Severe pre-eclampsia complicated by acute fatty liver diseas
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A 26-year-old Asian female patient in her first pregnancy with a body mass index of 25 kg/m2 and with no significant medical history. Her antenatal booking blood, serology, and blood pressure (BP) were all unremarkable. She had been taking 75 mg aspirin from 12 weeks’ gestation due to a family history of pre-eclampsia. At routine community midwife visit, her BP was 132/72 mm Hg and there was +3 protein on urine dipstick. This was 2 days prior to her attendance at our maternity unit at 37 weeks’ gestation with a 7-day history of worsening nausea, vomiting, abdominal pain and anorexia, leading to a dramatic weight loss. She also reported that 2 weeks earlier she had a bout of fever with anosmia and loss of taste without any respiratory symptoms; this resolved spontaneously some days later. Her BP was 173/111 mm Hg, with significant proteinuria. She was admitted for observation and further investigations. Laboratory investigations were grossly abnormal and indicated a diagnosis of severe pre-eclampsia complicated by AFLP and ‘atypical’ HELLP syndrome with acute kidney injury.

A decision was made for immediate induction of labour with prostaglandin. Magnesium sulfate was administered for prevention of eclamptic seizures. She had spontaneous rupture of the amniotic membranes at 4 cm cervical dilatation which revealed significant meconium-stained liquor and abnormal fetal heart rate, leading to an uncomplicated emergency cesarean delivery under spinal anesthesia with an estimated blood loss of 500 mL. A live baby weighing 2760 g was born in good condition. Postnatally the patient was managed in a high-dependency setting on the labor ward with supportive treatment. Her BP rapidly normalized after the delivery of the baby. Magnesium sulfate was continued for 24 hours postnatally. Her liver function gradually improved, but renal function slowly deteriorated with mild metabolic acidosis. Three days later, she felt dizzy and developed tachycardia, with a significant drop in hemoglobin (68 g/L). She received a transfusion of two units of packed red blood cells and intravenous broad-spectrum antibiotics.

A CT scan of the abdomen and pelvis showed a large intra-abdominal hematoma, which was evacuated via repeat laparotomy. CT scan also showed an incidental finding of bilateral basal ground glass opacifications in the lungs, suggestive of COVID-19 infection. This was confirmed by nasal and throat swab for SARS-CoV-2 using reverse transcriptase PCR. The following day, she developed sudden-onset confusion with retrograde amnesia, restlessness, sighing, and inability to recall the date or her current location. An urgent CT scan of the head was arranged, which was normal. Her confusion spontaneously resolved a few days later, with rapidly improving creatinine and liver function tests. She was discharged home on the seventh postnatal day with low molecular weight heparin, oral labetalol and antibiotics. Her baby was asymptomatic for COVID-19 and was not tested as per local protocol. Two weeks later, her liver and renal function tests returned to normal

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