaparine 0,4 ml once a day
8) Hepa merz 10 ml (Ornitin) improves urea cycle, however better to give glutathione {it may
protect against damage by hydrogen peroxide, Glutatione levels are low in HELLP}
9) Albumin transfusion 20%, 100 ml, thrombocytes 3-5 doses
10) Antithrombin therapy? Checked once 70,5%, however important to monitor in HELLP
11) plasma exchange with fresh frozen plasma done for progressive elevation of bilirubin and
creatinine
12) RBC, platelets infusion
 The end !!!

Thanks for your attention!!!!