Recipients: None        Discharge:     Summary:  Admission Date: .07-Sep-2021 16:20:00  Discharge Date: 11-Sep-2021   Admission Reason: Acute fatty liver of pregnancy  Final Discharge Diagnoses: Acute fatty liver of pregnancy  Procedures: Date: 08-Sep-2021 05:22:00  Procedure Name: 1. Exam under anesthesia  2. JADA placement  3. Second degree perineal laceration repair  Condition at Discharge: Satisfactory  Disposition at Discharge: .Home  Vital Signs:       T   P  R  BP   SpO2  Value  36.4  72  18  127/74   99%  Date/Time 9/11 9:14 9/11 9:14 9/11 9:14 9/11 9:14  9/11 9:14  Range  (36.4C - 37C )  (62 - 72 )  (16 - 18 )  (116 - 127 )/ (74 - 78 )  (96% -  99% )  Highest temp of 37 C was recorded at 9/11 4:34  Hospital Course:   DOA: 9/7  DOD: 9/8 NSVD c/b PPH 2/2 LUS atony, hemabate, cytotec, second pit bolus, FFP  x1, Mg paused, JADA with 140cc of fluid, total EBL 800cc     Preop Hgb 14.8 -- > EBL 800cc -- > 2hr post-op hgb 13.2 -- > 14.1 -- > 13.8 -- >  13.0     28 y/o G1P1 now PPD#3 (9/11) s/p NSVD @ 38.5ga by 13 week US who initially  presented for scleral icterus and was kept for induction due to concern for  acute fatty liver or pregnancy. She denied HA, scotoma, CP, SOB, RUQ pain, ctx,  LOF, VB, or decreased FM. Her pregnancy overall had been uncomplicated. On  arrival, she had one severe range BP that resolved spontaneously. However she  continued to have mild ranges and then was also noted to have abnormal HELLP  labs (primarily elevated LFTs, Cr, t bili, and low fibrinogen). As a result,  the concern was for severe PEC vs AFLP. She received 24 hrs of magnesium for  the concern for severe preeclampsia. However, the clinical picture seemed more  consistent with acute fatty liver of pregnancy. Hepatology was consulted and  requested multiple hepatology labs. At time of delivery, patient did have  uterine atony that required hemabate, cytotec, pit bolus x2, and placement of a  JADA. After removal of the JADA, patient's bleeding was stable. Total EBL was  800ccc. She also received 2U of FFP due to her fibrinogen being 158 on  admission.     Meanwhile, the patient's blood work started to improve throughout her  postpartum period (see trends below). She was deemed stable for discharge on  PPD#3. Prior to discharge, hepatology requested an alpha-1-antitrypsin  phenotype test which will be followed up with PCP. A PCP appointment was  requested in 1-2 weeks. Patient will always have a BP check in 1 week with OB.  She was discharged home with a BP cuff.  ________________________________________________________________________________  ________     sPEC vs AFLP  -Severe range BP x1 on admission, now normotensive to mild range (including  mild range BPs > 4hr apart)  -P:C 0.94  -To trend labs q4hr  -To trend labs q4hr      -Hgb 14.8 -- > EBL 800cc -- > 2hr post-op hgb 13.2 -- > 14.1 -- > 13.8 -> 13.0  -> 15.1 -- > 12.1 (9/10)      -Plt 211 -> 205 -> 175 -> 135 -> 141 -> 161 -> 151 -> 181 -- > 139 (9/10)      -Cr 2.77 -- > 2.92 -> 2.88 -> 3.0 -> 3.02 -> 3.04 -> 2.83 -> 2.79 -- > 2.01  (9/10)      -ALT/AST 351/261 -- > 320/241 -> 273/196 -> 195/156 -> 166/149 -> 137/131 ->  132/131 -- > 63/63      -Tbili 5.4 -> 5.4 -> 4.8 -> 4.1 -> 4.8 -> 4.9 -> 4.5 -> 5.1 -- > 3.1 (9/10)      -INR 1.2 -- > 1.1 -> 1.1 -> 1.1      -Fibrinogen 158 -- > FFP x1 -- > 169 -- > FFP x1 -- > 156 -- > 162 -> 167      -Amylase: 18, Lipase: 52 9/10  -s/p 4g Mg bolus, Mg level 4.39 -- > Mg @ 1g/hr -> Mg 4.47 -> 4.55 -> 5.27 ->  6.41; finished Mg 1 g/hr at 0300 on 9/9  -RUQ US with hepatic steatosis, limited by habitus     Leukocytosis  - WBC 14 on admission ->>> 27 -- > 28 -- > 26 -> 24  - Will draw blood cx per hep rec     Blood glucose  - Glucose 50s -- > amp D50 x2 -- > D5NS @ 75cc/hr with q1hr POCTs -- > improving  90-100s  - Switch to fasting and 1 hr PP BG check     Labor Course  1830 2.5/70/-2, for pit  2100 3.5/70/-2, AROM for clear  0200 9/90/+1        Discharge Information:     and Continuing Care:  Lab Results - Pending:  Culture, Blood Drawn at 09-Sep-2021 14:36:00  Culture, Blood Drawn at 09-Sep-2021 14:34:00  Surgical Pathology Drawn at 08-Sep-2021 04:02:00  Alpha-1-Antitrypsin Phenotype, Serum Drawn at 07-Sep-2021 21:30:00  Radiology Results - Pending: None  Columbia Suicide Risk: negative  Discharge Instructions:  Activity:          Return to normal activity as tolerated     Nutrition/Diet:          Regular     Additional Orders:          Additional Instructions: pacifier use is best avoided during the initiation of  breastfeeding and used only after breastfeeding is well established.  In some  infants, early pacifier use may interfere with establishment of good  breastfeeding practices, whereas in others it may indicate the presence of a  breastfeeding problem that requires intervention.  Use of a pacifier may cause  problems with latching, and lead to decreased milk supply by missing feeding  opportunities.  Pacifiers may be used during painful procedures, but are not  otherwise recommended while the infant is learning to breastfeed.?        Follow Up Appointments:  Follow-Up - OB Provider:          Physician/Dept/Service:   OB Provider          Call to Schedule in:   1 week     Follow-Up Appointment 01:          Physician/Dept/Service:   Primary Care          Reason for Referral:   Acute fatty liver of pregnancy follow up          Call to Schedule in:   1 week     Discharge Medications: Home Medication  Pepcid 20 mg oral tablet - 1 tab(s) orally 2 times a day  ibuprofen 600 mg oral tablet - 1 tab(s) orally every 6 hours  Tylenol Extra Strength 500 mg oral tablet - 2 tab(s) orally every 6 hours  MiraLax oral powder for reconstitution - 17 gram(s) orally once a day      PRN Medication     Attestation:  Note Completion:  I am a:  Resident/Fellow  Attending Attestation I saw and evaluated the patient.  I personally obtained  the key and critical portions of the history and physical exam or was  physically present for key and critical portions performed by the  resident/fellow. I reviewed the resident/fellow?s documentation and discussed  the patient with the resident/fellow.  I agree with the resident/fellow?s  medical decision making as documented in the note.  I personally evaluated the patient on 11-Sep-2021           Electronic Signatures:    Authored: Send Summary, Summary Content, Ongoing Care, Note Completion    Authored: Ongoing Care, Note Completion   Co-Signer: Summary Content, Ongoing Care, Note Completion