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”.