A CASE OF JAUNDICE COMPLICATING PREGNANCY III Medicine Unit Presentor Chief P.Vathsalyan Prof Dr Natarajan MD Asst Professors Dr Palani Kumar MD Dr Valli Devi MD

A 22 yr old female with obstretic history of G2A1, married since 11/2 yr with EDD on 11/12/2016 has been referred from Karur GH to OG casualty as a case of Jaundice complicating pregnancy Patient was admitted in OG ward on 9/11/16 and later transferred to Medicine ward for further management

History of present illness H/o yellowish discolouration of urine x 3 days H/o headache x 2 days H/o nausea x 2days H/o abdominal pain x 2days No h/o vomiting No h/o fever No h/o oliguria/ polyuria No h/o clay coloured stools No h/o itching No h/o altered sensorium No h/o bleeding manifestations

Past history No h/o similar complaints before Not a k/c/o SHTN /DM /Asthma /Epilepsy / Thyroid /CLD /CAD /CKD Menstrual history Attained Menarche at 14 yrs RMP- 3/30 No h/o Menorrhagia Marital history Married since 11/2 yrs Non consanguinous marriage

Obstetric history I pregnancy- Induced abortion at 3rd month due to fetal anomaly at a private hospital II pregnancy- Present pregnancy Booked & immunised at Karur GH Personal history Pt takes mixed diet Bowel & bladder habits normal Sleep pattern normal No h/o drug intake other than IFA tablets

General Examination Conscious Oriented Afebrile No pallor Icterus ++ No cyanosis No clubbing No pedal edema No generalised lymphadenopathy No palmar erythema No spider naevi

Vitals Blood Pressure: 110/70 mmHg Pulse Rate: 78/minute Respiratory rate: 18/min SpO2: 98% at room air

System Examination CVS RS B/L air entry Abdomen Fetal heart sound + S1S2 No murmur RS B/L air entry No added sounds Abdomen Soft No organomegaly No free fluid Uterus 28 to 30 weeks Fetal heart sound +

Per Vaginum Cervix uneffaced head at -2 station no draining no bleeding PV CNS No focal neurological deficit No flapping tremor

Provisional Diagnosis Jaundice Complicating Pregnancy

Investigations (On Admission) RBS- 67 mg/dl Blood urea- 20 mg/dl Serum Creatinine- 0.7 mg/dl Total Bilirubin- 33.7 mg/dl Direct bilirubin- 22.2 mg/dl Indirect Bilirubin- 11.5 mg/dl SGOT- 74 IU/L SGPT- 135 IU/L ALP- 372 IU/L Prothrombin Time- 28.9 sec INR- 2.2

Total Protein- 7.1 g/dl Serum Albumin- 3 g/dl Serum Globulin- 4.1g/dl Hb-13.8 gm/dl Total count- 13,400 cells/mm3 Differential count- N72 L20 M6 E2 ESR- 69 mm/hr PCV- 37% Platelet count- 1.3 lakh/mm3

Viral Markers- Negative Urine routine Albumin- nil Sugar- nil Deposits- 0-2 pus cells VCTC- Non reactive Viral Markers- Negative Hepatitis A HBsAg HCV Hepatitis E IgM Leptospirosis- Negative

Next day (10/11/16) Pt delivered a dead born male fetus via labour naturalis Birth weight of the baby was 1.75 kg No congenital anomalies are seen

Following 3 days (11/11/16 to 13/11/16) Over next 3 days patient developed Deepening of jaundice Progressive abdominal distension Bilateral pitting pedal edema Elevated renal parameters Prolonged PT, INR

Hepatic Encephalopathy (14/11/16 to 15/11/16) Pt went in for altered sensorium on 14/11/16 Pt was started on Inj Cefotaxime 1gm IV BD C. Rifaximin 550mg BD Syrup Lactulose 15ml TDS T. UDCA 300 mg 1TDS Inj Vitamin K IM OD x 3days FFP transfusion 4 units

Recovery from encephalopathy Pt recovered from hepatic encephalopathy However ascites, pedal edema, & jaundice persisted for next 3 days USG Abdomen showed gross ascites with normal sized liver, spleen & gall bladder wall edema Ascitic fluid analysis report Sugar- 30mg/dl Protein- 975 mg/dl Polymorphs 6 Lymphocytes 4

Opinions MGE opinion To add T. Spironolactone 25mg 2OD Serum ceruloplasmin Portal venous doppler Ophthalmology opinion Rt cornea- adherent leucomatous opacity Lt cornea- maculonebular staining No evidence of KF ring at present Both Eye fundus- normal

Investigations Serum ceruloplasmin- 15.3 mg/dl Portal venous doppler- Normal flow with normal phasic variations Serum Uric Acid- 17.9mg/dl Repeat serum uric acid- 8.7mg/dl

Course of illness Following recovery from hepatic encephalopathy, there is a gradual decrease in abdominal girth resolution of pedal edema diuresis itching However icterus persisted until she was discharged at request on 28/11/16

Investigation Chart Date 9/11 12/11 15/11 18/11 21/11 24/11 27/11 20 Urea 20 48 58 35 15 18 21 Creatinine 0.7 1.0 2.1 0.6 Total bilirubin 33.7 49 15.8 34 24 17.8 Direct 22.2 39 30 13.8 12 9.7 Indirect 11.5 10 5 2.0 4 8.1 SGOT 74 22 52 45 60 SGPT 135 77 67 53 32 56 54 ALP 372 108 103 62 Total count 14400 16100 16800 15200 9700 7300 5700 Platelet count 1.3L 1.1L 37000 52000 1.24L 2.5L 3.5L

Swansea criteria Vomiting Abdominal pain Polydipsia/polyuria Encephalopathy Elevated bilirubin > 0.8 mg/dl Hypoglycemia <72 mg/dl Elevated urea > 5.7 mg/dl Leucocytosis >11000 cells/mm3 Ascites or bright liver on ultrasound Elevated transaminases (AST or ALT)>42 IU/L

Elevated ammonia >47 micromol/L Renal impairment (creatinine >1.7mg/dl) Coagulopathy (PT> 14sec or APTT >34 sec) Microvesicular steatosis on liver biopsy

Acute Fatty Liver of Pregnancy Final Diagnosis Acute Fatty Liver of Pregnancy

Aim Of Presentation To highlight the approach to a case of jaundice complicating pregnancy To know about complications of AFLP & their management

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