A 30-year-old female who is 34 weeks pregnant (G1PO) has presented with nausea and vomiting for 3 days with right upper quadrant pain. On examination she is confused, jaundiced with a blood pressure of 120/70 mmHg.
The following are results from a venous blood sample taken on admission:
Parameter |
Patient Value |
Normal Adult Range |
Sodium |
138 mmol/L |
135 - 145 |
Potassium |
3.8 mmol/L |
3.5 - 5.0 |
Urea |
15.0 mmol/L* |
3.0 - 8.0 |
Creatinine |
245 µmol/L* |
45 - 90 |
Albumin |
30 q/L* |
33 - 40 |
Glucose |
2.5 mmol/L* |
3.0 - 7.8 |
Bilirubin (total) |
142 umol/L* |
< 20 |
Alkaline phosphatase |
293 U/L* |
30 - 110 |
Aspartate aminotransferase |
99 U/L* |
< 31 |
Alanine aminotransferase |
88 U/L* |
< 34 |
y-Glutamyl transferase |
67 U/L* |
< 40 |
Lactate dehydrogenase |
180 U/L |
110 - 250 |
Uric acid |
0.72 mmol/L* |
0.15 - 0.50 |
Activated partial thromboplastin time |
45 sec* |
36 - 38 |
International normalised ratio |
2.8* |
0.9 - 1.3 |
Platelets |
123 x 109/L* |
150 - 450 |
List three likely differential diagnoses for the above clinical picture. (30% marks)
Additional Examiners‟'Comments:
Many candidates did not complete part 2.
The abnormalities are:
Thus, this is pre-eclampsia, or something along the spectrum between pre-eclampsia and HELLP syndrome. A distant third possibility is TTP-HUS, but the LDH is within the normal range, which means that there is probably no haemolysis.
Thus, the differentials might include
Such things are usually best described in the form of a table. Good articles inform the discussion, most notably the article by Guntupalli et al from the 2005 special pregnancy issue of Critical Care Medicine.
Cause | Diagnostic features | Notes and management options |
Causes of liver failure which are unrelated to pregnancy | ||
Drug-induced hepatitis |
|
|
Shock, haemorrhage |
|
|
Decompensation of pre-existing liver disease |
|
|
Causes of liver failure which are exacerbated by pregnancy | ||
Viral hepatitis |
|
|
Portal vein thrombosis |
|
|
Hepatic venous thrombosis |
|
|
Cholecystitis |
|
|
Pregnancy-related causes of liver failure | ||
Hyperemesis gravidarum |
|
|
Intrahepatic cholestasis of pregnancy (icterus gravidarum) |
|
|
Pre-eclampsia |
|
|
HELLP |
|
|
Acute fatty liver of pregnancy |
|
|
Acute hepatic rupture |
|
|
Other causes of febrile jaundiced coma with thrombocytopenia | ||
TTP/HUS |
|
|
Sepsis with DIC |
|
Chapter 64 (pp. 684) General obstetric emergencies by Winnie TP Wan and Tony Gin
Chapter 65 (pp. 692) Severe pre-existing disease in pregnancy by Jeremy P Campbell and Steve M Yentis
Pandey, Chandra Kant, et al. "Acute liver failure in pregnancy: Challenges and management." Indian journal of anaesthesia 59.3 (2015): 144.
Sahai, Shweta, and Ravi Kiran. "Acute liver failure in pregnancy: Causative and prognostic factors." Saudi journal of gastroenterology: official journal of the Saudi Gastroenterology Association 21.1 (2015): 30.
Guntupalli, Saketh R., and Jay Steingrub. "Hepatic disease and pregnancy: an overview of diagnosis and management." Critical care medicine 33.10 (2005): S332-S339.
Aggarwal, Neelam, et al. "Pregnancy and cirrhosis of the liver." Australian and New Zealand journal of obstetrics and gynaecology 39.4 (1999): 503-506.
Horowitz, Rivka S., et al. "Placental transfer of N-acetylcysteine following human maternal acetaminophen toxicity." Journal of Toxicology: Clinical Toxicology 35.5 (1997): 447-451.
Outlaw, William M., Jamal A. Ibdah, and Kenneth L. Koch. "Hyperemesis Gravidarum and Maternal Liver Disease." (2000).
Munazza, Bibi, et al. "Liver function tests in preeclampsia." J Ayub Med Coll Abbottabad 23.4 (2011): 3-5.
Manas, Kenneth J., et al. "Hepatic hemorrhage without rupture in preeclampsia." New England Journal of Medicine 312.7 (1985): 424-426.
Kang, Yun Dan. "Portal Vein Thrombosis during Pregnancy." Korean Journal of Perinatology 26.3 (2015): 245-249.
Casey, Brian M., and Susan M. Cox. "Cholecystitis in pregnancy." Infectious diseases in obstetrics and gynecology 4.5 (1996): 303-309.
McMinn, Johnny R., and James N. George. "Evaluation of women with clinically suspected thrombotic thrombocytopenic purpura‐hemolytic uremic syndrome during pregnancy." Journal of clinical apheresis 16.4 (2001): 202-209.