|Year : 2021 | Volume
| Issue : 1 | Page : 30-32
Complications of severe pre-eclampsia associated with acute intestinal intussusception—A case report
Jemea Bonaventure, Berinyuy Emelinda Nyuydzefon, Iroume Cristella Raissa Bifouna, Esiene Agnes
Yaounde University Hospital Center; Faculty of Medicine and Biomedical Sciences, University of Yaounde 1, Cameroon
|Date of Submission||26-Aug-2020|
|Date of Acceptance||27-Dec-2020|
|Date of Web Publication||16-Apr-2021|
Dr. Berinyuy Emelinda Nyuydzefon
Faculty of Medicine and Biomedical Sciences, University of Yaounde 1, PO BOX 1364, Yaounde
Source of Support: None, Conflict of Interest: None
We present a challenging case of severe pre-eclampsia later complicated by eclampsia, severe renal failure, intestinal intussusception, septic shock, and stroke in a 26-year-old female primigravid patient in third trimester. We navigate through the diagnostic and therapeutic challenges faced in managing our patient to bring out lessons and proposals to prevent and manage similar cases in the future.
Keywords: Acute kidney Injury (AKI), case report, eclampsia, HELLP syndrome, intussusception, septic shock, stroke
|How to cite this article:|
Bonaventure J, Nyuydzefon BE, Bifouna IC, Agnes E. Complications of severe pre-eclampsia associated with acute intestinal intussusception—A case report. J Obstet Anaesth Crit Care 2021;11:30-2
|How to cite this URL:|
Bonaventure J, Nyuydzefon BE, Bifouna IC, Agnes E. Complications of severe pre-eclampsia associated with acute intestinal intussusception—A case report. J Obstet Anaesth Crit Care [serial online] 2021 [cited 2021 Jun 15];11:30-2. Available from: https://www.joacc.com/text.asp?2021/11/1/30/313915
| Introduction|| |
Severe pre-eclampsia is a life-threatening condition in pregnancy complicating 4 to 10% of all pregnancies, especially in Africa. It often presents as new-onset hypertension and proteinuria during the third trimester, and can progress rapidly, leading to death of both mother and fetus. Complications seen as a result of the pathology include Eclampsia, HELLP, perinatal death, and acute kidney injury (AKI).,, Rare complications include stroke., Intussusception during this period is very rare, No such case has yet been reported. Our patient developed several complications (Eclampsia, HELLP, AKI), including Stroke and intestinal intussception. We navigate through the diagnostic and therapeutic challenges faced in her management and thus draw lessons and proposals to prevent and treat similar cases in the future.
| Case History|| |
The 26-year-old, G1P1ooo, was referred for better management of altered consciousness and oliguria 12 hours postpartum.
Patient's blood pressure were normal at 38 weeks gestation. However, at 40 weeks, during labor, she presented raised blood pressure: 170/123 mmHg, headache VAS 8/10, followed by 3 episodes of generalized tonico-clonic seizures. She was rushed to a nearby health center where eclampsia was then diagnosed on admission and treatment initiated rapidly with a loading dose of 14 g MgSO4 and IV Nicardipine. Further work up revealed raised liver enzymes ASAT = 521 UI, ALAT = 217 UI, Proteinuria +++, low platelets 80,000/mm3, leucocytosis 14060/mm3, urea = 0.23 g/l, creatinine = 11.5 mg/l, and Hb: 12.5 g/dl. HELLP syndrome was diagnosed. She received 2 units of fresh frozen plasma, and was delivered of a male stillborn 24 hours after admission. Eight hours later oliguria, hematuria, and an altered state of consciousness (GCS: 10/15) set in motivating her transfer to our intensive care unit (ICU) for better management.
Upon admission, biological work up revealed impaired renal function (Urea: 0.48 g/l, Creatine: 23.7 mg/l), raised liver enzymes (10-fold normal) and moderate hyperkalemia k: 5.59 mEq/L. FBC revealed leucocytosis, 21130/mm3 predominantly neutrophyles 15210/mm3 (suggesting bacterial sepsis), severe anemia (Hb: 5.7 g/dl), and moderate thrombocytopenia (Platelets: 70,000/mm3). Our working diagnosis was eclampsia complicated by HELLP syndrome, stage 3 acute kidney injury and severe anemia sepsis. She was thus administered normal saline 40 ml/kg, 3 units fresh whole blood, MgSO4 0.5 g/hr IV, and phenobarbital 3 mg/kg for prevention of seizures. Hemostatic agents (tranxenamic acid 8 g IV continuous infusion for 24 hours), Oxytocics, antihypertensives (nicardipine) as well as amoxicillin-clavulanic acid as antibiotic were used in optimal doses. Insulin 10 units in 10% glucose was used to manage hyperkalemia. Omeprazole 40 mg IV was administered to prevent stress ulcer. Patient was given oxygen by nasal prongs (3 l/m) and monitored with a cardioscope.
Despite optimal treatment, only transient amelioration was noticed within 48 hours with return of consciousness. Day 3 of hospitalization was marked by aggravation of renal function, with the development of acute pulmonary oedema treated with IV frusemide 1 mg/kg/6 hours. Day 4 hospitalization was marked by complaints of right upper quadrant abdominal pains associated with no passage of flatus and feces. These associated with worsening renal function urée/créatinine: 1,25 g/l/68,1 mg/l and anuria necessitated initiation of hemodialysis. An abdominal ultrasound revealed small intestinal intussusception of the right flank and a large uterus with heterogenous content. An emergency laparotomy was thus performed under general anesthesia. Per-operative surgical management was by manual reduction of the intussuscepted segment. Meticulous inspection by palpation and translumination of the patient's entire small bowel showed no lead point. Uterine revision was also done leading to the evacuation of a heterogenous uterine content, suspicious of containing placenta remnants and blood clots. Immediate evolution post operatively was marked by, severe anemia requiring transfusion of 2 units of RBCs, persistence of SIRS. Antibiotherapy was with immipinem 500 mg/8 hrs, amikacin 500 mg/48 hourly and Metronidazole 500 mg/8 hours IV. Hemodialysis was continued (thrice weekly).
Despite treatment, day 9 post-op was marked by respiratory distress, partial myoclonic seizures, hypotension, and a SOFA score of 10. A diagnosis of septic shock was made. A left sub-clavian central line was placed for fluid resuscitation with crystalloids and vasopressor Adrenaline in electric syringe. The patient was intubated and placed on volume control artificial ventilation. Culture specimens were collected and a cerebral CT scan was done. Treatment of septic shock necessitated adjustment of antibiotics to Ofloxacin 200 mg/12 hours IV, Amikacin 500 mg/48 hours initially titrated to renal function following sensitivity of Klebsiella and Pseudomonas sp on culture results. CT scan was unrevealing. Evolution was favorable. Extubation was 48 hours after endotracheal intubation and apyrexia on day 17 post-op. However, patient had as sequellae aphasia due probably to an acute ischemic stroke (normal CT scan). Physiotherapy with a speech therapist was initiated with good response. Patient was discharged on the 27th postoperative day and is regularly followed by the gynecologist, the psychologist, and the speech therapist.
| Discussion|| |
Eclampsia occurs with an incidence that varies between 9 and 34 per 1000 live births in sub-Saharan Africa and about 1/105 deliveries in Cameroon. HELLP syndrome occurs in 0.1%-0.6% of all pregnancies and in 4%-12% of patients with severe pre-eclampsia. It typically occurs between week 27 of gestation and delivery, or immediately postpartum in 15%-30% of cases. Maternal deaths in HELLP range from 4 to 14.28% with perinatal deaths ranging from 9.1 to 46.73%.,, As in the case of our patient, the incidence of HELLP syndrome mostly occurs in primigravid and primiparous women when compared to multiparous women.
On the other hand, renal failure is frequently seen in severe pre-eclampsia especially when complicated by HELLP with an incidence of 21.1%., The most common histological lesion being acute tubular necrosis (ATN). However, renal cortical necrosis has been reported in pre-eclamptic women with AKI. Sepsis and low intravascular volume due to intussusception could have initiated or worsened AKI in our patient., Pregnancy-related AKI may have long-term renal, cardiovascular and neurocognitive consequences beyond the post-partum period and therefore must be managed aggressively.,
Preeclampsia being a multiorgan endotheliopathy, affects not only kidneys and liver but also the brain leading to stroke. It is shown to be most common in the peripartum and postpartum periods., Management requires timely brain imaging, supportive and antihypertensive treatment. Sepsis on admission, prothrombotic states and coagulopathies are shown to be associated with probability of stroke in pre-eclampsia, much consistent with our patients profile. Thrombolysis with recombinant tissue plasminogen activator (rt-PA) administered within 4.5 hours of stroke onset is shown to significantly improve overall outcome., However, such management wasn't available at the time of diagnosis of our patient.
A rare complication our patient had was intestinal intussusception. Pregnancy-associated bowel obstruction varies from 1 in 1500 to 1 in 66,431 deliveries and is most often diagnosed in the post-partum period., Co-existing intussusception and severe pre-eclampsia is quite rare. We know that any irritation within bowel walls that alter normal peristaltic activity can initiate intussusception. These could include inflammation. We also know that inflammation of the liver and stretching of the hepatic capsule accounts for right upperquadrant/epigastric pain in severe pre-eclampsia. However, that this inflammation can stretch to adjacent intestinal walls is not known, but is the only explanation we suggest for this idiopathic intestinal intussusception in the right upper quadrant in our patient.
While the cause of preeclampsia is still debated, clinical and pathological studies suggest that the placenta is central to the pathogenesis of this syndrome Management often requires evacuation of the placenta, leading us to think that uterine evacuation in the case of our patient could have relieved some symptoms of post-partum eclampsia.
The importance of biomarkers which correlate with disease severity and could have prognostic value in identifying women who subsequently develop maternal and/or perinatal complications cannot be over emphasized in the case of our patient. This however was not applicable in our setting.
| Conclusion|| |
Severe pre-eclampsia is a life-threatening pathology in pregnancy and the peuperium. When associated with sepsis and HELLP syndrome, a patient is likely to present several other complications such as acute renal failure, acute abdomen, and stroke. Such patients should be closely monitored and managed expectantly, especially if primiparous. Biomakers for pre-eclamspsia could be beneficial in detecting patients with possibility of poor prognosis.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ngwenya S. Severe preeclampsia and eclampsia: Incidence, complications, and perinatal outcomes at a low-resource setting, Mpilo Central Hospital, Bulawayo, Zimbabwe. Int J Womens Health 2017;9:353-7.
Onoh RC, Mamah JE, Umeokonkwo CD, Onwe EO, Ezeonu PO, Okafor L. Severe preeclampsia and eclampsia: A 6-year review at the Federal Teaching Hospital, Abakaliki, Southeast Nigeria. Trop J Obstet Gynaecol 2019;36:418-23. [Full text]
Rana S, Lemoine E, Granger JP, Karumanchi SA. Preeclampsia: Pathophysiology, challenges, and perspectives. Circ Res 2019;124:1094-112.
Hladunewich M, Karumanchi SA, Lafayette R. Pathophysiology of the clinical manifestations of preeclampsia. Clin J Am Soc Nephrol 2007;2:543-9.
Khalid AS, Hadbavna A, Williams D, Byrne B. A review of stroke in pregnancy: Incidence, investigations and management. Obstet Gynaecol 2019;22:21-33.
Ladhani NNN, Swartz RH, Foley N, Nerenberg K, Smith EE, Gubitz G, et al
. Canadian stroke best practice consensus statement: Acute stroke management during pregnancy. Int J Stroke 2018;13:743-58.
Abdul MA, Yusufu LMD, Haggai D. Intussusception in pregnancy: Report of a case. Niger J Surg Res 2004;6:61-3. DOI: 10.4314/njsr.v6i1-2.54799.
Marinis A, Yiallourou A, Samanides L, Dafnios N, Anastasopoulos G, Vassiliou I, et al
. Intussusception of the bowel in adults: A review. World J Gastroenterol 2009;15:407-11.
Félix E, Vanessa WYD, Esther NUM, Valère MK, Sama DSJ, Atomveng OS, et al
. Eclampsia in African Milieu, Yaounde-Cameroon: Epidemiology, seasonal variations and treatment regimen. Obstet Gynecol Int J 2019;10:176-83. doi: 10.15406/ogij. 2019.10.00440.
Kamble RC, Gupte NS. Maternal and perinatal outcome in patients with HELLP syndrome. MVP J Med Sci 2019;5:198-203.
Vigil-De Gracia P, Rojas-Suarez J, Ramos E, Reyes O, Collantes J, Quintero A, et al
. Incidence of eclampsia with HELLP syndrome and associated mortality in Latin America. Int J Gynecol Obstet 2015;129:219-22.
Lisonkova S, Sabr Y, Boutin A, Joseph KS. 509: Risk factors, pregnancy complications and severe adverse outcomes associated with HELLP syndrome: A population-based study. Am J Obstet Gynecol 2019;220(Suppl):S342.
Williams KP, Wilson S. The impact of parity on the incidence of HELLP syndrome and small for gestational age infants in hypertensive pregnant women. J Obstet Gynaecol Can 2002;24:485-9.
Wiwanitkit V. Prevalence rate of acute renal failure in HELLP syndrome: A summary from a single country's data. Ren Fail 2009;31:621.
Prakash J, Ganiger VC. Acute kidney injury in pregnancy-specific disorders. Indian J Nephrol 2017;27:258-70.
] [Full text]
Makris K, Spanou L. Acute kidney injury: Definition, pathophysiology and clinical phenotypes. Clin Biochem Rev 2016;37:85-98.
Fuhrman DY, Kane-Gill S, Goldstein SL, Priyanka P, Kellum JA. Acute kidney injury epidemiology, risk factors, and outcomes in critically ill patients 16-25 years of age treated in an adult intensive care unit. Ann Intensive Care 2018;8:26.
Szczepanski J, Griffin A, Novotny S, Wallace K. Acute kidney injury in pregnancies complicated with preeclampsia or HELLP syndrome. Front Med (Lausanne) 2020;7:22.
Suarez B, Alves K, Senat MV, Fromageot J, Fischer C, Rosenberg P, et al
. Abdominal pain and preeclampsia: Sonographic findings in the maternal liver. J Ultrasound Med 2002;21:1077-83; quiz 1085-6.
McDermott M, Miller EC, Rundek T, Hurn PD, Bushnell CD. Preeclampsia: Association with posterior reversible encephalopathy syndrome and stroke. Stroke 2018;49:524-30.
Ladhani NNN, Swartz RH, Foley N, Nerenberg K, Smith EE, Gubitz G, et al
. Canadian Stroke Best Practice Consensus Statement: Acute Stroke Management during pregnancy. Int J Stroke 2018;13:743-58.
Miller EC, Gatollari HJ, Too G, Boehme AK, Leffert L, Marshall RS, et al
. Risk factors for pregnancy-associated stroke in women with preeclampsia. Stroke 2017;48:1752-9.
Zotto E, Giossi A, Volonghi I, Costa P, Padovani A, Pezzini A. Ischemic stroke during pregnancy and puerperium. Stroke Res Treat 2011;2011:606780.
Kolusari A, Kurdoglu M, Adali E, Yildizhan R, Sahin HG, Kotan C. Sigmoid volvulus in pregnancy and puerperium: A case series. Cases J 2009;2:9275.
Renzulli P, Candinas D. Idiopathic small-bowel intussusception in an adult. CMAJ 2010;182:E148.
Weledji EP, Simo AW. Idiopathic post-partum intussusception: A case report. Clin Surg 2019;4:2603.
Lam MTC, Dierking E. Intensive Care Unit issues in eclampsia and HELLP syndrome. Int J Crit Illn Inj Sci 2017;7:136-41.
] [Full text]
Chaiworapongsa T, Chaemsaithong P, Korzeniewski SJ, Yeo L, Romero R. Pre-eclampsia part 2: Prediction, prevention and management. Nat Rev Nephrol 2014;10:531-40.