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24. HELLP Syndrome: “I Need Somebody HELLP, Not Just Anybody…”
Keywords
HELLPThrombotic microangiopathyPregnancyCase
Pregnant, Hypertensive, and in Pain
Pertinent History
A 32-y/o G4P3 EGA 33-week patient presented to the ED with 3 days of epigastric discomfort, malaise, and nausea. She recently moved to the area and had no documented OB visits for this pregnancy but stated that her last three pregnancies were unremarkable. Her pain in the epigastric region, dull and nonradiating, had been getting worse. She reported that her nausea did not resolve with ondansetron at home. She denied other GI symptoms. She tolerated oral fluids this morning. She reported mild headache for the last 2 days and denied neck pain, trauma, fever, photophobia, or weakness.
Pertinent Physical Exam
Except as noted below, the findings of the complete physical exam are within normal limits.
Vitals: HR 92 beats per minute, BP 132/90 mmHg, RR 22, SaO2 96% on RA, afebrile.
General: Sitting in bed, appears uncomfortable.
Cardiac, pulmonary, and neurological exams were unremarkable.
Abdominal exam showed normal BS, tenderness in epigastrium and RUQ, negative Murphy’s sign, and no rebound or guarding.
Generalized edema is noted.
Fetal heart tones on Doppler were within normal limits.
PMH
GERD, iron-deficiency anemia, G4P3000
SH
Denies use of alcohol, tobacco, and other recreational drugs
FH
Hypertension in both mother and father
Pertinent Test Results
Test | Result | Units | Normal range |
|---|---|---|---|
WBC | 12.3 | K/μL | 3.8–11.0 103/mm3 |
Hgb | 11 | g/dL | (Male) 14–18 g/dL (Female) 11–16 g/dL |
Platelets | 45 | K/μL | 140–450 K/μL |
Sodium | 140 | mEq/L | 135–148 mEq/L |
Potassium | 4.9 | mEq/L | 3.5–5.5 mEq/L |
Chloride | 103 | mEq/L | 96–112 mEq/L |
Bicarbonate | 24 | mEq/L | 21–34 mEq/L |
BUN | 20 | mg/dL | 6–23 mg/dL |
Creatinine | 1.85 | mg/dL | 0.6–1.5 mg/dL |
Glucose | 98 | mg/dL | 65–99 mg/dL |
ALT | 140 | IU/L | 8–32 IU/L |
AST | 160 | IU/L | 6–21 IU/L |
Alk Phos | 88 | IU/L | 32–110 IU/L |
Total Bili | 1.3 | mg/dL | 0.2–1.4 mg/dL |
INR | 1.0 | – | ≤1.1 |
LDH | 1586 | U/L | 50–150 U/L |
Emergency Department Management
High-flow O2 was initiated with improvement of SpO2 to 100%; 2 units of platelets was given in anticipation of C-section, and the repeat platelet count was 75 K/μL. Antihypertensive medications were held due to consistent SBP < 150 mmHg. Six grams of magnesium sulfate were given, followed by a 2 g/h infusion. OB was consulted emergently.
Updates on ED Course
OB evaluated the patient and recommended immediate delivery. OB anesthesia was consulted for neuro-axial anesthesia and epidural was inserted. The patient was taken emergently to the OR for C-section.
Learning Points
Priming Questions
- 1.
At what stages of pregnancy can HELLP present?
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