1. Interesting case 10/29/09 BMH-GT Dr.Huxford,DrBusch,Dr.Alnas, Dr.Witty,Dr.Khan

2. 28 YO WF in 3 rd trimester Presents with RUQ pain and tenderness Presents with RUQ pain and tenderness Raised LFT Raised LFT Thrombocytopenia Thrombocytopenia Eclempsia Eclempsia Anemia Anemia Acute renal failure Acute renal failure

3. Events post C-section Renal shut down Renal shut down Multiple IVF plus mannitol drips Multiple IVF plus mannitol drips Magnesium sulfate drips Magnesium sulfate drips Edema /anasarca Edema /anasarca Pt transferred from NewAlbany to BMHGT Pt transferred from NewAlbany to BMHGT

4. Situation on arrival Intubated Intubated Bilateral lung infiltrates Bilateral lung infiltrates Wbs 32000; platelets 90,000 to 150,000 Wbs 32000; platelets 90,000 to 150,000 Mg 10 Mg 10 Creatinine 5.7 Creatinine 5.7 Hemoglobin 10 Hemoglobin 10 D-dimer >20 D-dimer >20 ALT 3000 down to 130; LDH 1530 ALT 3000 down to 130; LDH 1530

7. HELLP 3 per 1000 pregnancies( 3 rd trimester/postartum) 3 per 1000 pregnancies( 3 rd trimester/postartum) Complement activation ; endothelial injury Complement activation ; endothelial injury Coagulation cascade activation Coagulation cascade activation LDH >600; ALT >70; PLT 600; ALT >70; PLT <50; SCHISTOCYTES ON SMEAR; RENAL FAILURE PROTEINURIA Maternal mortality 1-3% Maternal mortality 1-3% Fetal mortality 10-35% Fetal mortality 10-35%

8. Management of HELLP Fetal maturity ; iv steroids Fetal maturity ; iv steroids Prompt delivery Prompt delivery Treat renal and pulmonary according to situation Treat renal and pulmonary according to situation IV Magnesium to prevent seizures IV Magnesium to prevent seizures Plasmaphresis if persists >72 hours post partum Plasmaphresis if persists >72 hours post partum DIC treatment ; platelets for counts<20,000 or bleeding diasthesis DIC treatment ; platelets for counts<20,000 or bleeding diasthesis

9. How did this patient do here ? Urgent Hemodialysis for volume overload Urgent Hemodialysis for volume overload Diaysis was difficult due to hemodynamic compromise ; had to use IV albumin ; blood transfusion ; suffered severe bradycardia during HD Diaysis was difficult due to hemodynamic compromise ; had to use IV albumin ; blood transfusion ; suffered severe bradycardia during HD After 2 HD Rx started IV lasix drip with good diuresis After 2 HD Rx started IV lasix drip with good diuresis Lung infiltrates slowly improved Lung infiltrates slowly improved ADAM TS 13____ 43 % ADAM TS 13____ 43 %

11. Course of events On lasix drip lung infiltrates slowly improved On lasix drip lung infiltrates slowly improved Extubated Extubated Needed supports of BIPAP Needed supports of BIPAP Fever due to lines Fever due to lines Hypernatremia Hypernatremia d/c on biaxin d/c on biaxin Drug rash due to biaxin Drug rash due to biaxin

12. Follow up issues WBC COUNT >20,000 WBC COUNT >20,000 RENAL FAILURE RENAL FAILURE RASH RASH ANEMIA ANEMIA