A 34 year old lady who is 34 weeks pregnant presents with acute onset epigastric pain. The plasma biochemistry and the haematology report are provided.

Test

Normal Range

Sodium           138 mmol/L

135-145

Potassium        4.4 mmol/L

3.2-4.5

Chloride         102 mmol/L

100-110

Bicarbonate      27 mmol/L

17-28

Anion Gap        9 mmol/L

5-15

Creatinine       66 micromol/L

50-100

Urea             4.3 mmol/L

1.0-5.0

Tot Protein      76 H g/L

55-75

Albumin          36 g/L

28-38

Calcium          2.35 mmol/L

2.00-2.50

Ca Alb Cor       2.53 H mmol/L

2.00-2.50

Phosphate        1.03 mmol/L

0.7-1.4

Magnesium        0.8 mmol/L

0.7-1.0

Glucose          4.7 mmol/L

3.6-7.7

CK Total         71 U/L

<160

LD               748 H U/L

100-200

AST              241 H U/L

10-45

ALT              189 H U/L

5-45

GGT              45 U/L

10-70

ALP              185 H U/L

65-180

Bilirubin Total        40 micromol/L

<20

WCC              12.4 ^9/L
Hb               88 g/L
Plat             64L x10^9/L

4.0-15.0
110-160
150-400

1. What is the most likely diagnosis?

2. What 2 additional tests will support your diagnosis?

3. List 4 treatment options

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College Answer

1. What is the most likely diagnosis? HELLP

2. What 2 additional tests will support your diagnosis?

Haptoglobins : low
Blood film showing evidence of hemolysis

3. List 4 treatment options

  • Delivery of baby
  • Steroids
  • Antihypertensives
  • Magnesium sulphate
  • Plasma exchange

Discussion

1) This is HELLP syndrome. The platelets are low, the LDH is high, and there is raised bilirubin.

2) a blood film, reticulocyte count and serum haptoglobin would support this diagnosis

3) There is no specific management strategy for HELLP; delivery of the baby is the only "curative" procedure. Contrary to the college answer, neither plasma exchange nor corticosteroids have been show to improve maternal morbidity or mortality.

HELLP is discussed at lengths elsewhere.