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Love ’ s Labour ’ s Lost

Love ’ s Labour ’ s Lost. CCM Inter-Hospital Grand Round 13 Nov 2012 SK Yung Chairman: Dr Osburga Chan Queen Elizabeth Hospital. Case 1. F/34 Para 0 Twin pregnancy USG at 22 weeks 6 days both twins size appropriate for gestation Placenta both not low Liqour normal for both fetuses

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Love ’ s Labour ’ s Lost

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  1. Love’s Labour’s Lost CCM Inter-Hospital Grand Round 13 Nov 2012 SK Yung Chairman: Dr Osburga Chan Queen Elizabeth Hospital

  2. Case 1 • F/34 • Para 0 • Twin pregnancy • USG at 22 weeks 6 days • both twins size appropriate for gestation • Placenta both not low • Liqour normal for both fetuses • No gross fetal abnormalities for both

  3. Case 1 • OGTT –ve, AN Blood unremarkable • AN follow up 34 weeks 5 days • BP 133/56, Urine alb trace • AN follow up 36 weeks 5 days • BP 131/72, urine alb >= 3+ • MSU saved no significant growth • Clinically admitted for elective Cesarean section for twins 16/11/2010 (37 weeks 5 days)

  4. Case 1 • BP/P 159/89, 80/min, Urine alb 2+ • Rechecked BP 165/98, 78/min • No symptoms of PET • Blood test • Hb 13.6, WCC 6.9, Plt 121 • RFT 139/4.2/4.7/82 • ALP 179 • Alb 29, ALT 18 • Urate 0.42 (0.16-0.39)

  5. Case 1 • Diagnosis: Pre-eclampsia complicating twin pregnancy • Emergency Lower segment Cesarean Section under spinal anaesthesia • Operation uneventful, blood loss 300ml • Both twins’ Apgar scores satisfactory • BP at end of operation 130/74, 88/min • Transferred to labour ward post op

  6. Case 1 • Upon arrival to Labour ward • BP 186/93, 55/min • Headache +ve, no blurred vision/ other symptoms of PET • Started on MgSO4 infusion 4g as loading, 1g/hr • Given nifedipine5mg q4h poprn if SBP >= 160 for BP control

  7. Case 1 • Noticed sudden onset of slurring of speech the next morning • Examination showed cerebellar signs with nystagmus, GCS 15/15, no other symptoms of PET e.g. epigastric pain • Urgent CT Brain

  8. CT Brain17/11/2010

  9. CT Brain17/11/2010

  10. CT Brain17/11/2010

  11. CT Brain17/11/2010

  12. Case 1 • Urgent CT Brain • Hypodense areas in pons, midbrain, bilateral basal ganglia and thalami • Taken over to ICU for close monitoring

  13. Case 1 • Seen by Neurology colleagues: • Bilateral past pointing • Horizontal gaze limited in abduction and adduction, left worse than right side • Slurred speech • No other focal neurological deficits • CT Brain: hypo-densities over bilateral pons, midbrain, thalami, basal ganglia • Likely pre-eclampsia related cerebral dysfunction, causing cerebral flow limitation over posterior circulation • For BP control

  14. Case 1 • BP controlled by labetalol infusion • Reviewed by neurology 18/11/2010 • Sustained bilateral horizontal nystagmus with impaired left lateral and vertical gaze, mild divergent squint, features suggestive of left pontine, midbrain and thalamic dysfunction, dysarthria with wet voice compatible with bulbar dysfunction • Condition showed improvement after control of BP and MgSO4 infusion • Suggested for MRI

  15. MRI Brain T2 19/11/2010

  16. MRI Brain T2 19/11/2010

  17. MRI Brain T2 19/11/2010

  18. MRI Brain FLAIR Coronal 19/11/2010

  19. MRI Brain FLAIR Coronal 19/11/2010

  20. MRI Brain FLAIR Coronal 19/11/2010

  21. Case 1 • MRI Brain and brain stem with contrast + MR angiography 19/11/2010 • T2 hyperintense signal in central portion of the pons, medulla and midbrain, also patchy seen in bilateral basal ganglia & external capsular regions • No abnormal contrast enhancement • Small patchy areas of restricted diffusion in pons and medulla • No obvious signal change suggestive of intracranial haemorrhage • MRA showed patent and normal intracerebral arteries

  22. Case 1 • BP gradually stabilized with amlodipine, methyldopa, minoxidil, weaned off labetalol • Clinically improving diplopia/ slurring of speech • Discharged from ICU on 22/11/2010 • CT Brain repeated 24/11/2010

  23. CT Brain 17/11/2010 24/11/2010

  24. CT Brain 17/11/2010 24/11/2010

  25. CT Brain 17/11/2010 24/11/2010

  26. CT Brain 17/11/2010 24/11/2010

  27. Case 1 • Neurological symptoms completely resolved ~ 2 months post delivery • No longer need antihypertensives

  28. Case 2 • F/35 • Non smoker, non drinker • 3rd pregnancy (same partner)

  29. Case 2 • Past obstetric history • 1st delivery in 1999 • Full term NSD • Tonic clonic seizure during episiotomy wound suturing • CT Brain unremarkable • EEG no definite epileptiform activities, intermittent generalized slow waves both hemispheres compatible with interictal changes • Not on anticonvulsants all along and defaulted follow up in neurology clinic • 2nd delivery 2007 • Full term NSD, uneventful

  30. Case 2 • Current (3rd pregnancy) • AN uneventful • Admitted to UCH 26/4/2012 (39+ 3 weeks) for uterine contraction and show • BP 160/80, urine alb + • No symptoms of PET

  31. Case 2 • Blood test • CBC, R/LFT, urate, clotting profile within normal ranges • Noticed abnormal CTG and decided for emergency Caesarean Section • Developed generalized tonic clonic seizure during anaesthesic assessment

  32. Case 2 • Emergency LSCS under GA for fetal distress and eclampsia • Intraoperatively given MgSO4 infusion • BP controlled by hydralazine infusion • Not extubated and transferred to UCH ICU • 2 more GTC, aborted by valium each time • Started on phenytoin • CT Brain done

  33. CT Brain 26/4/2012

  34. Case 2 • Pupils 2mm, reactive and symmetrical • BP stable, given mannitol • Transferred to QEH for further management • Noticed unequal pupils shortly after arrival to QEH • Proceeded to emergency left craniectomy + EVD insertion

  35. Case 2 • ICP remained high side ~ 40-50mmHg with asymmetrical pupil sizes (2, 3mm, reactive) • Given 1 more dose of mannitol • CT Brain repeated ~ 1 hour post op

  36. CT Brain post 1st craniectomy

  37. Case 2 • Decided for 2nd craniectomy + clot evacuation • Pupils 3mm bilaterally post op, reactive • CT Brain repeated ~ 3 hours post 2nd craniectomy

  38. CT Brain post 2nd craniectomy + clot evacuation

  39. Case 2 • BP under control with labetalol infusion, later weaned off to oral amlodipine and methyldopa • MgSO4 infusion off, remained seizure free, continued on phenytoin • GC remained poor

  40. Case 2 • Septic workup negative. Empirically given ceftriaxone • Autoimmune markers including ANA, AntidsDNA, AntiENA, RF, ANCA, Anticardiolipin Ab were negative • ECHO • Mild MR, AR, TR • LVEF 60% • No vegetations • No pericardial effusions

  41. Case 2 • Noticed asymmetrical pupil sizes with Cushing’s reflex day 5 post op • CT Brain repeated

  42. CT Brain 2/5/2012

  43. Case 2 • Urgent left craniectomy, clot evacuation, EVD, partial left temporal lobectomy • Post op pupils equal • CT Brain repeated

  44. CT Brain post 3rd craniectomy, clot evacuation, left partial temporal lobetomy

  45. Case 2 • Tracheostomized • EVD off 11/5/2012 (9 days after last craniectomy) • To neurosurgical ward on 12/5/2012 • GCS E4VTM4 • CT angiogram of brain revealed no aneurysm / AVM

  46. Case 2 • Left cranioplasty done, however complicated with wound infection requiring debridement • Persistent hydrocephalus on CT Brain with multiple LPs done and eventually VP shunt inserted • To Kowloon Hospital with prolonged stay • Wean off tracheostomy • Dense right hemiplegia, wheelchair bound • NG feeding, aphasic

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