1. 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

2. 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

3. 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

4. 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

5. 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

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

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

8. 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 +

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

10. Provisional Diagnosis
Jaundice Complicating Pregnancy

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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

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

24. Acute Fatty Liver of Pregnancy
Final Diagnosis
Acute Fatty Liver of Pregnancy

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

26. THANK YOU