Obstetric Emergencies, can you help Lauren?
You are working in ED and have received a call from Pathology regarding blood results that you took earlier on Lauren, who is 18 years old and 30 weeks pregnant with her first child.
Lauren presented earlier in the day with her partner complaining of “feeling unwell” with upper abdominal pain and a headache. Her blood pressure was 130/90 on admission and is now 145/95. Pathology informs you that Lauren’s LFTs (liver function tests) are high, and her platelets are low.
What may be causing Lauren’s abnormal blood results?
Lauren’s blood results indicate that she has HELLP syndrome, a life threatening obstetric emergency.
HELLP syndrome is so named due to the triad of characteristics of the syndrome which are Haemolysis, Elevated Liver enzymes, and Low Platelets, although it may be complete or incomplete (only one or two criteria met).
It is often considered a variant of pre-eclampsia, with similar clinical symptoms. The diagnostic criteria for HELLP is haemolysis, increased LDH (> 600 U/L), increased AST (>or= 70 U/L) and low platelets (< 100 x 10(9)/L).
Complications for the mother include liver or cerebral infarction, abruptio placentae, severe postpartum haemorrhage, subcapsular liver haematoma, intracerebral or brainstem haemorrhage and/ or DIC, with a 1-2% mortality. Risks for the baby include abruptio placentae, preterm delivery, or foetal demise in utero.
HELLP syndrome usually presents in the third trimester but may occur up to 7 days post delivery. Postpartum onset of HELLP has a higher risk of Acute Pulmonary Oedema (APO) and Acute Kidney Injury (AKI).
HELLP syndrome may be difficult to diagnose as the typical signs of pre-eclampsia may not be apparent. Symptoms may include one or more of the following:
- Epigastric or substernal pain, particularly RUQ
- Dyspnoea
- Nausea, vomiting, or indigestion
- Headache not relieved by paracetamol
- Shoulder pain or pain with deep inspiration
- Bleeding
- Blurred vision, diplopia, seeing flashing lights or auras
- Oedema particularly face or hands
- Polyuria
Investigative signs include:
- Hypertension
- Proteinuria
- Elevated LFT’s – bilirubin, AST, ALT, LDH
- Low platelets
- Normal PT, APTT and coag screen
- Haemolysis on blood film
Management and treatment includes:
- Delivery of the baby if HELLP syndrome occurs after the 34th gestational week or if foetal and/or maternal conditions deteriorate
- Consider HDU/ ICU admission
- Antihypertensives - consider invasive monitoring
- IV MgSO4 IV for eclamptic seizure prophylaxis
- IV corticosteroids for foetal lung maturity
- Recognise and treat complications
Related courses
Critical Bytes: Obstetric Emergencies webinar
References
ACI. (2024). Pre eclampsia and eclampsia.Emergency Care Institute. https://aci.health.nsw.gov.au/networks/eci/clinical/clinical-tools/obstetrics-and-gynaecology/pre-eclampsia-and-eclampsia. Date accessed: 10 Apr 2024
LEE, R., AJAY, B.The Unusual Presentation of HELLP Syndrome. Journal of Clinical Gynecology and Obstetrics, North America, 8, dec. 2019. Available at: https://jcgo.org/index.php/jcgo/article/view/605. Date accessed: 10 Apr 2024
Nickson, C. (2020). HELLP Syndrome. Life in the Fast Lane. Date accessed: 10 Apr 2024
Pe-eclampsia Foundation. (2022). https://www.preeclampsia.org/ Date accessed: 10 Apr 2024
Jenny Browne, RN, Cert IV (TAE), CritCareCert, MN(AdvClinEd), has an extensive background in critical care nursing and education. Jenny has worked across a variety of Australian ICUs, including the John Hunter Hospital (Newcastle), Princess Margaret Hospital (Perth) and the Royal Adelaide Hospital. She has been an ALS and PALS instructor for over 12 years, including with the ACCCN, and is also a sessional academic at the University of Newcastle.
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