A 33 year old lady on a Maternity Ward. Clinical information is 'Collapse
post Caesarian Section'. Serum results were:

Sodium:	121 mmol/L	(134 - 145)
Potassium:	3.6 mmol/L	(3.6 - 5.3)
Bicarbonate:	10 mmol/L	(22-31)
Urea:		2.7 mmol/L	(2.8 - 7.0)
Creatinine:	61 umol/L	(62 - 133)
Glucose:	32.8 mmol/L	(random, 3.5 - 10.0)
Albumin:	17 g/L		(35 - 49)
Globulins:	25 g/L		(17 - 35)
Adjusted calcium:	2.47 mmol/L	(2.10 - 2.55)
Phosphate:	1.16 mmol/L	(0.81 - 1.45)
Uric acid:	298 umol/L	(female, 149 - 446)
Bilirubin:	8 umol/L	(3-22)
Alkaline phosphatase:	154 IU/L	(<126)
AST:		23 IU/L		(<41)
ALT:		20 IU/L		(<56)
CK:		114 IU/L	(<230)

This Case attracted 36 participants. There was a clear consensus on a
probable explanation, and almost everyone mentioned the need for urgent
contact with the Ward. 

1 participant would check these analyses before taking further action.
[0.3]

30 participants commented iv fluid contamination/ excess IV fluids; [1.4]
2 commented diabetic ketoacidosis; [0.8]
6 queried whether this was a known diabetic patient; [0.5]
2 commented that the patient was unlikely to be diabetic if she had had
normal antenatal care; [0.8]
3 said that the albumin and alkaline phosphatase were consistent with
immediate post pregnancy. [0.3, one assessor commenting 'not the albumin']

6 were concerned about the low bicarbonate,
	4 querying severe acidosis; [0.5]
	1 suggesting that this could be a consequence of a prolonged labour, and
receiving dextrose-containing IV fluids. [0.0]

3 participants thought it important to exclude the possibility of Sheehan's
syndrome. [-1.0]

11 participants would suggest an urgent repeat with a sample taken from a
non-drip arm; [1.8]
4 would suggest urgent blood gases; [0.5]
1 would check for serum ketones on this sample with a dip-stick; [-0.3]
3 would ask for a urine sample for ketones; [0.3]
1 would ask for a urine sample for osmolality; [-0.5]
1 would ask for a sample for serum lactate; [-0.3]
2 would measure chloride on this sample and calculate an anion gap. [-0.3]

Many participants mentioned conditional possibilities, along the lines of
'If results are genuine, suggests acute ketoacidosis in a diabetic brought
on by surgical stress'. As with previous Cases, I have not included these,
since strictly speaking they are not a comment on this particular set of
results, they are a comment on the next set (and also, including
conditional possibilities makes my job almost impossible!).

I phoned the Ward, and found that the patient had been transferred to our
ITU, who sent another sample when ! contacted them (77 minutes after the
first sample was taken - how's that for a rapid turn-round?). This gave
results:

Sodium:	132 mmol/L
Potassium:	2.7 mmol/L
Glucose:	18.4 mmol/L
Albumin:	9 g/L
Globulins:	16 g/L
Haemoglobin:	10.2 g/L

A sample taken 6 hours later gave
Sodium:	135 mmol/L
Potassium:	5.3 mmol/L
Glucose 	11.4 mmol/L

The following morning, the albumin was 19 g/L; and two weeks later,
everything was within reference limits. I guess the abnormalities were
caused by a dextrose overload on top of surgical shock; but I was surprised
the albumin went so low. Blood gases were never requested.

We all know how difficult in can be to interpret results in late pregnancy
and immediate post-partum, and Raymond Wulkan was kind enough to suggest a
useful reference [Crit Rev Clin Lab Sci 1997; 34: 67 - 139]. This gives for
a wealth of analytes reference ranges through pregnancy and thereafter.

Best wishes
Gordon Challand



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