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[Massive proteinuria and HELLP syndrome]
J E Toblli1, H J Engel, I Podzun
1Hospital Alemán, Buenos Aires.
Insights
HELLP syndrome, a severe form of preeclampsia, involves hemolysis, elevated liver enzymes, and low platelets. This case highlights its challenging diagnosis and rapid deterioration, necessitating timely intervention.
Area of Science:
- Obstetrics and Gynecology
- Maternal-Fetal Medicine
- Critical Care Medicine
Background:
- HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets) is a severe obstetric complication.
- It is increasingly recognized as a variant of severe preeclampsia.
- Diagnostic challenges persist despite established criteria.
Observation:
- A 33-year-old pregnant patient at 27 weeks presented with epigastric pain, nausea, epistaxis, and mild hypertension.
- Laboratory findings included abnormal liver function tests (elevated GOT, GPT, LDH), heavy proteinuria (14.4 g/day), thrombocytopenia (92,000/mm3), and elevated bilirubin.
- The patient's condition rapidly deteriorated, leading to cesarean delivery.
Findings:
- The case illustrates the complex presentation of HELLP syndrome.
- Hepatic injury may precede the vascular and renal manifestations typical of preeclampsia.
- Endothelial microvascular injury drives platelet activation, leading to a cascade of vascular spasm and aggregation.
Implications:
- Early recognition and management of HELLP syndrome are crucial for maternal and fetal outcomes.
- Understanding the pathophysiology may improve diagnostic accuracy and treatment strategies.
- Further research into the specific mechanisms of HELLP syndrome is warranted.
Abstract:
HELLP syndrome continues to be a clinical entity of difficult diagnosis. Weinstein first defined it in 1982 giving the practicing obstetrician a sequence of useful initials (H = hemolysis; EL = elevated liver enzymes; LP = low platelets). Since then a lot has been written and it has become clear that the syndrome is a form of severe preeclampsia. The American College of Obstetrics and Gynecology does not include HELLP in the description of severe pre-eclampsia as such but does accept each of its components as being part of severe pre-eclampsia. The case presented deals with a 33 year old white female, admitted at 27 weeks gestation with nausea, epigastric pain resembling acute abdomen, nose bleeding and mild hypertension. The analysis revealed an abnormal liver profile with elevated GOT, GPT and LDH, heavy proteinuria (14.4 g/day), decreased platelet count (92000/mm3) and elevated total bilirubin. Pregnancy was terminated by cesarean section 24 hours after admission because the patient's condition was deteriorating. Obviously in pre-eclampsia/eclampsia there is a systematic injury to all tissues. Proof of this is the hypertension as a consequence of vascular spasm and proteinuria due to glomerular injury. In HELLP the sequence of events is probably altered; hepatic injury precedes vascular and renal injury of conventional preeclampsia. The syndrome results from many clinical and pathological symptoms derived from endothelial microvascular injury which determine a rapid platelet activation causing vascular spasm, platelet aggregation and further endothelial injury through a feedback mechanism.(ABSTRACT TRUNCATED AT 250 WORDS)