Acute subdural haemorrhage in the postpartum period as a rare manifestation of possible HELLP (haemolysis, elevated liver enzymes, and low-platelet count) syndrome: a case report.

Malitha Patabendige

doi:10.1186/1756-0500-7-408

Abstract

BackgroundThe HELLP syndrome (haemolysis, elevated liver enzymes, and low-platelet count) occurs in about 0.5 to 0.9% of all pregnancies. With occurrence of thrombocytopaenia, it signals for several potentially lethal conditions such as complete or partial HELLP syndrome, thrombotic thrombocytopaenic purpura and acute fatty liver of pregnancy.Case presentationA previously healthy 27-year-old, Sinhala ethnic primigravida with pregnancy-induced hypertension was admitted at 38 weeks of gestation with lower abdominal pain and a blood pressure of 140/90 mmHg. She underwent emergency Caesarian section due to faetal distress giving birth to a healthy baby girl. Since postpartum day one, she was having intermittent fever spikes. All the routine investigations were normal in the first three weeks. Platelet count started dropping from post-partum day-20 onwards. On day-23, she had developed a seizure and computed tomography scan brain showed a subdural haemorrhage. She had a platelet count of 22,000 × 109/liter and was managed conservatively. She also had elevated liver enzymes, lactate dehydrogenase and bilirubin levels. Blood picture on day-24 showed haemolytic anemia. On day- 36, patient again developed seizures and she was having intermittent fever with generalized headache and signs of meningism. Computed tomography scan revealed an acute on chronic subdural haemorrhage.ConclusionsHypertensive disorders in pregnancy should be managed as high-risk throughout the postpartum period. Development of thrombocytopaenia can be considered as an early warning sign for HELLP, thrombotic thrombocytopaenic purpura or acute fatty liver of pregnancy which are lethal conditions. Prompt recognition of intracranial haemorrhages and early neurosurgical intervention is lifesaving.

Highlights

The HELLP syndrome occurs in about 0.5 to 0.9% of all pregnancies
Hypertensive disorders in pregnancy should be managed as high-risk throughout the postpartum period
Development of thrombocytopaenia can be considered as an early warning sign for HELLP, thrombotic thrombocytopaenic purpura or acute fatty liver of pregnancy which are lethal conditions

Summary

Conclusions

In this case differential diagnosis includes HELLP syndrome, AFLP and TTP [3,5]. AFLP is very rare and has very poor prognosis with an estimated maternal mortality of 12.5%–18% [6]. It’s reported that HELLP syndrome has resulted in a fatal intracranial haemorrhage during the perinatal period of a primigravida in Japan in 2009 [11]. There was another case of HELLP syndrome with disseminated intravascular coagulation resulting in a lethal pontine haemorrhage followed by maternal death [4]. Subdural haemorrhage leading to fever was not frequently reported in literature unless it’s an infected haematoma associated with meningitis [24] It is more common in elderly patients [24]. Development of thrombocytopaenia should be considered as a sign of alarm in postpartum mothers because it can be one of the many lethal conditions causing maternal death such as HELLP, TTP or AFLP etc. Authors’ information Dr Malitha Patabendige MBBS (Hons), Medical Officer, University Obstetrics Unit, De Soysa Hospital for Women, Colombo, Sri Lanka

Background

Findings

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