23 /F female G4P2 L1D1A1 with anaemia and icterus

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23 yr female with G4P2L1D1A1 was apparently asymptomatic till 4 th month of her 2 nd pregnancy

 AOM : 13 yrs Normal regular cycles

 Got married to 3 rd degree consanguinity and conceived spontaneous after 6 months of marriage.

Due to absent fetal heart rate induced abortion was done with D and C . All her blood investigations are normal during that period ( records not available)

 2 nd pregnancy after 6 months of abortion which is spontaneous and she was normal till 3 rd month of 2 nd pregnancy 

 During her 4 th month of 2 nd pregnancy she developed yellowish discolouration of eyes , decreased appetite , nausea and vomting - non projectile non bilious not associated with pain abdomen with food as content

  She is on regular antenatal checkup in one of the hospitals in miryalaguda where her routine investigations were done then her hb was low 4gm/dl and LFT is dearranged(? indirect hyperbilirubinemia) . 2 blood transfusions were done during her 5 th month cervical cerclage was done. Pt had icterus till the time of delivery. she was referred to higher centre during her 7 th month on 30 th august 2017 i/v/of anaemia- hb 6.8 , TB - 2.4 ,DB -0.8 , sr alb 2.8 , sr lipase 174,PT 17, INR 1.3 . Then she went to Gandhi hospital where 4 blood transfusions done prenatally and she developed sudden onset of labour pains and delivered a male baby pre -term (7 th month) died after 1 month. she received 1 blood transfusion postnatal

  she came to our hospital on 3/10/2017 with the complaints of fever, breathlessness, giddiness since 8 days, cough since 3 days.

03/10/2017  HB - 3.6 TC-20000

PLATELETS - 2.6

TB - 4.2

DB - 1.49

SGOT - 33

SGPT - 13

Albumin - 3.9

G6PD - 5.8 u/g/hb

RFT - Normal

Serum LDH - 300 IU/L

04/10/2017

PH - 7.1

PCO2 - 11.1

PO2 - 13.7

HCO3 - 3.9

SPO2 - 95.6

05/10/2017

HB - 3.7

TC - 16000

Blood cultures - No growth 

06/10/2017

PH -7.4

PCO2 - 19.4

PO2 - 113

HCO3 - 14.2

SPO2 - 98.8

ANA - 48 u/ml

she was diagnosed as autoimmune hemolytic anaemia

 ? autoimmune pancreatitis ? septic shock                   with dct and ict positive and started on         -inj.monocef 1 gm iv bd                                                            -inj.levoflox 500 mg iv od, tab. doxycycline 100 mg bd, -inj. falcigo 500 mg iv bd (28/09/2017 malaria positive) -tab. prednisolone 40 mg od                                            she was admitted her for 3 days and patient was discharged on.                                                                   -tab. prednisolone 40 mg od,.                                           -tab. orofer xd po od                                                    -tab. folvite 5 mg od                                                           

she was asked to review after 1 week .       

18 October 2017 she visited NIMS in view of yellowish discoloration of eyes since 1 and half month, facial puffiness and pedal oedema since 1 week

hb - 7.4

tb- 4.0

db- 0.76

tp- 5.0

albumin- 3.1

direct combs test - +2

and kept on.                                                                             - tab. prediselone 40 mg for 14 days                             -tab. orofer xd po od                                                        -tab. folvite 5 mg od    

 on 19/ 11/2017 she came to our hospital with swelling over both cheeks since 1 month treatment given.         tab. prednisolone 40 mg for 1 month

hb- 11.

19/12/2017 she cane with complaints of facial puffiness, acne, hypertrophy of papillae with ulcer on the  tip of tongue tapered the dose of prednisolone from 40 mg to 30 mg she used tab. prednisolone for 3 month

hb- 13.

tb- 3.3

db- 0.5

ldh- 47

she came on 27/2/2018 for reviewOn 27-2-2018

Tab.predinisolone tapered from 20mg for 2 weeks to 15 mg for 2 weeks to 10 mg for 2 weeks to 5 mg for 2 weeks and then to stop it.

On 28-4-2018

she was advised for ANI,lupus anti-coagulant and anti-cardiolipin antibodies testing.

On 12-7-2018

Patient stopped steroids for 2 weeks after developing  Cushinoid features for 2 weeks and steroids were started again as 10 mg for 4 weeks

She came in 2019 ,with the C/O 5 months of ameorrhoea and she was Apparently asymptomati

Came for an antenatal checkup with 22 weeks of gestational age.

LMP: 10-7-2019 ,EDD: 17-4-2020

Patient was on Inj prulotin IM weekly once

Tab ecospirin 75 mg OD and Tab susten 200mg B

O/E: Pallor and icterus were present with stable vitals

Referred to GM on 11-12-19 i/v/o hemolytic anaemia and she was advised

 tab prednisolone 40 mg OD

Inj vit B12 1000mcg O

On 13-12-19

Thermal amplitude test was positive for cold antibodies

DCT positive,ICT negative

Raised reticulocyte count

Raised bilirubin-> which suggested of cold autoimmune Hemolytic anemia and was advised warm blood transfusion and steroid administration in case of severe hemolysis

28-12-2019

Hb electrophoresis was done which showed Beta-thalassemia

Immunofluorescence showed SPR positive for polymyositis and ANI positive

On 18-1-2020

 Cervical encirclage  was done i/v/o short cervix with cervical length being 2.5cm, after receiving one PRBC blood transfusion on 4-1-2020

(Hb:8.6gm%

She was diagnosed to have GDM during her 6th month of pregnancy and was kept on MNT for 2 weeks and changed to insulin HAI 6-6-8 UNITS.

24-1-2020

Endocrinologist referreral was taken i/v/o GDM and kept on

Regular: 4-3-3

NPH: 5-x-5

On 26-1-202

Insulin doses were adjusted a

Regular : 6-7-6

NPH:6-x-6

On 21-3-20

Emergency LSCS was done i/v/o oligohydramnios 

4 th pregnancy:

6/3/2021

Hb 8.5

TC 7600

plt count 2.7

cue: Alb Nil

 pus cells :2-3

LMP lactation ammennorhoea

EDD 1/8/2021 ( 16 wks scan)

POG 33 weeks 1 day

came for cervical cerclage ( short cervix 2.9 cms on TIFFA scan)

No complaints 

O/ex pallor ++

iceterus +

no pedal odema ,facial puffiness, generalised lymphadenopathy

HT : 147 cms

wt :37 kgs

BMI 17.1 kg/m2

PR : 100 bpm

BP: 100/70 mm of hg

GRBS :70 gm/dl

spo2 : 98 with RA

CVS : s1,s2 

CNS : NAD

R/S : NVBS +

P/A : uterus 22weeks, relaxed

   FM +, FP +

  FHS + (159 bpm)

 suprapubic transverse scar +

6/4/2021

Hb 6.5

TC 8700

plt count 1.5

MCHC

cue: Alb Nil

 pus cells :1-2

TB : 3.3

DB :O.77

TP: 5.5

alb: 3.0

Rectic count: 1.8%

sr iron 79 ug/dl

sr ferritin 

1 prbc transfusion done on 7/4/2021 hb increased to 8.3 from 6.4

1 prbc transfusion done on 9/4/2021

Diagnosis:

23 F G4P2L1D1A1 with 23 weeks of gestation with AIHA with Beta thalassemia trait