Review Question - QID 108692

The patient is most likely suffering from HELLP syndrome, which presents with hemolysis, elevated liver enzymes, and low platelets, along with hypertension and proteinuria.

In this clinical vignette, the patient's hypertension and proteinuria indicate preeclampsia, a widespread vascular disorder that usually presents in the third trimester of pregnancy. While fatigue and minimal pedal edema may be benign symptoms of pregnancy, the patient's vision changes, headaches, elevated liver enzymes, and peripheral blood smear should raise suspicion for HELLP syndrome. HELLP syndrome is considered to be a complication of preeclampsia. In HELLP syndrome, fibrin forms cross-linked networks in small blood vessels causing hemolysis and consumption of platelets. Liver enzymes are elevated due to ischemia caused by interruption of blood flow. HELLP syndrome is an obstetric emergency as it can progress to disseminated intravascular coagulation, which threatens the life of both mother and fetus.

Figure A shows schistocytes, which are a key finding indicating hemolysis that is caused by shearing of red blood cells.

Incorrect Answers:
Answer 1: Eclampsia is another complication of preeclampsia. It presents with seizures in addition to evidence of preeclampsia.

Answer 3: Gestational Hypertension is defined as new onset hypertension after 20 weeks of gestation, without proteinuria or end-organ damage.

Answer 4: Hepatorenal syndrome is the development of renal failure in patients with severe liver disease. While this patient has both elevated liver enzymes and proteinuria, HELLP syndrome is the more likely diagnosis in this pregnant patient given her symptoms of hypertension, blurred vision, hemolysis.

Answer 5: Though there are many physiologic changes of pregnancy, hemolysis, elevated liver enzymes, visual changes, and severe hypertension are very unlikely to be normal in pregnancy.

Bullet Summary:
HELLP syndrome presents in late pregnancy with Hemolysis, Elevated Liver enzymes, and Low Platelets along with symptoms of preeclampsia including hypertension and proteinuria.