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.
Answer and interpretation
(a) List 4 likely differential diagnoses for this clinical presentation.
- HELLP Syndrome
- Sepsis with DIC
- 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.
- Deliver baby
- Control BP
- Hydralazine, beta blockers
- SNP/GTN if intravenous agent required.
- Prevention of seizures
- Magnesium sulphate
- 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.
- 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
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.