CICM SAQ 2010.1 Q6
Question
6. A 20 year old primi-gravida presents at 37 weeks gestation with jaundice, headache, blurred vision and hypertension (140/90mmHg). The antenatal period was otherwise unremarkable. She is febrile, drowsy, pale, icteric and has pedal oedema. The uterus is palpated as for a full term pregnancy with a normal CTG trace. Examination is otherwise normal.
The following are her early blood results:
- (a) List 4 likely differential diagnoses for this clinical presentation.
- (b) What other investigations would you order for this patient and why?
- (c) List the important management interventions for each of your differential diagnoses.
Answers
Answer and interpretation
(a) List 4 likely differential diagnoses for this clinical presentation.
- Pre-eclampsia
- HELLP Syndrome
- Sepsis with DIC
- HUS-TTP
- Acute fatty liver of pregnancy
(b) What other investigations would you order for this patient and why?
- Transaminases (full liver function tests)
— Assessment of HELLP - Peripheral blood film smear
— Evidence of haemolysis or MAHA - Reticulocyte count, haptoglobins, conjugated/unconjugated bilirubin
— Haemolysis screen - Blood, sputum, urine and vaginal swab for MC&S
— Septic screen - Urinalysis – protein, WBCs, RBCs, casts
— Evidence of infection or proteinuria (pre-eclampsia) - Renal tract ultrasound
— Rule out obstruction
(c) List the important management interventions for each of your differential diagnoses.
Pre-eclampsia
- Deliver baby
- Control BP
- Hydralazine, beta blockers
- SNP/GTN if intravenous agent required.
- Prevention of seizures
- Magnesium sulphate
HELLP Syndrome
- Deliver baby
- Regular monitoring of platelet count and liver function
- Supportive measures whilst observing in HDU for dangerous complications – hepatic haemorrhage/rupture, progressive renal failure, pulmonary oedema.
- Sepsis with DIC
- Timely delivery of baby in consultation with obstetrician.
- Early broad spectrum antibiotics.
- Cardiovascular support – adequate volume resuscitation and establish a MAP > 65mmHg.
HUS-TTP
- Deliver the baby
- Fresh frozen plasma
- Therapeutic plasma exchange
- Corticosteroid therapy
- Monoclonal antibody therapy – Rituximab
Acute fatty liver of pregnancy
- Timely delivery of baby once mother stabilised
- Correction of DIC
- Supportive therapy
- Monitoring and treatment of complications post delivery eg pancreatitis
- Consideration for liver transplantation in irreversible severe liver failure despite delivery and aggressive supportive care
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Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
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