Multidisciplinary Clinical Case Study

Multidisciplinary Approach to Complicated Pregnancy

Authors: Josip Andelo Borovac, BSc, MD candidate, Josko Bozic, MD, PhD, Tina Ticinovic Kurir, MD, PhD, Nikola Zaja, MD, Kresimir Kolic, MD, PhD, Vedran Hrboka, MD

Abstract

A nulliparous pregnant woman in her mid-20s and in the 32nd week of gestation presented to the emergency department with severe headache and vomiting. She had an uneventful medical history; however, the physical examination upon hospital admission revealed a hypertensive emergency, papilledema, and 2+ dipstick proteinuria. Upon establishing the diagnosis of preeclampsia, aggressive therapy with corticosteroids, antihypertensive medication, and seizure prophylaxis was initiated. Hemodynamic stability was achieved within 24 hours and the patient remained in the observation unit located within the gynecology clinic. On the ninth day postadmission, however, her condition abruptly deteriorated and advanced to imminent eclampsia, accompanied by transient vision loss, altered mental status, and acute hypertensive crisis.

After the patient underwent successful emergent delivery via caesarean section, a laboratory workup revealed hemolysis, elevated liver enzymes, and low platelet count, suggesting HELLP syndrome, a serious complication of eclampsia. This patient concurrently developed posterior reversible encephalopathy syndrome, which was confirmed by magnetic resonance imaging and acute respiratory distress syndrome (the latter presented with diffuse bilateral infiltrates on x-ray and developing pulmonary edema in the absence of cardiac etiology). Because of these life-threatening dynamics, the patient was transferred to the intensive care unit for further treatment.

This case is a rare cascade of life-threatening complications that developed in a patient and required skillful multidisciplinary decision making and experienced management within an acute critical care setting. The final outcome of the treatment and intensive care was successful because both the patient and child survived and had no chronic or debilitating sequelae.

This content is limited to qualifying members.

Existing members, please login first.

If you have an existing account please login now to access this article or view your purchase options.

Purchase only this article ($15)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.

References

1. Vigil-De Gracia P, Ortega-Paz L. Pre-eclampsia/eclampsia and hepatic rupture. Int J Gynaecol Obstet 2012;118:186-189.
 
2. Kupferminc MJ, Fait G, Many A, et al. Severe preeclampsia and high frequency of genetic thrombophilic mutations. Obstet Gynecol 2000;96:45-49.
 
3. Lin J, August P. Genetic thrombophilias and preeclampsia: a meta-analysis. Obstet Gynecol 2005;105:182-192.
 
4. Walker P, Gregg AR. Screening, testing, or personalized medicine: where do inherited thrombophilias fit best? Obstet Gynecol Clin North Am 2010;37:87-107.
 
5. Ghulmiyyah L, Sibai B. Maternal mortality from preeclampsia/eclampsia. Semin Perinatol 2012;36:56-59.
 
6. Sibai B, Dekker G, Kupferminc M. Pre-eclampsia. Lancet 2005;365:785-799.
 
7. Venkatesha S, Toporsian M, Lam C, et al. Soluble endoglin contributes to the pathogenesis of preeclampsia. Nat Med 2006;12:642-649.
 
8. Liberis A, Stanulov G, Ali EC, et al. Pre-eclampsia and the vascular endothelial growth factor: a new aspect. Clin Exp Obstet Gynecol 2016;43:9-13.
 
9. Phipps E, Prasanna D, Brima W, et al. Preeclampsia: updates in pathogenesis, definitions, and guidelines. Clin J Am Soc Nephrol 2016;11:1102-1113.
 
10. Bartsch E, Medcalf KE, Park AL, et al. Clinical risk factors for pre-eclampsia determined in early pregnancy: systematic review and meta-analysis of large cohort studies. BMJ 2016;353:i1753.
 
11. Desai P, Desai M. Uterine artery pulsatility index less than 1.0 as an isolated marker in predicting low-risk subjects for preeclampsia. Int J Reprod Contracept Obstet Gynecol 2016;5:1300-1303.
 
12. Williams PJ, Broughton Pipkin F. The genetics of pre-eclampsia and other hypertensive disorders of pregnancy. Best Pract Res Clin Obstet Gynaecol 2011;25:405-417.
 
13. Fong FM, Sahemey MK, Hamedi G, et al. Maternal genotype and severe preeclampsia: a HuGE review. Am J Epidemiol 2014;180:335-345.
 
14. Wu X, Yang K, Tang X, et al. Folate metabolism gene polymorphisms MTHFR C677T and A1298C and risk for preeclampsia: a meta-analysis. J Assist Reprod Genet 2015;32:797-805.
 
15. Li X, Luo YL, Zhang QH, et al. Methylenetetrahydrofolate reductase gene C677T, A1298C polymorphisms and pre-eclampsia risk: a meta-analysis. Mol Biol Rep 2014;41:5435-5448.
 
16. Morgan JA, Bombell S, McGuire W. Association of plasminogen activator inhibitor-type 1 (-6754G/5G) polymorphism with pre-eclampsia: systematic review. PloS One 2013;8:e56907.
 
17. Zhao L, Bracken MB, Dewan AT, et al. Association between the SERPINE1 (PAI-1) 4G/5G insertion/deletion promoter polymorphism (rs1799889) and pre-eclampsia: a systematic review and meta-analysis. Mol Hum Reprod 2013;19:136-143.
 
18. Said JM, Tsui R, Borg AJ, et al. The PAI-1 4G/5G polymorphism is not associated with an increased risk of adverse pregnancy outcome in asymptomatic nulliparous women. J Thromb Haemost 2012;10:881-886.
 
19. Atalay MA, Ozerkan K, Karkucak M, et al. Polymorphisms in angiotensin-converting enzyme and glutathione s-transferase genes in Turkish population and risk for preeclampsia. Clin Exp Obstet Gynecol 2012;39:466-469.
 
20. Kaur R, Jain V, Khuller M, et al. Association of angiotensin-converting enzyme gene polymorphism with pregnancy-induced hypertension. Acta Obstet Gynecol Scand 2005;84:929-933.
 
21. Bereketoglu C, Kasap M, Pazarbasi A. Studies on angiotensin-converting enzyme insertion/deletion polymorphism and genotype distributions in Turkish preeclampsia patients. J Pregnancy 2012;2012:108206.
 
22. Reshetnikov EA, Akulova LY, Dobrodomova IS, et al. The insertion-deletion polymorphism of the ACE gene is associated with increased blood pressure in women at the end of pregnancy. J Renin Angiotensin Aldosterone Syst 2015;16:623-632.
 
23. Chen Z, Xu F, Wei Y, et al. Angiotensin converting enzyme insertion/deletion polymorphism and risk of pregnancy hypertensive disorders: a meta-analysis. J Renin Angiotensin Aldosterone Syst 2012;13:184-195.
 
24. Sayed-Tabatabaei FA, Oostra BA, Isaacs A, et al. ACE polymorphisms. Circ Res 2006;98:1123-1133.
 
25. Wu O, Robertson L, Twaddle S, et al. Screening for thrombophilia in high-risk situations: systematic review and cost-effectiveness analysis. The Thrombosis: Risk and Economic Assessment of Thrombophilia Screening (TREATS) Study. Health Technol Assess 2006;10:1-110.
 
26. Robertson L, Wu O, Langhorne P, et al. Thrombophilia in pregnancy: a systematic review. Br J Haematol 2006;132:171-196.
 
27. Machin SJ. Pros and cons of thrombophilia testing: cons. J Thromb Haemost 2003;1:412-413.
 
28. McLaughlin K, Drewlo S, Parker JD, et al. Current theories on the prevention of severe preeclampsia with low-molecular weight heparin. Hypertension 2015;66:1098-1103.
 
29. Roberge S, Demers S, Nicolaides KH, et al. Prevention of pre-eclampsia by low‐molecular-weight heparin in addition to aspirin: a meta-analysis. Ultrasound Obstet Gynecol 2016;47:548-553.
 
30. Aracic N, Roje D, Drmic Hofman I, et al. Low molecular weight heparin treatment and impact of inherited thrombophilia type in pregnancies with previous adverse outcome. J Matern Fetal Neonatal Med 2015;28:306-310.
 
31. American College of Obstetricians and Gynecologists Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy. Obstet Gynecol 2013;122:1122-1131.
 
32. Tranquilli AL, Brown MA, Zeeman GG, et al. The definition of severe and early-onset preeclampsia. Statements from the International Society for the Study of Hypertension in Pregnancy (ISSHP). Pregnancy Hypertens 2013;3:44-47.
 
33. Sibai BM. Diagnosis, controversies, and management of the syndrome of hemolysis, elevated liver enzymes, and low platelet count. Obstet Gynecol 2004;103(5 Pt 1):981-991.
 
34. Arulkumaran N, Lightstone L. Severe pre-eclampsia and hypertensive crises. Best Pract Res Clin Obstet Gynaecol 2013;27:877-884.
 
35. Martin JN, Jr Rinehart BK, May WL, et al. The spectrum of severe preeclampsia: comparative analysis by HELLP (hemolysis, elevated liver enzyme levels, and low platelet count) syndrome classification. Am J Obstet Gynecol 1999;180:1373-1384.
 
36. Martin JN, Jr. Milestones in the quest for best management of patients with HELLP syndrome (microangiopathic hemolytic anemia, hepatic dysfunction, thrombocytopenia). Int J Gynaecol Obstet 2013;121:202-207.
 
37. Woudstra DM, Chandra S, Hofmeyr GJ, et al. Corticosteroids for HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome in pregnancy. Cochrane Database Syst Rev 2010;9:CD008148.
 
38. Pourrat O, Dorey M, Ragot S, et al. High-dose methylprednisolone to prevent platelet decline in preeclampsia: a randomized controlled trial. Obstet Gynecol 2016;128:153-158.
 
39. Fakhouri F. Pregnancy-related thrombotic microangiopathies: clues from complement biology. Transfus Apher Sci 2016;54:199-202.
 
40. Thomas MR, Robinson S, Scully MA. How we manage thrombotic microangiopathies in pregnancy. Br J Haematol 2016;173:821-830.
 
41. Hinchey J, Chaves C, Appignani B, et al. A reversible posterior leukoencephalopathy syndrome. N Engl J Med 1996;334:494-500.
 
42. Lamy C, Oppenheim C, Meder JF, et al. Neuroimaging in posterior reversible encephalopathy syndrome. J Neuroimaging 2004;14:89-96.
 
43. Bartynski W. Posterior reversible encephalopathy syndrome, part 2: controversies surrounding pathophysiology of vasogenic edema. AJNR Am J Neuroradiol 2008;29:1043-1049.
 
44. Fugate JE, Claassen DO, Cloft HJ, et al. Posterior reversible encephalopathy syndrome: associated clinical and radiologic findings. Mayo Clin Proc 2010;85:427-432.
 
45. Aya AG, Ondze B, Ripart J, et al. Seizures in the peripartum period: epidemiology, diagnosis and management. Anaesth Crit Care Pain Med 2016;35(Suppl 1):S13-S21.
 
46. Staykov D, Schwab S. Posterior reversible encephalopathy syndrome. J Intensive Care Med 2012;27:11-24.
 
47. Definition Task Force ARDS, Ranieri VM, Rubenfeld GD, et al. Acute respiratory distress syndrome: the Berlin definition. JAMA 2012;307:2526-2533.
 
48. Sibai BM, Mabie BC, Harvey CJ, et al. Pulmonary edema in severe preeclampsia-eclampsia: analysis of thirty-seven consecutive cases. Am J Obstet Gynecol 1987;156:1174-1179.
 
49. Phua J, Badia JR, Adhikari NK, et al. Has mortality from acute respiratory distress syndrome decreased over time? A systematic review. Am J Respir Crit Care Med 2009;179:220-227.
 
50. Mabie WC, Barton JR, Sibai BM. Adult respiratory distress syndrome in pregnancy. Am J Obstet Gynecol 1992;167(4 Pt 1):950-957.
 
51. Duarte AG. ARDS in pregnancy. Clin Obstet Gynecol 2014;57:862-870.