A 36 year old seamstress from Port Harcourt, Nigeria, presents at 35 weeks of her 6th pregnancy. 3 pregnancies went to term and she has 2 surviving children. She has had hypertension in previous pregnancies, and preterm labour with Caesarian sections; has had cervical cerclage. In this pregnancy she developed leg and facial swelling in the second trimester. She now complains of headaches and insomnia.
From the UK Kidney Association’s international case presentation series. This case contributed by Drs Fakrogha, Oka-Jaja, Ememchioma, David-West, and Prof Wokoma at the University of Port Harcourt Teaching Hospital.
She is restless and distracted. Legs are very oedematous and she has sacral oedema. Blood pressure is 180/100. Urine shows Protein +++ but serum albumin is normal for pregnancy. LFTs are normal.
- What is the most likely diagnosis? Are there any other important possibilities; what else would you like to check?
- What is the correct immediate management?
Write what you think
What happened next
This so far looks most likely to be typical pre-eclampsia. We may wonder later about the recurrent history. The most immediate measures required are
- Control of blood pressure (labetalol IV, oral nifedipine, methyldopa as available)
- Administration of Magnesium
Obstetric ultrasound to judge fetal condition, and size for dates, is valuable if available and there is time. Administration of steroids to protect fetal lungs is desirable if there is time.
She had an urgent Caesarian section, but 6h later had several generalised tonic-clonic seizures, treated with Diazepam. These settled, but at 24h she begins to show petechial haemorrhages and bruising, with mild anaemia but marked thrombocytopenia (estimated by PCV and blood film). Blood pressure remains high but controlled. Her general condition deteriorates over the next days.
On Day 4 she is noted to be oliguric, and thought to be becoming encephalopathic again. Her Creatinine has risen from 85 to 525. On day 8 creatinine has risen further and now she is jaundiced and LFTs (transaminases, ALP not available) are abnormal and albumin 25. Potassium is 4.5. Ultrasound shows normal liver, gallbladder, and kidneys.
- Has your diagnosis changed?
- Are there any other investigations you would do now?
- How would you manage her?
Write what you think
What the experts thought; outcome
The most likely diagnosis remains (pre-)eclampsia. You may now think she has features of HELLP, and she does, but preeclampsia has an extended spectrum of severity and features. HELLP is one way that severe preeclampsia presents.
Management is essentially conservative. Patients with AKI die of high potassium, fluid overload, infection, and lastly uraemia. So managing electrolytes and fluid balance is critical. Dialysis is an extravagant intervention if patients have to pay for it, it is not always an easy option. And it is not a cure, it merely gives more time for recovery, and flexibility with diet.
There was no immediate indication for dialysis and she was managed with low potassium and low salt, low protein, high calorie diet. However she remained oliguric. Creatinine rose further and she became hyperkalaemic, and encephalopathy was not improving, so she received haemodialysis on three occasions. Her urine output picked up after a further 4 days. She improved and creatinine recovered spontaneously.
Postnatal presentation of new features may make you suspect that she could have atypical HUS, but eclampsia is a much more common explanation. In this case, the presentation was entirely typical for eclampsia, and she has had hypertension and features of preeclampsia in previous pregnancies, with full recovery. Sometimes there are minimal or no features before delivery.
Recurrent preeclampsia: an important cause is underlying kidney disease. We don’t know whether this patient had any evidence of CKD or hypertension between pregnancies, or proteinuria in early pregnancy.
- NICE-CKS: preeclampsia is excellent (available in UK only, unfortunately)
- WHO recommendations on preeclampsia (points to pdf)
- Obstetric renal failure was a major cause of AKI (ARF) in the UK in the 1960s. Obstetric renal failure in the UK in 1965 from the History of Nephrology blog.
- Salford Royal Hospital is a sister centre for Port Harcourt. Contact Dr Ibi Erekosima at Salford. The UK Kidney Association’s International Committee
- The header image shows a patient with a similar presentation and outcome, with her renal team, in Blantyre, Malawi. Via Dr Gavin Dreyer.