CASE PRESENTATIO N 28 y G 4 L

CASE PRESENTATIO N

28 y / G 4 L 2 Ab 1 98 / 6 / 31 Fever & menstrual retardants & Mod. VB Bp : 90/60 , PR : 114 , T : 37. 7 Icteric , agitation , oliguria VE : CX hyperemic, malodor bloody discharge, UT: 12 w ,

PSH: 2 C/S , Appendectomy PMH: Addiction PDH: citalopram , clonazepam Consultation , US , CXR , Abdominal X ray , Lab was done , AB therapy started

Hb : 7. 2 , Plt : 47000 , WBC : 68000 HCG : 629 , Cr : 8. 2 ESR : 96 , CRP : 101 AST : 115 , ALT : 226 , Bil. R (T : 25 , D: 16. 1 ) LDH : 8325 , PBS : 4 % schitocytose coag test : NL , viral markers : NL , Na / K: 148 / 4. 1

Echocardiography: PAP: 35 , Mod. Pericardial effusion, EF: 60% Ultrasonography: UT: NL size, heterogeneous hyper echo mass-like lesion in endometrial cavity (34*44 MM), ↑Liver & renal echogenicity

Infectious consult: Meropenem , Linzolide, Caspofongine GI consultation: Hepatic failure, transfer to Shiraz for urgent transplantation Hematologic consult: PBS : Plt 10000 , shistocytes : 3 -4% Nephrologic consult:

WHAT IS YOUR DIFFEREN

Severe sepsis + TTP

98/7/1 Confusion , Plt : 23000 , INR : 1. 7 PT : 45 , PTT : 87 , Fib : 120

WHAT IS YOUR PLAN

98/7/1 The patient transferred to OR For D&C OR HYSTERECTOMY

EUA UT is very soft , > NL , malodor necrotic tissue in endometrial cavity , in Cervical inspection ; necrosis of lower segment seem Laparotomy Total hysterectomy + pack 3 longas in peritoneal cavity + correction of Acidosis + FFP + PLT + PC + Cryo + Fibrinogen

98/7/2 WBC : 23200 , Hb : 5. 8 , PLT : 47000 coag test : NL , Cr : 6. 8 , K : 4. 9 , anuria AST : 62 , ALT : 26 , Bil. R (T : 14. 3 , D: 10. 7 ) LDH : 1421

98/7/2 Dialysis & plasmaphoresis was done After 48 h re-laparotomy for remove the Longaze Finally : 5 courses of Dialysis & 8 courses of plasmaphoresis

What is place for rituximab? Do FFP instead of PEX ? What is duration of GC ?

98/7/10 Discharged with good general condition

98 / 6 / 24 24 y / G 1/ 38 w + 6 d ROM Induction of labor Labor arrest C/S uterine atony , extension in LT border of uterine incision Blood product / uterine repair

In recovery @ 2 hours severe VB , hemorrhagic Shock Re-laparotomy 2 lit clot , blood + vast left retroperitoneal hematoma suction & evacuation of retroperitoneal hematoma & 11 u PC , 10 u. FFP , 10 u PLT send to Al-zahra hospital

In emergency room: BP : 70/50 , PR : 160 , T : 36. 5 , confused abdominal distention , anuria sever bleeding from abdominal sutures Hb: 4. 2 , PLT: 43000 Fib: 119 , PT: 13 , PTT : 53 , INR : 1. 3 Na/K : 143/5. 5, LFT: NL , BS: 129 Cr : 0. 9 , LDH: 1058

WHAT IS YOUR PLAN

Laparotomy ( midline incision ) 1 u whole blood , 2 u PC , 3 u cryo , 4 u FFP , 10 u PLT , 1 gr fib 2. 5 lit blood , clot in peritoneal cavity Extensive left retroperitoneal hematoma Acute bleeding from left IP

LSO open the incision & bilateral uterine arteries ligation uterine incision repair prepare active drains pack with 6 Lon gaze

6 h @ surgery Hb : 11. 6 , PLT : 36000, LDH : 881 , Cr : 0. 8 coag test : NL , Fib : 370 Hematologic consult , PBS : DIC is propounded , 10 u PLT ordered

98/6/26 Re-laparotomy for remove Lon gaze 10 u PLT , 1 u PC 98/7/2 Discharged with good condition

DEAR RESIDENTS Know about DIC management

Warm acidosis Oxyzanation BP Ca , K Transid

Goal of TX Hb > 7 PLT > 50000 PT , PTT < 1. 5 LN Sa. O 2 > 95% SBP > 90 , MAP > 60 UO > 0. 5 cc/kg/h

Packing if Continue bleeding + PH < 7. 30 Control time try > 90 min T < 35 Need to PC > 10 u

THANKS