A Pregnant Woman With Right Upper Quadrant Pain

Information sourced from BMJ:

BMJ 2016;353:i3035
[Free full-text BMJ article PDF]


Case Review

A pregnant woman with anaemia and thrombocytopenia

Muhajir Mohamed, Arsalan Mahmud

Correspondence to: M Mohamed muhajirbm@yahoo.com


A 28 year old woman who was 31 weeks pregnant attended the emergency department of our hospital with acute onset of abdominal pain in her right upper quadrant. She had undergone regular antenatal check-ups in the midwifery clinic, with no problems reported. She had no medical history of note and was not taking any drugs. She was a non-smoker and before she was pregnant she rarely drank alcohol. Her cardiovascular, respiratory, and neurological examinations were unremarkable and she had no peripheral oedema. The fetal heart sounds were normal. Her blood pressure was high (136/104 mm Hg) and her pulse was 88 beats/min. The urine protein to creatinine ratio showed no evidence of proteinuria.

A full blood screen showed a low platelet count (25×109/L; reference range 150-400), high neutrophil count (14×109/L; 2.0-8.0), low haemoglobin (94 g/L; 130-170), and raised absolute reticulocyte count (204×109/L; 50-100). Red blood cells with morphological abnormalities were seen on the blood film (fig 1) . Liver function tests showed moderately raised alanine transferase (356 U/L; 0-33) and aspartate transferase (304 U/L; 0-32), mildly deranged alkaline phosphatase and γ-glutamyl transferase values, and normal bilirubin levels. Serum lactate dehydrogenase (LDH) was high (951 U/L; 125-243) and serum haptoglobin was undetectable. A direct antiglobulin test was negative. Coagulation parameters—prothrombin time, activated partial thromboplastin time, and fibrinogen concentration—were within normal limits and D-dimer was raised. Blood glucose, serum creatinine, iron studies, vitamin B12, and folate values were within the normal ranges.

Fig 1

1. What does the blood film show?

Polychromasia, fragmented red blood cells (schistocytes), and thrombocytopenia. These features are suggestive of microangiopathic haemolytic anaemia.

2. What is the most likely diagnosis?

HELLP (Haemolysis, Elevated Liver enzymes, and Low Platelet count) syndrome.

3. What are the differential diagnoses in this patient?

Other conditions that cause thrombocytopenia, microangiopathic haemolysis, and acute liver impairment during pregnancy.

4. How do you diagnose this condition?

By the presence of microangiopathic haemolytic anaemia, abnormal liver enzymes, and thrombocytopenia in a pregnant woman with severe pre-eclampsia.

5. How should the patient be managed and what is the prognosis?

Delivery usually cures HELLP syndrome. Management includes stabilising the mother, assessing fetal wellbeing, and deciding the timing of delivery.

Patient outcome

After she was reviewed by the obstetric team in the emergency department, our patient was started on antihypertensive drugs and magnesium sulphate. Because of the imminent risk of maternal and fetal complications secondary to HELLP syndrome, emergency caesarean section was performed. After delivery her blood pressure normalised within six hours and her platelet count recovered after three days; however, LDH and liver enzymes did not return to normal until 12 days later. Soon after delivery her preterm baby was managed in the nursery for feeding difficulty and was discharged home after three weeks.

Patient consent obtained.

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