Dr Pamela Anjara
Western Health


Title: A Case Of Pregnancy And Bleeding - From Diagnosis To Management
Anjara, P., Katsoulis, J.
Western Health, Victoria, Australia.

Background: Atypical Haemolytic Uraemic Syndrome (aHUS) affects 1 in 100,000 pregnancies (Bergmann and Rath, 2015). Although rare, prompt diagnosis will lead to immediate intervention to avoid irreversible end organ damage (Legendre et al., 2013).

Case Presentation: A 37-year-old primigravida delivered twins at 35 weeks' gestation. Antenatally, transient mild hypertension was noted. She had >2L post-partum haemorrhage secondary to a retained placenta and uterine atony complicated by hypovolaemic shock, acute kidney injury and Disseminated Intravascular Coagulation (DIC). Massive transfusion protocol was activated. She required renal replacement therapy (RRT) for anuria. Liver function (LFT) derangement with transaminases of 300U/L occurred with no hypoglycaemia. After hemodynamic stabilisation, she had hypertension and proteinuria. The diagnoses of pre-eclampsia and HELLP syndrome were considered.

Four days post-partum, hypertension, DIC and LFT derangement resolved, however she required ongoing RRT. There was ongoing moderate thrombocytopaenia and haemolytic changes that increased in severity 48 hours after resolution of DIC. A thrombotic microangiopathy was suspected. ADAMTS13 level was normal. In the absence of diarrhoea, aHUS was diagnosed. Eculizumab was promptly initiated. The haemolysis resolved, and platelets and renal function normalised. 

Conculsion: This case demonstrates the difficulty in diagnosing aHUS post-partum with multiple differential diagnoses. It highlights that aHUS cannot be diagnosed in the context of DIC and that early Eculizumab initiation avoids progression to chronic kidney disease. The differential diagnoses and approach to thrombocytopaenia and renal impairment in pregnancy will be discussed.

BERGMANN, F. & RATH, W. 2015. The Differential Diagnosis of Thrombocytopenia in Pregnancy. Dtsch Arztebl Int, 112, 795-802.
LEGENDRE, C. M., LICHT, C. & LOIRAT, C. 2013. Eculizumab in atypical hemolytic-uremic syndrome. N Engl J Med, 369, 1379-80.

Tite: Clinical Inertia to Dysclycaemia in General Medicine
Ta’eed A
1, Janus E1,2, Hendrich E1, Karahalios E 1,2,3
1 Western Health, Melbourne VIC, Australia, 2 Department of Medicine, Western Academic Centre, University of Melbourne, Melbourne VIC, Australia, 3 Centre of Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne VIC, Australia

Background: Dysglycaemia is a common and serious issue for hospitalized patients, associated with poor outcomes (1). In this retrospective audit we examined inpatient glycaemic outcomes for patients admitted into the General Internal Medicine (GIM) unit at Footscray Hospital, Victoria to ascertain the prevalence of dysglycaemia, assess clinical response and evaluate its effect on length of stay (LOS). 

Methods: Adult patients with diabetes admitted under the GIM unit at Footscray Hospital between 1 Jan 2014 to 31 Oct 2014 were identified. Every third consecutive patient with clinical data available and who was not admitted to intensive care was included in the study. Regular scheduled blood glucose recordings (i.e. before each meal and at bedtime or 6-hourly recordings for those fasting) were analysed, thereby reducing bias caused by repeated measurements at extremes of glycaemic excursions.

Results: A total of 312 patients were included with a median age of 79 [IQR 70,85] with a mean number of medical co-morbidities of 7 (±2.4). Median length of stay was 4 days [IQR 2,6] and the median blood glucose level was 9.5 mmol/L [IQR 7.9,11.9] with 43.2% of all blood glucose results being > 10 mmol/L, 14.8% > 15 mmol/L and 3.5% > 20 mmol/L. 127 patients (40.7%) were prescribed a supplemental insulin regimen but despite this treatment had a higher median blood glucose level of 11.6 mmol/L [IQR 9.9,13.9]. In addition, patients received an average of 7.6 supplemental insulin doses for every change to their regular glycaemic regimen. 54 patients (17.3%) experienced at least 1 hypoglycaemic episode of which only 26 (47.2%) had a change to their regular glycaemic regimen. After adjustment for age, number of co-morbidities and insulin use, an increase in blood glucose level was not associated with an increase in median LOS.

ConclusionAlthough a substantial proportion of our general medical inpatient population were found to have blood glucose levels above recommended targets (1), often despite supplemental insulin, this did not have a significant impact on length of stay. Our results also suggest there is significant clinical inertia present within our GIM unit which could be explored further to improve clinical response to persistently abnormal blood glucose levels.

References: 1. Association of Clinical Endocrinologists and American Diabetes Association Consensus Statement on Inpatient Glycaemic Control. Diabetes Care 2009; 32:6