A 20-year-old primigravida presents at 37 weeks gestation with jaundice, headache, blurred vision and hypertension (140/90 mmHg). 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:
Parameter |
Patient Value |
Normal Adult Range |
Hb |
80 G/L* |
115 – 160 |
Platelets |
52 x 109/L* |
140 – 400 |
International Normalised Ratio |
1.8* |
0.9 – 1.3 |
Activated Partial Thromboplastin Time |
55 seconds* |
25 – 38 |
Lactate Dehydrogenase |
654 U/L* |
110 – 250 |
Fibrinogen |
1.0 G/L* |
1.5 – 4.0 |
Total Bilirubin |
51 micromol/L* |
< 20 |
Urea |
30 mmol/L* |
3 – 8 |
Creatinine |
298 micromol/L* |
70 – 120 |
Potassium |
5.1 mmol/L* |
3.2 – 4.5 |
a) List four likely diagnoses for this clinical presentation.
b) For each of your differential diagnoses:
a)
b)
Pre-eclampsia
HELLP Syndrome
Sepsis with DIC
HUS-TTP
Acute fatty liver of pregnancy
This question closely resembles Question 6 from the first paper of 2010.
The college has yielded five differentials, each of which deserve a whole chapter dedicated to them.
There is little to add to the sufficently detailed yet concise college answer.
One must remember that in most of these conditions, the key step is to deliver the baby.
The one critical investigations for each differential would be...
A more complete list:
Cause | Diagnostic features | Notes and management options |
Causes of liver failure which are unrelated to pregnancy | ||
Drug-induced hepatitis |
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Shock, haemorrhage |
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Decompensation of pre-existing liver disease |
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Causes of liver failure which are exacerbated by pregnancy | ||
Viral hepatitis |
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Portal vein thrombosis |
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Hepatic venous thrombosis |
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Cholecystitis |
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Pregnancy-related causes of liver failure | ||
Hyperemesis gravidarum |
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Intrahepatic cholestasis of pregnancy (icterus gravidarum) |
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Pre-eclampsia |
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HELLP |
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Acute fatty liver of pregnancy |
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Acute hepatic rupture |
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Other causes of febrile jaundiced coma with thrombocytopenia | ||
TTP/HUS |
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Sepsis with DIC |
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The UpToDate links for the college's differentials are here: