PRESENTING COMPLAINTS

• 37-year-old primigravida , IVF conception , 29 weeks and 2 days with gestational diabetes mellitus on insulin and gestational hypertension on antihypertensives.
• Presenting complaints included acute febrile illness , pedal edema extending to thighs in the past 2 weeks with nausea, headache , myalgia and epigastric pain in the past 2 days.

PAST HISTORY 

•  H/o  of Untreated chronic liver disease with Portal Vein thrombosis

• H/o Pre- conceptional chronic thrombocytopenia 

VITALS AT ADMISSION  

• PR - 90/min
• BP- 130/75
• Temp – Normal
• GRBS - 251 mg/dl
• Grade 2 bilateral pedal edema
• Abdominal examination - 30 weeks, tense abdomen with abdominal wall edema , FHR -140/min

DIAGNOSTIC WORK UP  AND MANAGEMENT 

At Admission : 

• Hb -12.8 gm/dl
• Platelet count - 43000 cells/cu mm. 
• LFT -  normal
• Urine albumin 2 +

DAY -2 :

• FWBS  (DAY -2 ) - normal growth of the fetus
• Bilateral venous doppler of the lower limbs (DAY -2) – normal
• 24 Hour urine albumin - negative for microalbuminuria
• Maternal echo - concentric left ventricular hypertrophy with good left ventricular systolic function (LVEF- 55%)

DAY-3

• Maternal USG abdomen for abdominal organs -  Chronic portal vein     thrombosis with chronic liver disease changes and mild to moderate splenomegaly. 

DAY - 4 :

• 2 doses of steroids  i.m  24 hrs apart for lung maturity
• Intravenous magnesium sulphate for neuroprotection

DAY – 6 :

• Developed acute haematuria 
• Shifted to ICU for further management
• Protein Creatinine Ratio increased with uncontrolled sugars
• Delivery by Emergency LSCS

 

OUTCOME AND FOLLOW UP 

• Male baby , 2 Kg , Good Apgar ( LSCS)
• 2 drains were inserted (1 subcutaneous, 1 intraperitoneal) in view of possible bleeding risk due to low platelets. On post POD- 1 : Platelet count improved, blood pressure stabilized and sugar levels normalized
• POD – 3 :  Intraperitoneal drain removed
• POD – 7 :   Discharged in good condition 

CONCLUSION 

• A multidisciplinary approach including obstetricians, gastroenterologists, endocrinologist  and anaesthetists is essential to optimise the outcome. 
• Preconception counselling is vital. 
• Oesophageal and gastric varices should be treated in the prepregnant state. 
• Anticoagulant therapy plays an important role and should be advocated in all patients