Postpartum HELLP syndrome—the case of lost battle
The 31-year-old white primipara with twin pregnancy was admitted to hospital in the 38th week of gestation with elevated blood pressure (150/100 mmHg). After receiving antihypertensive treatment blood pressure was 120/80. All laboratory variables, including plasma proteins, were within their respective reference intervals. Few hours after admission to the hospital the contractions started, and the caesarean section was performed because of vertex-transverse presentation of twins. Liveborn female and male were delivered. The postoperative course was initially inconspicuous. Four hours postpartum she experienced sudden epigastric pain. The blood pressure rose to 190/130. Laboratory findings showed haemolysis, thrombocytopenia, and an increase in serum creatinine and aminotransferases (). Intravenous magnesium sulphate was administered. Abdominal ultrasound disclosed an empty uterine cavity without placenta residue. Five hours postpartum, the patient was transferred to the intensive care unit because of poor urine output, drowsiness, and suspicion of DIC. On examination she was sleepy and disoriented. The combination of haemolysis, thrombocytopenia, and elevated liver enzymes suggested a postpartum HELLP syndrome, complicated by DIC. The patient was rehydrated, and treatment was instituted with fresh frozen plasma, red cell transfusion, fresh platelets, and kybernin P (antithrombin III). High serum urea, creatinine, and persistent anuria were compatible with acute renal failure. A high dose of furosemide failed to increase diuresis. Sixteen hours postpartum her blood pressure was 60/40 and oxygen saturation 70%. Few minutes later the patient had acute cardiac arrest, and resuscitation started. Resuscitation was successful, and normal heart action was re-established; blood pressure rose to 150/110, and oxygen saturation was 90%. Laboratory findings were deteriorated, and development of acute renal failure indicated the necessity of urgent dialysis. Following dialysis, the patient was stable, oxygen saturation 98%. Twenty hours postpartum patient developed again cardiopulmonary arrest. Despite resuscitation attempts the outcome was lethal.\nDue to the fact that death occurred in the hospital a short time after a surgical intervention, a medico-legal autopsy was ordered. An autopsy revealed oedema of the brain and lungs as well as dilatation of right and left ventricles. Hydrothorax (900 mL), hydroperitoneum (2500 mL), and hydropericardium (200 mL) were present. The field of operation of the caesarean section was unremarkable. Petechial and suffusional haemorrhages were observed under the pleura, endocardium, in the mucosae of the renal pelvis, and peritoneum of the small and large bowel. Histology revealed periportal hepatocellular necrosis, bloodless glomeruli with swollen and vacuolated intracapillary cells, as well as confluent haemorrhages in kidneys, liver, and spleen. Death was attributed to multiple organ failure due to DIC as a consequence of HELLP syndrome.