Case records of the Massachusetts General Hospital. Case 35-2011: A 33-year-old woman with postpartum leukocytosis and Gram-positive bacteremia

Leukemoid reaction with severe thrombocytopenia in a dying patient: a case report and literature review

Leukemoid reaction complicated by thrombocytopenia is rare, usually seen in patients with malignant conditions, and is often associated with poor prognosis. Here, the case of a 28-year-old healthy female without exceptional past medical history, who suffered from severe vaginal infection, is reported. Although symptoms improved, the white blood cell (WBC) count continued to increase up to 78 460 cells/µl, however, the patient continued to improve and the outcome was good. The case revealed that an increasing WBC count may not change in synchrony with clinical symptoms. When faced with this scenario, procalcitonin measurements may play an important role in differentiating diagnosis and guiding treatment.

Disseminated Intravascular Coagulation Syndromes in Obstetrics

Disseminated intravascular coagulation (DIC) is a syndrome that can be initiated by a myriad of medical, surgical, and obstetric disorders. Also known as consumptive coagulopathy, DIC is a common contributor to maternal morbidity and mortality and is associated with up to 25% of maternal deaths. The etiopathogenesis of DIC is complex and currently thought to be initiated by tissue factor or thromboplastin, which is released from trophoblastic or fetal tissue, or maternal decidua or endothelium. Tissue factor activates the coagulation sequence to cause fibrin clotting and its dissolution by the fibrinolysin system. The result of this process can range from mild, clinically insignificant laboratory derangements to marked coagulopathy with bleeding at sites of minimal trauma. Although clinical recognition varies by disease severity, several organizations have attempted to standardize the diagnosis through development of scoring systems. Several important--albeit not necessarily common--obstetric disorders associated with DIC include placental abruption, amniotic fluid embolism, sepsis syndrome, and acute fatty liver of pregnancy. More common disorders include severe preeclampsia, hemolysis, elevated liver enzymes, and low platelet count syndrome, and massive obstetric hemorrhage. Importantly, many of these disorders either cause or are associated with substantive obstetric hemorrhage. Treatment of DIC is centered on two principles. The first is identification and treatment of the underlying disorder. Because many women with consumptive coagulopathy also have massive hemorrhage, the second tenet of treatment is that obstetric complications such as uterine atony or lacerations must be controlled simultaneously with prompt blood and component replacement for a salutary outcome.

Treating spontaneous and induced septic abortions

Worldwide, abortion accounts for approximately 14% of pregnancy-related deaths, and septic abortion is a major cause of the deaths from abortion. Today, septic abortion is an uncommon event in the United States. The most critical treatment of septic abortion remains the prompt removal of infected tissue. Antibiotic administration and fluid resuscitation provide necessary secondary levels of treatment. Most young physicians have never treated septic abortion. Many obstetrician-gynecologists experience, or plan to experience, global health activities and will likely care for women with septic abortion. Thus, updated knowledge of the pathophysiology, clinical presentation, microbes, and proper treatment is needed to optimally treat this emergency condition when it exists. The pathophysiology of septic abortion involves infection of the placenta, especially the maternal villous space that leads to a high frequency of bacteremia. Symptoms and signs range from mild to severe. The microbes involved are usually common vaginal bacteria, including anaerobes, but occasionally potentially very serious and lethal infection is caused by bacteria that produce toxins. The primary treatment is early curettage to remove infected and devitalized tissue even in the face of continued fetal heart tones. Important secondary treatments are the administration of fluids and antibiotics. Updated references of sepsis and septic shock are reviewed.