Case 82: Headache in pregnancy

 CASE 82: HEADACHE IN PREGNANCY

History

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.

Examination

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.

INVESTIGATIONS

Normal range for

pregnancy

Haemoglobin 9.3 g/dL 11–14 g/dL

Packed cell volume 42% 31–38%

Mean cell volume 81 fL 74.4–95.6 fL

White cell count 6.0×109/L 6–16×109/L

Platelets 97×109/L 150–400×109/L

Sodium 139 mmol/L 130–140 mmol/L

Potassium 4.2 mmol/L 3.3–4.1 mmol/L

Urea 4 mmol/L 2.4–4.3 mmol/L

Creatinine 83 mmol/L 34–82 mmol/L

Alanine transaminase 172 IU/L 6–32 IU/L

Alkaline phosphatase 238 IU/L 30–300 IU/L

Gamma glutamyl transaminase 26 IU/L 5–43 IU/L

Bilirubin 37 mmol/L 3–14 mmol/L

Albumin 26 g/dL 28–37 g/L

Urate 0.38 mmol/L 0.14–0.38 mmol/L

Urinalysis: protein +

Questions

• What is the likely diagnosis?

• How would you further investigate and manage this patient?100 Cases in Obstetrics and Gynaecology

232

ANSWER 82

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 prematurity, 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.

Investigation and management

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 be 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.

KEY POINTS

• HELLP syndrome is a very serious condition and requires urgent delivery.