We report the case of a previously healthy 28-year-old woman, Afro-Brazilian, in her first pregnancy.
Our patient had no medical records until the 36th pregnancy week and reported allergy to diclofenac.
She presented to our emergency department with an acute onset of abdominal pain, jaundice, nausea and vomiting, with no signs of encephalopathy.
Her arterial blood pressure was 110/60mmHg, heart rate was 98bpm, axillary temperature was 35°C, she was severely dehydrated and with decreased peripheral perfusion.
The laboratory examinations revealed hemoglobin 12.3g/dL, leukocytes 13 × 109/mL, platelets 97 × 103/mm3, international nationalized ratio (INR) 6.9, fibrinogen 98mg/dL, total bilirubin 14.2mg/dL, serum creatinine 3.4mg/dL, serum aspartate aminotransferase (AST) 306U/L, serum alanine aminotransferase (ALP) 302U/L, arterial bicarbonate 11mEq/L, arterial pH 7.21, blood glucose 65mg/dL and ionic calcium 1.02mmol/L.
An abdominal ultrasound depicted fatty infiltration of the liver and confirmed fetal viability.
Our patient received an initial fluid load with crystalloids.
The calcium, glucose and hypothermia were reversed.
The diagnosis of AFLP was confirmed following the Swansea’s criteria [9].
Therefore, a cesarean section was indicated.
A thromboelastometry (ROTEM®, Pentapharm Co., Munich, Germany) was performed at the beginning of the surgery.
The thromboelastometry analysis showed an intense kinetic and structural hypocoagulable state (Fig.1 and Table 1).
The FIBTEM revealed an impairment in fibrinogen function quality while the EXTEM depicted a coagulation factor deficiency (Fig.1a-c and Table 1).
Based on, respectively, FIBTEM maximum clot firmness (MCF) (0mm; Table 1) and EXTEM clotting time (CT) (228s; Table 1), 4.0g of fibrinogen concentrate (Haemocomplettan® P, CSL Behring, Marburg, Germany) and 1000UI of prothrombin complex concentrate (Beriplex® P/N 500UI, CSL Behring, Marburg, Germany) were administered at the beginning of the cesarean section.
The fluid input (crystalloids) and output during the caesarian section were, respectively, 2000mL and 200mL.
The cesarean section succeeded with no major bleeding after the hemostatic therapy.
Additional hemocomponent transfusion, such as fresh frozen plasma (FFP), cryoprecipitate, platelets or blood concentrates, was not necessary.
A second thromboelastometry analysis was performed at the end of surgery (Fig.1d-e and Table 1), showing a mild hypocoagulation state.
The patient was admitted to the intensive care unit (ICU) and remained stable, with no bleeding during the recovery phase.
She was discharged from the ICU 3 days after admission and then 3 days later she was discharged from the hospital.