HEADACHE IN PREGNANCY
A 32-year-old woman who is 34 weeks’ gestation has felt generally unwell for 24 h. She has a headache and has noticed odd visual symptoms such as ‘wobbling’ of objects. She initially felt that she had a viral infection but the symptoms are worsening and she thought she should get ‘checked out’.
She has epigastric discomfort and nausea. Her legs have been swollen for some weeks but now her hands and face are puffy. The baby has been moving normally and there is no lower abdominal pain and no bleeding or abnormal discharge.
She booked in the pregnancy at 10 weeks with a blood pressure of 107/60 mmHg. Booking blood tests and 12- and 20-week ultrasound scans were normal.
Her blood pressure is 140/85 mmHg and pulse rate 98/min. There is moderate oedema to the knees and she also appears digitally and facially oedematous. The fundi are normal.
On abdominal palpation there is mild right upper quadrant and epigastric tenderness. The uterus is not tender and symphysiofundal height measures 33 cm. The fetus is cephalic and free, with fetal parts easily felt on palpation. Patellar reflexes are normal.
· What is the likely diagnosis?
· How would you further investigate and manage this patient?
The diagnosis is HELLP syndrome (haemolysis, elevated liver enzymes and low platelets).
HELLP syndrome is part of the spectrum of pre-eclampsia, and is a serious condition with a relatively high maternal mortality (1 per cent) and perinatal mortality (up to 60 per cent). Maternal complications include placental abruption, renal failure, liver failure and disseminated intravascular coagulopathy (DIC). Fetal complications arise from prema- turity, abruption and uteroplacental insufficiency.
The diagnosis is made on the blood test results showing the relevant features of HELLP. In this case there is also pregnancy-induced hypertension and proteinuria. However these clinical features do not need to be present to make the diagnosis of HELLP syndrome.
HELLP may present antenatally or in the first few days postpartum.
The symptom of epigastric or right upper quadrant pain should always raise suspicion in a pregnant woman, as it is a sign of liver capsule stretching and may precede liver rupture.
The woman needs urgent delivery. This may be vaginal, with regular monitoring of the blood test results and proteinuria every 6 h. Hourly blood pressure should be recorded.
A clotting screen is helpful to indicate any severe risk of bleeding at delivery. If the cervix is unfavourable and the woman is nulliparous then Caesarean section may be considered, but the increased risk of associated bleeding should be borne in mind.
Fetal wellbeing should be checked with cardiotocography and possibly ultrasound for growth, liquor volume and umbilical artery Doppler. The fetal parts being easily palpable may be suggestive of oligohydramnios from uteroplacental insufficiency.
Steroids should be administered to reduce the chance of respiratory distress syndrome, though there may be insufficient time before delivery for them to the effective.
Postnatally the woman should be monitored in hospital for up to 5 days as the condition may deteriorate before recovery. Once recovery occurs it is usually complete, but there is an increased risk of pre-eclampsia (and possibly HELLP syndrome) in subsequent pregnancies.