Introduction
Preëclampsia is diagnosed by raised blood pressure occurring after 20 weeks’ gestation, and involvement of one or more organ systems, including renal, haematological, hepatic and neurological; also, the developing fetus1. Preëclampsia in Australia, affects ~3% of pregnancies2. It increases maternal and perinatal mortality and morbidity, with HELLP Syndrome, a well-documented sequela of severe preëclampsia.
Case Description
Miss M, a 16y.o G1P1, Aboriginal girl at 39 weeks with confirmed preeclampsia, diagnosed by hypertension and urine protein creatinine ratio of 483, prompting induction of labour. This resulted in an emergency caesarean section, whilst on magnesium sulfate for signs of neurological involvement and systolic blood pressures >160, for failure to progress at 4cm. Miss M was transferred from her regional facility on day 4 postpartum in a stable condition, after routine preeclampsia monitoring and treatment, to her local rural facility for mother crafting and ongoing blood pressure monitoring. On day 5 she developed lethargy, pyrexia, tachycardia, worsening hypertension and a unilateral swollen face. Given the limited resources available, investigations conducted with biochemistry, being available the following day revealed anaemia, thrombocytopaenia, elevated creatinine and mild elevated transaminases. A clinical suspicion of postpartum HELLP syndrome was made. The high mortality and morbidity of this condition and potential for rapid deterioration necessitated her transfer back to the regional centre for observation, investigation, diagnosis and treatment.
Discussion
This case vignette highlights the diagnostic and logistical dilemmas, especially for rural patients dealing with delayed results, minimal resource setting and inter-hospital transfer of a serious obstetric medical complication. The disease spectrum resulting from severe preëclampsia with HELLP syndrome shows overlap with other diseases that can threaten the lives of both mother and foetus, if not yet delivered. These include thrombotic thrombocytopenic purpura, haemolytic uraemic syndrome (secondary or atypical), acute fatty liver of pregnancy, systemic lupus erythematosus and antiphospholipid syndrome3,4. Therefore, an accurate diagnosis is important, for prompt management while avoiding delays.