Dr ahmed alkodousi case

1. AHMAD MAGED AL-
QUDDOSY
Egyptian nephrology fellowship trainee
Nephrology department
New Mansoura general hospital

2. 
• Name: FATMA FATH ALLAH
• Age : 25years old
• From el GAMALEYA
• Married
• No Child
Personal History

3. 
 No medical history not HTN nor DM
 No surgical history
 No special habits
Past history

4. 
 Patient presented by :
• Dyspnea ,Tachypnea ,Pale and easy fatigability
• BP=150/100 HR=110 RBS=83
• CHEST Bilateral basal crepitation
• Abdomen lax and audible intestinal sound
• Uterus contracted and 2 drains inserted at left
• She was pregnant at 36 weeks and went to her doctor
by acute abdominal pain and accidental vaginal
bleeding
Present history

5. 
• This is the first gestational urgent cesarean section
done and fetus died
• After labor BP=180/100 an uric for 12hrs
• She received 2cm Lasix, Epilate S.L, Ringer and
Glucose 10%
• Attack of fits admitted in ICU at 8/1/2018
Present history

6. 
 H= 10.1 ALB=2.1
 Plt= 52 BIL=2.4 mainly indirect
 WBCS= 16.20 INR=1.14
 S.Cr = 2.7 LDH=6750----2992
 Na = 133 R.C=5.50
 K= 5.1 PH=7.41
 Urea= 69 PCO2=25
 ALT= 286 PO2=92
 AST=296 HCO3=15.6
Laboratory at admission

7. 
 Liver and Spleen :average size
 U.B: Not visualized
 Both kidneys: average size,shape,increase
echogenicity grade II Nephropathy with poor C.M.D
and No back pressure
 G.B: multiple stones
 Free fluid is seen at Douglas pouch at pelvic region
 Uterus: Bulky hyper echoic foci mainly Hage
 For CT Pavli abdominal
Abdominal U.S.

8. 
 RIGHT KIDNEY:
• Normal size, shape, and position of the right kidney
• Normal parenchymal thickness.
• Normal palvi-calyceal system. No detected stone .
• Normal course and caliber of the right ureter . No detected
stone
 LIFT KIDNEY :
• Normal size, shape, and position of the lift kidney .
• Normal parenchymal thickness.
• Normal palvi-calyceal system. No detected stone .
• Normal course and caliber of the lift ureter . No detected stone
NON-CONTRAST MULTISLICE CT
SCAN OF THE URINARY TRACT
REVEALED :

9. 
Empty urinary bladder show the ballon of
folly catheter inside:
• Bulky post-partum uterus
• Bilateral minimal pleural effusion
Conclusion:
 Normal CT scan of the urinary system.
URINARY BLADDER:

10. 
 HELLP Syndrome with AKI for:
1. Fluid chart
2. Daily lab & blood ,urine cultures and analysis
3. Blood transfusion
4. If patient still an uric and S.cr rising for dialysis
5. Renal biopsy &CT abdomen and pelvic
First Diagnosis &Plan

11. 
 Levofloxacin 500iv/48h
 Cefipem 1gm iv/24h
 NaHCO3 cap /8h
 Alkapress 5mg tab /24
 Calcimat tab 2x3
 Dexamethazon ½ amp iv /12h
 Zantac amp iv /12h
 Saline 500mg /12h
 Lasix iv 1ml /houre
 Liver support
 Vit k IM /24h
 Kapron amp /12h
 Patient received 3 session of dialysis
Treatment

12. 
Urine analysis

13. 
 Organism :E.Coli
 Sensitive: Tobramycin
 Resistant: Imepenim,levofloxacin,Ceftriaxone and
Amoxicillin
Urine culture

14. 
 Organism:E.Coli
 Sensitive: Levofloxacin,,Imepenim,Chloramphenicol
and Amikacin
 Resistant :Ampicillin,Tobramycin and Amoxicillin
clavulinic acid
Blood culture

15. 
Chest x-ray

16. 
What is HELLP Syndrome?
The name HELLP stands for:
H- hemolysis ( breakdown of red blood cells)
EL- elevated liver enzymes (liver function)
LP- low platelets counts (platelets help
the blood clot)
What is HELLP Syndrome?

17. 
 How HELLP Syndrome is Classified
 The severity of HELLP syndrome is measured according
to the blood platelet count of the mother and divided into
three categories, according to a system called "the
Mississippi classification."
 Class I (severe thrombocytopenia): platelets under
50,000/mm3
 Class II (moderate thrombocytopenia): platelets between
50,000 and 100,000/mm3
 Class III (AST > 40 IU/L, mild thrombocytopenia):
platelets between 100,000 and 150,000/mm3
How HELLP Syndrome is
Classified

18. 
The most common symptoms of HELLP
syndrome include:
Headaches
Nausea and vomiting that continue to get
worse–(This may also feel like a serious case
of the flu).
Upper right abdominal pain or tenderness
Fatigue or malaise
What are the Symptoms of
HELLP Syndrome?

19. 
Visual disturbances
High blood pressure
Protein in urine
Edema (swelling)
Severe headaches
Bleeding
These symptoms may include:

20. 
 Because the symptoms of HELP can mimic many other
conditions or complications, it is encouraged that
physicians run a series of blood tests, including liver
function, on any woman experiencing symptoms during
the third trimester of pregnancy. HELLP syndrome may
occur before the third trimester but it is rare. It also may
occur within 48 hours of delivery, although symptoms may
take up to 7 days to be evident.
 Blood pressure measurements and urine tests to check for
protein are often monitored when diagnosing HELLP
syndrome.
How is HELLP Syndrome
Diagnosed?

21. 
 Hemolysis -Red blood bells
 Abnormal peripheral smear
 Lacatate dehydrogenase >600 U/L
 Bilirubin > 1.2 mg/dl
 Elevated liver Enzyme levels
 Serum aspartate amniotransferase >70 U/L
 Lacatate dehydrogenase >600 U/L
 Low Platelets
 Platelet count
How is HELLP Syndrome
Diagnosed?

22. 
 Placental Abruption
 Pulmonary Edema ( fluid buildup in the lungs)
 Diseminated intravascular coagulation (DIC—blood
clotting problems that result in hemorrhage)
 Adult Respiratory distress syndrome (lung failure)
 Ruptured liver hematoma
 Acute renal failure
 Intrauterine Growth restriction (IUGR)
 Infant respiratory Distress syndrome (lung failure)
 Blood transfusion
What are the Risks and Complications of
HELLP Syndrome?

23. 
The maternal mortality rate is about
1.1% with HELLP syndrome. The infant
morbidity and mortality rate is
anywhere from 10-60% depending on
many factors such as gestation of
pregnancy, severity of symptoms, and
the promptness of treatment.
What are the Risks and Complications of
HELLP Syndrome?

24. 

25. 
TMA

26. 
 Plasma pharoses is the next step
 Patient received 4 session last one today
 32fresh frozen plasma in all sessions
What is the next step

27. 
Date 4/1 11/1 14/1 19/1 22/1 26/1 29/1 31/1 4/2 6/2
PH 7.41 7.27 7.38 7.4 7.46 7.4 7.4 4.4 7.4 7.4
PCO
2
25 30 35 29 29 31 24 26 27 26
PO2 92 39 41 47 61 69 113 46 22 92
HCO
3
15.8 14.4 21 20 23 19 21 20 20 22
O2
sat
97 66 75 85 92 94 94 83 98 96
ABG

28. 
Date 8/1 9/1 11/1 14/1 19/1 26/1 28/1 31/1 4/2 6/2
S.Cr 2.7 4.4 7.4 8.2 11.8 15 17.2 13.9 12.5 10.4
Na 133 128 130 135 129 137 136 136 145 143
K 5.2 5.3 5.1 5.4 3.9 3.6 3.9 3.6 3.7 3.9
Ca 6.6 8.4
PO4 9.2 7 6.4
Urea 69 102 192 193 193 175 181 124 137 132
Kidney Function Test

29. 
Date 8/1 9/1 14/1 16/1 26/1 31/1 1/2 4/2 6/2
HB 10.1 8.5 8.1 5.6 8.4 7.8 7.9 7.7 8.1
RBCs 2.600 2.300 2.500 2.200 2.500 2.600 2.700 2.500 2.700
MCV 86.5 86 84 88 82 84 83 86 88
HCT 27.5 23 25 21 24 22 26 24 26
PLT 52 50 92 151 245 196 212 291 175
WBC
s
16.20
0
16.50
0
11.50
0
12.60
0
7.300 7.800 8.200 6.800 4.700
CBC

30. 
Date 8/1 11/1 12/1 14/1 15/1 17/1 20/1 27/1 4/2 6/2
ALT 286 182 84 65 45 30 28 07 /
AST 296 57 30 22 20 14 14 25 /
ALB 2.1 2.4 1.9 2.1 2.3 2.5 3.2 /
BIL 2.4 1.4 1.4 1.4 1.2 1.5 /
INR 1/15 1/14 /
Liver function test

31. Date 12/1 14/1 15/1 17/1 18/1 20/1 21/1 22/1 23/1 25/1
Urine
outpu
t
300 900 500 215 10 150 750 700 900 1200
Urine
input
000 900 400 1750 700 900 300 300 1000 1400
Fluid Balance
Date 26/1 27/1 28/1 29/1 30/1 31/1 1/2 2/2 3/2 6/2
Urine
outpu
t
1100 700 1150 300 1600 1900 1800 2000 2000 2400
Urine
input
1000 300 300 200 2300 2400 700 1400 1150 300

32. 
 Patient improving and Good prognosis
 Monitoring of renal function
 Follow up U.S.
Prognosis

33. 