A 20 year old primi-gravida presents at 37 weeks gestation with jaundice, headache, blurred vision and hypertension (140/90mmHg). The antenatal period was otherwise unremarkable. She is febrile, drowsy, pale, icteric and has pedal oedema. The uterus is palpated as for a full term pregnancy with a normal CTG trace. Examination is otherwise normal.
The following are her early blood results:
|
Hb* |
80 G/L |
(115-160) |
|
Platelets* |
52 x 109/L |
(140-400) |
|
INR* |
1.8 |
(0.9-1.3) |
|
APTT* |
55 seconds |
(25-38) |
|
LDH* |
654 U/L |
(110-250) |
|
Fibrinogen* |
1.0 G/L |
(1.5-4.0) |
|
Total Bilirubin* |
51µmol/L |
(<20) |
|
Urea* |
30 mmol/L |
(3-8) |
|
Creatinine* |
298 µmol/L |
(70-120) |
|
Potassium* |
5.1 mmol/L |
(3.2-4.5) |
(a) List 4 likely differential diagnoses for this clinical presentation.
(b) What other investigations would you order for this patient and why?
(c) List the important management interventions for each of your differential diagnoses.
(a) List 4 likely differential diagnoses for this clinical presentation.
• Pre-eclampsia
• HELLP Syndrome
• Sepsis with DIC
• HUS-TTP
• Acute fatty liver of pregnancy
(b) What other investigations would you order for this patient and why?
• Transaminases (full liver function tests) Assessment of HELLP
• Peripheral blood film smear
Evidence of haemolysis or MAHA
• Reticulocyte count, haptoglobins, conjugated/unconjugated bilirubin
Haemolysis screen
• Blood, sputum, urine and vaginal swab for MC&S Septic screen
• Urinalysis – protein, WBCs, RBCs, casts
Evidence of infection or proteinuria (pre-eclampsia)
• Renal tract ultrasound
Rule out obstruction
(c) List the important management interventions for each of your differential diagnoses.
a. Pre-eclampsia
i. Deliver baby
ii. Control BP
iii. Hydralazine, beta blockers
iv. SNP/GTN if intravenous agent required.
v. Prevention of seizures
vi. Magnesium sulphate
b. HELLP Syndrome
i. Deliver baby
ii. Regular monitoring of platelet count and liver function
iii. Supportive measures whilst observing in HDU for dangerous complications – hepatic haemorrhage/rupture, progressive renal failure, pulmonary oedema.
c. Sepsis with DIC
i. Timely delivery of baby in consultation with obstetrician.
ii. Early broad spectrum antibiotics.
iii. Cardiovascular support – adequate volume resuscitation and establish a MAP > 65mmHg.
d. HUS-TTP
i. Deliver the baby.
ii. Fresh frozen plasma
iii. Therapeutic plasma exchange
iv. Corticosteroid therapy
v. Monoclonal antibody therapy – Rituximab
e. Acute fatty liver of pregnancy
i. Timely delivery of baby once mother stabilised
ii. Correction of DIC
iii. Supportive therapy
iv. Monitoring and treatment of complications post delivery eg pancreatitis
v. Consideration for liver transplantation in with irreversible severe liver
failure despite delivery and aggressive supportive care
One cannot add very much to this question.
One also cannot help but notice that it closely resembles Question 28 from the second paper of 2013.The question has been slightly altered, but otherwise it is exactly the same.
(a) List 4 likely differential diagnoses for this clinical presentation.
Pre-eclampsia is present - on the basis of the hypertension
(b) What other investigations would you order for this patient and why?
(c) List the important management interventions for each of your differential diagnoses.
For all of them, expeditious delivery of the baby.
For all of them, correction of coagulopathy
For all of them, supportive measures and observation in critical care environment
For pre-eclampsia, standard management as routine
For HELLP, no specific management
For sepsis, IV antibiotics
For TTP, plasma exchange
For acute fatty liver of pregnancy, nothing specific until they need a transplant.
Brief summaries with references:
The UpToDate links for the college's differentials are here:
Oh's Intensive Care manual: Chapter 63 (pp. 677) Preeclampsia and eclampsia by Wai Ka Ming and Tony Gin
RCOG Guidelines for the management of severe pre-eclampsia/eclampsia (2006)
Haram, Kjell, Einar Svendsen, and Ulrich Abildgaard. "The HELLP syndrome: clinical issues and management. A review." BMC pregnancy and childbirth 9.1 (2009): 8.
Geary, Michael. "The HELLP syndrome." BJOG: An International Journal of Obstetrics & Gynaecology 104.8 (1997): 887-891.