OBSTETRICS
Pregnancy-induced hypertension complicated by acute liver disease and disseminated intravascular coagulation Five case reports
ALLE~
P. KILLA\1.
Co!O:>~EL
(\IC) L:SA. F.A.C.O G.
SAMUEL H. DILLARD. JR .. MAJOR (MC) USA ROBERT C. PATTON. MAJOR (MC) USA PAUL R. PEDERSOK. :'.lAJOR (MC) llSA
Fl Pwu,
'1'1'.\l!.\
Fh•t tall'.' ofjJregnanry-indwwl hypnttnsion colnjJlicated by anile liver disease and DIC art prc.,enlnl. Initial misdiagnosis is dcscribrd, with appropriate laboratory and histologic dotllltli'tl!ation uj'lht /me condition. Spaific thempeu/it· rrmmmewlations art di.I'I'USsed and j)(l/hofJhysiulogir mechanisms are suggel/1'11.
FtvE l'NllSliALcasesofpregnanry-induced hypertension complicated by acute liver disease and disseminated intravascular coagulation (DIC) were delivered
at William Beaumont Army Medical (:enter during a single year. None had eclampsia. T'he first three were initially misdiagnosed as having viral hepatitis, pyelonephritis. and symptomatic hiatal hernia. respectively. Fever, epigastric pain. lo\\ platelet munts. and abnormal blood smears, clotting studies. and liver function tests in gravidas with acute hypertension and proteinuria represent an ominous clinical condition. The cases are presented with appropriate laboratorv and histologic documentation of this disease triad. Specific therapeutic recommendatiom are discussed and pathophysiologic mechanisms arc suggested.
From the D~partmrnts ~~Obstetrics and Gynecology. Pathology. and Medicine. William Beawrwnt Army Mediml Cmll'l". Thi, material has hfl•n reviewed bv th1• Commander, William Beaumont ,-Jnn~ iHedirai Cente1·, El Paso, Tr'xas, wulthne is no objection to its presn1tation and/or Jmb/imtiun. This rn•iew does not imp~>' any indorsonenl ol th,, opinions 1uh•anred or any recommendation oj' surh products a~" may he named. Tlu· opinion, ur assumptions jJrt•.sentfll here are the pm•al!' 1•iew,· of tht' rwthor(s) and are not to be ronstn.lfd. as offtriaf or liS refierting the views tif thl' Department of the Army or thr Deparlm!'llt oj'Defewe.
Case presentations Case l. J. B.. a 25-year-old gravida 3. para 2. was admitted at 33 weeks' gestation to Williarn Beaumom Army Medical Center. She complained of epigastric pain, radiating to the right upper quadrant. associated with malaise. anorexia. nausea. and \'omiting. Antacids and aspirin had provided no relief. Past history was significant in that she had delivered a stillborn male infant at 8 months' gestation and a 9 pound 6 oume
Rl'('eh•ed )or publication October 9, 1974. RrPi.1ed Derember 17, 1974. Atl't'/Jlnl lhcnnber 18, 1974.
Reprint requests: Colonel Allen P. 1\.illam, MC, Departmmt of Obstetrics and Gvnecology, William Btaumont Army Medical Center, El Paso, Texas 79920.
823
824
!.~),
lkt('lllht'l
Killam et al. \111.
I. ( )f>.,tt'l.
[q-;_~)
C\ JH'Col.
Table I. Clinical inf(mnatum (;fl.\1'
C'0.\1'
Pari~>
~lala-ise
r\ au sea & 'omiting Epigastric pain Dark urine Ecchvn1l
Minimal Minimal Severc ~larked
l'enzymes I + 2 2~~5
H3
:\t>gativc
r\egatiH·
l\egativ-I()
ti-17
'1-1:!
I -1-l:'i
14-1 K
O.H-tUI 6.0-H.O :'\ormal
tl.ii-1.1 fi.Cl-\l.:l Normal
O.H
1.0 l'i.4-ti.li
II.H-0.~1
6.~1-H.ti
r\ormal
1\'llowing admission. she had developed 11·ine-colored urine and scleral icterus. Amniocentesis r-evealed an LIS ratio of ~: I. It was agreed that the patient should have induction of labor. During the 12 hotli'S preceding delivet·y, she received
Volume
I~:~
Pregnancy-induced hypertension
Number~
825
Table IlL Hematologic studies Caw 1
Case 2
Case 3
Ca.1e 4
Case 5
Hematocrit (o/c):
Admission Low
40 26
41) 24
37 26
7,000 9,000
7,500 16.500
8,900 10,300
8,000 11,200
12.800 18,400
40,000 180,000
26,000 470,000
46,000 640,000
53,000 210,000
40,000 370,000
3H.7 37.2
40.0 27.9
11BC !Ptr nwt."!:
Admission High
Platdet count (jier
ttw1 8 ):
Lowest Discharge Peripheral smear (Burr cells, schistO!:vtf's. helmet ~ells) Reticulocyte count
Marked
.\1oderate
.\1oderate
.\1inimal
.\!inimal
5.0
8.9
8.9
15.5 12.2
15.1 13.3
13.0 13.4
12.5 11.9
11.9 12.4
43.5 29.6
36.0 33.5
32.8 30.7
40.0 32.5
80.0 ·10.2
17.2 13.0
15.5 I 1.5
21.0 12.7
14.6 12.0
17.5 10.9
:Ui
( maxin1un1)
Prothrombin timt (scr .):
Patient Control
Partial thrombojJ{astin tim•· (lee.):
Patient Control
Thrombi11 timt, maximum (sec.):
Patient Control
Fibrmop;rn (normal 115-38 COl/g.
'!r);
Lo\vest Highest Fibrin split products.
442 !,004 20
547 575 20
575 862 20
~)75
504
510 40
!,!()()
I tiO
n1axitnum (nonna]
10 ng./ml. or less) Factor studies (/ow %):
:)
8 10
100'7r 65% 62%
2,500 units of heparin at 6 hour intervals for three doses, with a resulting platelet increase to I 00,000 per cubic millimeter. Fetal heart tones were last heard 4 hours prior to induction of labor. The patient was delivered of a 4 pound 14 ounce stillborn female infant 6 hours after beginning the oxytocin. Within ! 2 hours post partum, the patient developed diuresis, became normotensive, and was subjectively much improved. She did have uterine atony and vaginal bleeding, requiring three units of fresh whole blood. Her coagulation studies returned to normal by 24 hours post partum and she was discharged 6 days post panum. asymptomatic and with entireiy normal laboratorv studies. Case 2. L. W .. a 32-year-old primigravida with history of infertility, chronic hypertension, and recurrent urinary tract infections, was admitted at 36Y2 weeks' gestation for bed rest and evaluation of fetal growth and well being. During pregnancy, her blood pressure ranged from 120 to 160 mm. Hg systolic and from 70 to 90 mm. Hg diastolic. She had no edema or proteinuria prior to admission. She had taken
:-.lot
available
115% 160% 115%
90%
i~H
Pregnancy-induced hypertension complicated by acute liver disease and disseminated intravascular coagulation Five case reports
ALLE~
P. KILLA\1.
Co!O:>~EL
(\IC) L:SA. F.A.C.O G.
SAMUEL H. DILLARD. JR .. MAJOR (MC) USA ROBERT C. PATTON. MAJOR (MC) USA PAUL R. PEDERSOK. :'.lAJOR (MC) llSA
Fl Pwu,
'1'1'.\l!.\
Fh•t tall'.' ofjJregnanry-indwwl hypnttnsion colnjJlicated by anile liver disease and DIC art prc.,enlnl. Initial misdiagnosis is dcscribrd, with appropriate laboratory and histologic dotllltli'tl!ation uj'lht /me condition. Spaific thempeu/it· rrmmmewlations art di.I'I'USsed and j)(l/hofJhysiulogir mechanisms are suggel/1'11.
FtvE l'NllSliALcasesofpregnanry-induced hypertension complicated by acute liver disease and disseminated intravascular coagulation (DIC) were delivered
at William Beaumont Army Medical (:enter during a single year. None had eclampsia. T'he first three were initially misdiagnosed as having viral hepatitis, pyelonephritis. and symptomatic hiatal hernia. respectively. Fever, epigastric pain. lo\\ platelet munts. and abnormal blood smears, clotting studies. and liver function tests in gravidas with acute hypertension and proteinuria represent an ominous clinical condition. The cases are presented with appropriate laboratorv and histologic documentation of this disease triad. Specific therapeutic recommendatiom are discussed and pathophysiologic mechanisms arc suggested.
From the D~partmrnts ~~Obstetrics and Gynecology. Pathology. and Medicine. William Beawrwnt Army Mediml Cmll'l". Thi, material has hfl•n reviewed bv th1• Commander, William Beaumont ,-Jnn~ iHedirai Cente1·, El Paso, Tr'xas, wulthne is no objection to its presn1tation and/or Jmb/imtiun. This rn•iew does not imp~>' any indorsonenl ol th,, opinions 1uh•anred or any recommendation oj' surh products a~" may he named. Tlu· opinion, ur assumptions jJrt•.sentfll here are the pm•al!' 1•iew,· of tht' rwthor(s) and are not to be ronstn.lfd. as offtriaf or liS refierting the views tif thl' Department of the Army or thr Deparlm!'llt oj'Defewe.
Case presentations Case l. J. B.. a 25-year-old gravida 3. para 2. was admitted at 33 weeks' gestation to Williarn Beaumom Army Medical Center. She complained of epigastric pain, radiating to the right upper quadrant. associated with malaise. anorexia. nausea. and \'omiting. Antacids and aspirin had provided no relief. Past history was significant in that she had delivered a stillborn male infant at 8 months' gestation and a 9 pound 6 oume
Rl'('eh•ed )or publication October 9, 1974. RrPi.1ed Derember 17, 1974. Atl't'/Jlnl lhcnnber 18, 1974.
Reprint requests: Colonel Allen P. 1\.illam, MC, Departmmt of Obstetrics and Gvnecology, William Btaumont Army Medical Center, El Paso, Texas 79920.
823
824
!.~),
lkt('lllht'l
Killam et al. \111.
I. ( )f>.,tt'l.
[q-;_~)
C\ JH'Col.
Table I. Clinical inf(mnatum (;fl.\1'
C'0.\1'
Pari~>
~lala-ise
r\ au sea & 'omiting Epigastric pain Dark urine Ecchvn1l
Minimal Minimal Severc ~larked
l'enzymes I + 2 2~~5
H3
:\t>gativc
r\egatiH·
l\egativ-I()
ti-17
'1-1:!
I -1-l:'i
14-1 K
O.H-tUI 6.0-H.O :'\ormal
tl.ii-1.1 fi.Cl-\l.:l Normal
O.H
1.0 l'i.4-ti.li
II.H-0.~1
6.~1-H.ti
r\ormal
1\'llowing admission. she had developed 11·ine-colored urine and scleral icterus. Amniocentesis r-evealed an LIS ratio of ~: I. It was agreed that the patient should have induction of labor. During the 12 hotli'S preceding delivet·y, she received
Volume
I~:~
Pregnancy-induced hypertension
Number~
825
Table IlL Hematologic studies Caw 1
Case 2
Case 3
Ca.1e 4
Case 5
Hematocrit (o/c):
Admission Low
40 26
41) 24
37 26
7,000 9,000
7,500 16.500
8,900 10,300
8,000 11,200
12.800 18,400
40,000 180,000
26,000 470,000
46,000 640,000
53,000 210,000
40,000 370,000
3H.7 37.2
40.0 27.9
11BC !Ptr nwt."!:
Admission High
Platdet count (jier
ttw1 8 ):
Lowest Discharge Peripheral smear (Burr cells, schistO!:vtf's. helmet ~ells) Reticulocyte count
Marked
.\1oderate
.\1oderate
.\1inimal
.\!inimal
5.0
8.9
8.9
15.5 12.2
15.1 13.3
13.0 13.4
12.5 11.9
11.9 12.4
43.5 29.6
36.0 33.5
32.8 30.7
40.0 32.5
80.0 ·10.2
17.2 13.0
15.5 I 1.5
21.0 12.7
14.6 12.0
17.5 10.9
:Ui
( maxin1un1)
Prothrombin timt (scr .):
Patient Control
Partial thrombojJ{astin tim•· (lee.):
Patient Control
Thrombi11 timt, maximum (sec.):
Patient Control
Fibrmop;rn (normal 115-38 COl/g.
'!r);
Lo\vest Highest Fibrin split products.
442 !,004 20
547 575 20
575 862 20
~)75
504
510 40
!,!()()
I tiO
n1axitnum (nonna]
10 ng./ml. or less) Factor studies (/ow %):
:)
8 10
100'7r 65% 62%
2,500 units of heparin at 6 hour intervals for three doses, with a resulting platelet increase to I 00,000 per cubic millimeter. Fetal heart tones were last heard 4 hours prior to induction of labor. The patient was delivered of a 4 pound 14 ounce stillborn female infant 6 hours after beginning the oxytocin. Within ! 2 hours post partum, the patient developed diuresis, became normotensive, and was subjectively much improved. She did have uterine atony and vaginal bleeding, requiring three units of fresh whole blood. Her coagulation studies returned to normal by 24 hours post partum and she was discharged 6 days post panum. asymptomatic and with entireiy normal laboratorv studies. Case 2. L. W .. a 32-year-old primigravida with history of infertility, chronic hypertension, and recurrent urinary tract infections, was admitted at 36Y2 weeks' gestation for bed rest and evaluation of fetal growth and well being. During pregnancy, her blood pressure ranged from 120 to 160 mm. Hg systolic and from 70 to 90 mm. Hg diastolic. She had no edema or proteinuria prior to admission. She had taken
:-.lot
available
115% 160% 115%
90%
i~H
