Emma presented to the Birthing Unit at 9.00pm with epigastric pain. She was 39 weeks 1 day gestation in her
first pregnancy. There was no uterine tenderness of pain, no uterine contractions, and no vaginal bleeding. She was otherwise well. Her baby’s heart rate pattern (CTG) was normal. Her blood pressure was 154/81 she had 3+ of protein on urinalysis. I was contacted. I prescribed Endone for the pain and drove to the hospital to assess her.
The epigastric pain was a lot less when I arrived and assessed her. I was concerned about preeclampsia with consideration of her borderline elevation of blood pressure and proteinuria. I requested preeclampsia blood tests and an ultrasound scan assessment of her baby the next morning.
The next morning her blood pressure was 124/55. Emma was feeling a lot better. The midwife phoned me about discharge. The blood results were not yet available. I suggested we wait for them and her ultrasound before deciding about discharge.
30 minutes later I was phoned to advise me her platelet count was 44 x 10^9/L (normal 150 -450 x 10^9/L). The other results were not yet available. This prompted concern that she had HELLP Syndrome. HELLP (Haemolysis, Elevated Liver enzymes and Low Platelets) syndrome is a life-threatening pregnancy complication which is usually considered to be the most severe form of preeclampsia. HELLP syndrome can be difficult to diagnose, because all of the typical signs of preeclampsia may not be apparent. For instance, Emma was now clinically well and her blood pressure was not elevated over night and was now normal at 124/72. I prescribed the oral steroid prednisolone (50mg) in view of the moderately severe thrombocytopenia.
The rest her blood results came through and were abnormal. She had an elevated uric acid (0.49 mmol/L), which is the most common indication of a preeclampsia problem, and elevated liver enzymes. I arranged for further blood tests to be repeated. Now her platelet count was 48 x10^9/L. The increase in her platelet count may have been due to the high dose of steroid administered to her. Her D-Dimer level was elevated at 7.07mg/L, consistent with a clotting problem and HELLP Syndrome. Her clotting studies were normal.
The picture now emerged that she had HELLP Syndrome and so would need delivery that day. It was too dangerous for her and her baby to continue the pregnancy. I discussed her condition with the haematologist.
I discussed the situation with Emma and her husband in detail. I advised Emma she will need to be delivered that day by Caesarean section under a general anaesthetic. Emma understood and reluctantly agreed.
Her cervix was long and closed. For a vaginal delivery she would need prostaglandin ripening of her cervix. That would take hours. She would not be able to have an epidural in labour. She was too unwell and unstable to go through what could be long difficult labour. As well her baby most likely would not cope with labour contractions.
On the advice of the haematologist, she was given a bag of platelets in the hour before the Caesarean section. While there were no clinical suggestions of imminent eclampsia (fitting or seizures with preeclampsia), she was commenced on the magnesium sulphate regime to minimise the risk of this possibility. I arranged for an experienced obstetrician colleague to assist me with the operation.
The Caesarean section operation proved uneventful with the measured blood loss being no more than usual. We were very careful to achieve haemostasis (stopping internal bleeding). She was given three different oxytocic agents to make sure her uterus remained contacted after delivery. I inserted two internal drains. One was just outside the uterus outer skin (peritoneum) where it had been sutured close. The other was below the two lines of sutures inserted to close her subcutaneous fat.
Emma’s daughter Georgia was born in good condition and did well.
Emma was transferred to the ICU unit after the Caesarean section. Her haemoglobin level fell to 72 g/L. There was no evidence of internal bleeding and there was not excessive blood in the drain bags. Her ferritin (iron) level was elevated at 303 ug/L (normal 15 – 200). This was consistent with the fall in haemoglobin and her anaemia being due to haemolysis (breakdown of red blood cells), which is one of the HELLP Syndrome developments. Her platelet count was now 88 x 10^9/L. Her liver function enzymes were less elevated.
In ICU she was a commenced on a labetalol antihypertensive regime, as her blood pressure started to rise.
On the second postdelivery day Emma was transferred to the postnatal ward. She continued to improve. Her drains, bladder catheter and then her intravenous line were removed. She was discharged home on the 6th post-delivery day. Her last platelet count was almost in the normal range at 144 x 10^9/L and her ferritin was 176 ug/L.
Three weeks after delivery I was able to stop her antihypertensive. Emma felt well. Her platelet count was normal at 316 x 10^9/L and her liver function was normal.
It was an unusual presentation of this life-threatening adverse development of pregnancy. While the blood tests were not done until early in the morning after her evening presentation, if the blood tests had not been ordered by me the night that she arrived they may not have been done. After all, she was clinically well with no pain and with normal blood pressure readings overnight. She could have been discharged home without any knowledge of the underlying pathology. She and /or her baby could even died at home. If she had been managed by a more junior and less experienced obstetrician or as a public patient this sadly could have been the scenario.
