Case 2
A.E., a 24-year-old female, gravida 4, para 3, at unknown weeks of
amenorrhea, was admitted to our Gynecology ward with a history of fever
and chills, general body weakness, tea-colored urine and cramping lower
abdominal pain, radiating to the waist, that started spontaneously and
increased progressively in intensity. There was no history of vomiting
or nausea, vaginal bleeding, or discharge; the patient reported normal
micturition and bowel habits. The history of complaints of other systems
was unremarkable.
The patient, who was married with three living children, did not attend
antenatal care for the current pregnancy; obstetric and gynecological
histories were unremarkable. There was no history of chronic illnesses,
while the HIV status was unknown. The patient denied the use of herbal
medicine or any other medication in this pregnancy.
On physical examination, she was sick looking, with moderate pallor,
severe jaundice with dry mucous membranes, dry skin, and no edema. Her
BP was 93/61 mmHg, with PR of 94 beats per minute and a temperature of
36.8°C.
Abdominal examination revealed a normal fullness, with a moderate
tenderness in the hypogastric region; no organomegaly or masses were
palpable. On per vagina exam, vulva and vagina were normal, the cervical
os was closed and there was no active bleeding or discharge. The
physical examination of the other systems was unremarkable.
Her investigations showed a positive urine hCG quick test, while the
blood smear did not evidence any malaria parasites. The complete blood
count showed a white cell count of 28.1× 109/L, with
granulocytes of 20.5x109/L, Hb of 11.7g/dl, and red
blood cells of 3.66×1012/L, platelets of
270×109/L and negative hepatitis B surface antigen
test. Liver function: Alanine transferase of 1,796U/L (0-40), Aspartate
transferase of 1,628U/L (0-37), Alkaline phosphatase of 159 U/L (98-279)
and albumin of 2.5g/dl (3.8-5.1). Renal function test: urea of 82mg/dl
(10-55), creatinine of 7.1mg/dl (0-1.3) and urea/creatinine ratio of
11.54. Serum electrolytes: sodium of 128.2mmol/L (134-146), potassium of
4.6mmol/L (3.5-5.5) and chloride of 105.9mmol/L (98-108).
A pelvic ultrasound scan showed a gravid uterus with an intrauterine
fetus in cephalic presentation, but no cardiac activity was present; the
amniotic fluid was reduced and the internal cervical os was open.
Moreover, the left maternal kidney was mildly enlarged and echogenic,
with normal margins. The findings of the ultrasound scan were in line
with a missed abortion at 14 weeks of gestation and maternal left
nephropathy. Our impression was a para 3, abortus 1, with missed
abortion at 14 weeks of gestation, acute hepatitis, and nephropathy. The
patient was stabilized and managed conservatively, without relevant
improvement.
On the 2nd day of hospital stay, there was a new
complaint of bleeding per vagina; the patient was still sick looking,
afebrile, with moderate pallor and deep jaundice. Her BP was 110/65
mmHg, with PR of 69 beats per minute and random blood sugar (RBS) of 3.4
mmol/L. On per vagina examination, the cervical os was still closed but
fresh blood was found on the examining finger. The patient was treated
with dextrose, lactulose, and broad-spectrum antibiotics; after the
administration of one dose of Misoprostol, the fetus and the placenta
were expelled. Thereafter, the patient was restless, although the vital
parameters were in the normal range.
On the 3rd day of hospital stay, the patient became
lethargic, with slurred speech and restless, moderately pale, and
increasingly jaundiced. Her BP was 119/73 mmHg, with PR of 69 beats per
minute, temperature of 36.7°C and RBS of 4.5mmol/l. GCS was 12/15 (E=4,
M=5, V=3), with pupils equal and reactive to light, normal tone, and
reflexes. The patient was in mild respiratory distress, with a
respiratory rate of 28 breaths/minute and oxygen saturation of 95% on
room air. The urine was greenish, with a urine output of 300ml/24hrs. A
nasogastric tube was inserted and drained 200 ml of dark brown colored
fluids. The patient was lethargic and disoriented to time; a diagnosis
of hepatic encephalopathy grade 2, based on West Haven criteria, was
made and the plan was to continue the conservative therapy. On the early
morning of the 4th day of hospital stay, the patient
passed away.
Only after her death, a collateral history could be obtained. The
patient’s husband, who wanted more children, wasn’t aware that his wife
was pregnant. The couple had previously argued on this issue since the
patient was not willing to face a new pregnancy, but the husband
prohibited her from using any modern contraceptive methods. As reported
by the mother in law, when the patient realized that she was pregnant,
she consulted a traditional healer, who provided her a local herb known
as “bitter leaf”.