Case #034

Upper abdominal pain in the third trimester is the presentation that gets mistaken for indigestion, and the antenatal record is what reframes it: blood pressure rising across successive visits with new proteinuria is pre-eclampsia, and the headache and visual flashes mark it as severe. HELLP is its haematological expression, and all three components are on the sheet. Haemolysis shows as schistocytes with a raised LDH and bilirubin and an unrecordable haptoglobin, the liver enzymes are several times normal, and the platelets are low. The second panel exists to kill the mimics, because each is treated differently. Normal prothrombin time, APTT and fibrinogen exclude disseminated intravascular coagulation, in which the clotting screen is deranged. A negative Coombs excludes autoimmune haemolysis. ADAMTS13 activity well above 10% excludes thrombotic thrombocytopenic purpura, which otherwise looks nearly identical and would need plasma exchange rather than delivery. Normal glucose and ammonia argue against acute fatty liver of pregnancy, where hypoglycaemia and coagulopathy dominate. The right upper quadrant pain comes from stretching of the liver capsule, and its worsening matters: subcapsular haematoma and hepatic rupture are the feared complications. Nothing reverses HELLP except delivery, and at 35 weeks, with platelets down to 58, transaminases still climbing and reduced variability on the trace, there is no argument left for waiting. Magnesium sulfate runs for seizure prophylaxis, and the pressure is brought below 160/110 with labetalol or nifedipine to prevent maternal stroke. Platelets are transfused only if the count falls very low or surgery is planned. The 48 hours after delivery still need watching, because the counts and liver enzymes characteristically worsen before they turn.