BOF: 45
A 28-year-old female is admitted
to the obstetric unit. She is in her 35th week of gestation. She
complains of pain in her right upper quadrant, nausea vomiting and headache.
Since her 28th week
of gestation she has had hypertension, oedema and proteinuria. On examination
there is tenderness in the right upper quadrant, no other physical signs.
Investigations reveal:
Hb 9.5 g /dL
The blood film shows deformed
red cells
Platelet count 75 x 109/l
LDH 650 u/l
AST 165 IU/l
Serum bilirubin 55
mmol/L
In this patient the best course
of action would be:
a)
Urgent delivery of the baby by caesarean section
b)
Low dose aspirin
c)
Corticosteroids
d)
Plasma volume expansion
e)
Vasodilatation
Answer:
a)
This patient has per-ecclampsia. The definition of
pre-ecclampsia is the development of hypertension, oedema and proteinuria
following the 20th week of gestation.
This patient has developed haemolysis, elevated liver
enzymes and low platelets on a background of pre-ecclampsia.
She has the HELLP syndrome (Haemolysis, Elevated Liver
enzymes, Low Platelets).
This usually resolves after delivery of the baby hence the
mainstay of treatment is prompt delivery.
If the period of gestation is not advanced medical
treatments may be used to try and gain time for the foetus to mature and thus
improve foetal outcome. Regimens used have been plasma volume expansion, low
dose aspirin, vasodilatation and corticosteroids. There is little trial based
evidence to support these regimes.
If the HELLP syndrome is advanced or complicated by organ
failure then treatment of these complications with intensive care facilities
should precede delivery. Hypoxia, seizures, fluid imbalance, hypertension and
coagulopathy should be corrected prior to delivery.
Dexamethasone may be used to promote maturity of the foetal
lung and alleviate the HELLP syndrome. This is based on experience not on
trials.
Last Updated: 30/04/06
