Question 21.1

A 28-year-old 35-week pregnant woman presents to the Emergency Department with acute onset epigastric pain. The biochemical profile and haematology report are as follows:

Parameter	Result	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	22 – 27
Urea	4.3 mmol/L	3.0–8.0
Creatinine	0.07 mmol/L	0.07 – 0.12
Calcium	2.35 mmol/L	2.15 – 2.6
Corrected Calcium	2.53 mmol/L	2.15 – 2.8
Phosphate	2.75 mmol/L*	0.7 –1.4
Magnesium	0.8 mmol/L	0.7 –1.0
Glucose	4.7 mmol/L	3.6 –7.7
Albumin	36 G/L	33 – 47
CK	71 U/L	<160
Total Bilirubin	40 micromol/L*	4 – 20
GGT	45 U/L	0 – 50
ALP	185 U/L*	40 – 110
LDH	748 U/L*	110 – 250
AST	241 U/L*	<40
ALT	189 U/L*	<40

Haemoglobin	88 G/L*	110 – 160
White Cell Count	12.4 x 109/L	4.0 –15.0
Platelets	64 x 109/L*	150 – 400

What is the most likely diagnosis?
Give two additional tests that would support your diagnosis

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College Answer

HELLP syndrome

Haptoglobins – low
Blood film showing evidence of haemolysis

Discussion

The diagnosis and management of HELLP syndrome is well covered elsewhere.

The things to look for:

Blood film shows fragmented RBCS - schistocytes
There is a raised reticulocyte count
The unconjugated bilirubin fraction increases
The haptoglobin decreases (as haptoglobin/hemoglobin complexes are removed)

Thus, one would order the following tests:

Blood film
Reticulocyte count
Unconjugated fraction of bilirubin
Haptoglobin

References

Oh's Intensive Care manual: Chapter 63 (pp. 677) Preeclampsia and eclampsia by Wai Ka Ming and Tony Gin

Haram, Kjell, Einar Svendsen, and Ulrich Abildgaard. "The HELLP syndrome: clinical issues and management. A review." BMC pregnancy and childbirth 9.1 (2009): 8.

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