DDSEP® 8 Quick Quiz

May 2017 Quiz 2

Publish date: April 24, 2017

Q2. A consult is requested for a 32-year-old woman who is 29 weeks pregnant and has presented to the emergency department with nausea, vomiting, and right upper quadrant abdominal pain. She is afebrile, pulse 89, BP 160/105. On exam, she has mild to moderate epigastric and right upper quadrant tenderness. Her labs are notable for WBCs 13.0 x 109/L, Hgb 8.9 g/dL, platelets 55,000 x 109/L, AST 145 U/L, total bilirubin 2.1 mg/dL; PT and PTT are normal, blood glucose is 110 mg/dL.

Which of the following do you recommend to confirm the diagnosis?

Bile acid level

Peripheral blood smear

Liver biopsy

Serum lipase

Right upper quadrant ultrasound

Q2: Answer: B

Objective: Diagnose HELLP syndrome

Rationale: This patient’s presentation and laboratory findings are consistent with HELLP syndrome – the syndrome of hemolysis, elevated liver enzymes, and low platelets. HELLP is on the preeclampsia spectrum, which encompasses preeclampsia, eclampsia, and HELLP. Patients with HELLP will have hypertension (BP above 140/90), thrombocytopenia to less than 100,000/mm3 and aminotransferase levels above 70 U/L.

The diagnosis can be confirmed with an LDH (lactate dehydrogenase) greater than 600 U/L and microangiopathic hemolytic anemia on peripheral blood smear. On liver biopsy, HELLP is characterized by periportal or focal parenchyma necrosis with hyaline deposition of fibrin material in the sinusoids. However, liver biopsies are rarely performed in this setting as it likely will not change management (delivery of the fetus) and it exposes the mother and fetus to additional risks.

There is significant overlap between HELLP and acute fatty liver of pregnancy, although elevated prothrombin and partial thromboplastin time, severe hypoglycemia, and elevated creatinine are more common in acute fatty liver of pregnancy. Hypertension is more common in HELLP, and therefore this patient’s presentation is more consistent with HELLP.

Reference

1. Kia L, Rinella ME. Interpretation and management of hepatic abnormalities in pregnancy. Clin Gastroenterol Hepatol. 2013;11(11):1392-8.

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