Author | Zhang Qiaoyun
Unit | Department of Clinical Laboratory, Liuzhou Workers' Hospital
1. Preface
Working in the hospital every day, I encounter all kinds of people, and doctors sometimes have to see more than just sheriffs but also Sherlock Holmes who can "solve cases". Every clinician, like our laboratory physicians, faces the test of independent duty, and it is definitely a headache to treat a pregnant woman with coagulation dysfunction during the night shift, and it is time for the laboratory department to play its true talent. Next, I will share with you such a case that occurred in the night shift.
2. Case history
The patient, a female, 33 years old, was transferred from the emergency department of the lower hospital to our hospital for "20 weeks and 1 day of menopause, 2 days of fall"(2021-10-23).
The patient gave birth to 3 births, 1 abortion, and 1 spontaneous abortion. The patient was conceived naturally this time, and the obstetric examination during pregnancy was normal. Pregnant women accidentally fell 2 days ago caused by buttocks landing on the ground, right ankle sprain, yesterday morning the family found that there was blood on the sheets, the specific amount is unknown, no other discomfort, so they went to XX County People's Hospital, check the coagulation function is abnormal, through its hospital consultation, consider the abnormal coagulation function (DIC), it is recommended to transfer to a higher hospital. Our emergency department is proposed to "pregnancy complicated by coagulation dysfunction (DIC?" Placental abruption? "Admitted to the maternity ward.
For pregnant women during pregnancy coagulation function abnormalities, obstetricians will be highly vigilant, that night the patient specimen has not been sent to the laboratory department, the clinician will call the patient to explain that the coagulation function of the patient should be detected as soon as possible, and emphasize that the 3P test should also be fast. After putting down the phone, I thought to myself, "Looks like I've met another patient in obstetric DIC." The main test results of the patient are as follows: (Liver supplementation results)
3. Case study
After the specimen was sent to the laboratory department, I immediately centrifuged and tested, the patient FIB: 5.68g/L, DD: 1.27mg/L, FDP: 3.1ug/mL, PLT: 299×109/L, WBC: 10.90×109/L, check the medical records The pregnant woman has no lower abdominal distention and pain, no vaginal bleeding fluid, no dizziness and headache, no panic, chest tightness, no nausea and vomiting and other discomforts, according to the diagnostic criteria of DIC can basically exclude DIC.
Not DIC, what is that? It is estimated that experienced people have guessed the answer at this moment, first look at my analysis: 1. The patient's obstetric examination is normal, and the coagulation function is found abnormal for the first time, which can basically rule out congenital diseases with lack of coagulation factors. 2. Common causes of simultaneous prolongation of PT and APTT are impaired liver function and secondary vitK deficiency, etc., which can lead to multiple coagulation factor synthesis disorders, resulting in prolonged coagulation time of exogenous and endogenous pathways. The patient's liver function is normal, and no other abnormal results have been found since the obstetric examination, which can be ruled out.
The most common causes of secondary vitK deficiency are: oral warfarin anticoagulants, long-term use of certain broad-spectrum antibiotics, intestinal diseases, long-term parenteral nutrition, taking some proprietary Chinese medicines, rat poisoning, the patient does not have any organic diseases, does not take any anticoagulant drugs (patients are pregnant women can basically rule out the possibility of oral warfarin, because pregnant women usually use low molecular weight heparin), traditional Chinese medicine and antibiotics, normal diet during pregnancy, early obstetric examinations are normal, only rat poisoning can not be ruled out.
3. There are certain anticoagulant substances in the body, generally common in some with a history of surgery, blood transfusion history, autoimmune diseases, etc., the patient does not have any relevant medical history, and the anticoagulant substances that cause PT and APTT prolongation at the same time are relatively rare. After comprehensive analysis, it is speculated that it is most likely to accidentally eat food containing rat poison.
Next, we take the initiative to contact the clinic and inform: 1. The patient may be related to anticoagulant rat poisoning, it is recommended to ask the medical history in detail, be sure to pay attention to what special foods have been eaten, whether there is rat drug delivery around the home, etc. 2. It is recommended to further examine and send blood to be tested for internal and external coagulation factors before clinical treatment. 3. It is recommended to consult with relevant departments. 4. Toxicity testing may be considered if necessary.
After putting down the phone, I think the patient's poisoning process should be very secret, pregnant women usually eat carefully, consultation may not be harvested, it seems that waiting for the clinic will send a sample to detect coagulation factors. Unexpectedly, under repeated questioning by clinicians, the patient complained that he had purchased 3 packs of rat poison in the local market 1 week before admission and took them all.
It turned out to be pregnant women taking rat poison by themselves, I was a little surprised, the reasons behind it we do not need to explore, but remind us that the inspectors must use the test data to speak, can not guess out of thin air, can be boldly hypothesized but must be cautious and serious to verify. In the end, the coagulation factor was not tested clinically, combined with the current market prevalence of rat drug, considering bromine rat poisoning, treatment was given fresh frozen plasma, vitamin K1 injection to improve coagulation function and other symptomatic treatment, the patient's coagulation function quickly returned to normal, and was discharged with medicine.
Bromovirin belongs to the second generation of anticoagulant rodenticides, on the one hand, it inhibits vitamin K hydroxidate reductase and vitamin K quinone reductase, inhibits the oxidation of hydroquinone vitamin K to vitamin K 2,3-epoxide, reduces the reduction of vitamin K epoxide to vitamin K1, thereby inhibiting vitamin K circulation, blocking the γ carboxylation of coagulation factors that rely on vitamin K after translation, interfering with the liver's utilization of vitamin K, and hindering the synthesis of coagulation factors II., VII., IX., X. [1].
On the other hand, it can improve the permeability and fragility of capillaries, so that the rat bleeding is fatal, and it also has a similar effect on the human body, resulting in abnormal coagulation function, laboratory results are manifested as PT and APTT at the same time prolonged, the treatment is mainly supplemented with vitamin K1, it should be noted that the half-life of bromine rat spirit can be up to 2 months, so it should be taken for 2-3 months or more, during which attention should be paid to monitoring coagulation function.
4. Summary
This is an uncomplicated case, because the timely communication and efforts of the laboratory department and the clinic make the patient's follow-up treatment much smoother, and finally everyone is happy. In actual work, misdiagnosis and missed diagnosis of rat poisoning occur from time to time [2-3], and the treatment process of patients is quite difficult, for example, in this case, the patient failed to immediately find the cause in the first hospital, and also experienced twists and turns in the transfer. Clinicians' thinking is often from the macroscopic perspective of clinical manifestations, while the laboratory department is based on the microscopic of laboratory data, and it is our consideration to explain the reason for the increase and decrease of experimental data.
Therefore, for diseases with special laboratory results such as rat poisoning, in terms of diagnosis, the laboratory department has an advantage over clinicians, and if the laboratory department can play an advantage, starting from the experimental data and stripping away the cocoon, it can often help the clinic to fill in the gaps, and even find out the key information, so that the clinicians are suddenly enlightened in confusion. Attaching importance to the interpretation of the test results, so that the test results can really help the clinic, so that the importance of the test can be highlighted, and it is possible to improve the status of medical testing in the medical industry.
bibliography:
[1] Ling Xiang, Qiao Li. Research progress on long-acting anticoagulant rodenticide poisoning[J/CD].Chinese Journal of Critical Care Medicine (Electronic Edition),2021,14(4):339-342.
Xu Yao,Lin Limei. Diagnosis and treatment experience of a case of bromine rat poisoning misdiagnosis[J].Hainan Medicine,2017,28(19):3254-3255.
[3] Dong Jianguang, Qiu Zewu, Zhang Peng, et al. A case of acute severe bromine rat poisoning correction and treatment[J].Clinical Misdiagnosis and Mistreatment,2016,29(1):14-16.
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Note: This article is an original contribution and does not represent the new media views of laboratory medicine. When reprinting, please indicate the source and the name and unit of the original author.
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