Case of the Month is a new EUSOM series: each month an interactive teaching case from obstetric medicine. Work through it step by step: think first, then click to reveal the next results. The diagnosis and discussion follow next month. The case is fictional and composed for teaching.
Step 1 – Presentation
A 32-year-old woman in her first pregnancy presents at 35+2 weeks with two days of nausea, vomiting, malaise and vague epigastric discomfort. She feels thirsty and has been passing more urine. She has no headache or visual symptoms. Her pregnancy had been uncomplicated, with normal blood pressure at the last antenatal visit two weeks ago.
On examination she is alert but looks unwell. Blood pressure 146/92 mmHg, pulse 104/min, temperature 37.4 °C. There is mild epigastric and right upper quadrant tenderness. No jaundice is obvious yet. Urine dipstick: protein 1+. CTG is reassuring.
Initial blood tests
| Test | Result |
|---|---|
| Haemoglobin | 10.4 g/dL |
| Platelets | 98 × 10⁹/L |
| White cell count | 18 × 10⁹/L |
| ALT / AST | 310 / 280 U/L |
| Creatinine | 128 µmol/L |
Question 1. What is your differential diagnosis at this point? Which additional tests would you request, and why? Make your list before you click.
Click to reveal: results of the additional tests
The team requested the following:
| Test | Result |
|---|---|
| Glucose | 3.1 mmol/L |
| Bilirubin (total) | 68 µmol/L |
| INR | 1.6 |
| Fibrinogen | 1.2 g/L |
| Antithrombin | 38% |
| Uric acid | 0.52 mmol/L |
| LDH | 620 U/L |
| Haptoglobin | 0.5 g/L |
| Blood smear | No schistocytes |
| Ammonia | 68 µmol/L |
| sFlt-1/PlGF ratio | 41 |
| Liver ultrasound | No haematoma; liver slightly bright, otherwise normal |
Question 2. Which diagnosis do you favour now? Which findings tip the balance, and which of them would also fit HELLP syndrome or a thrombotic microangiopathy? Is there a scoring system that helps you here?
Click to reveal: what happened next
Within six hours her glucose falls to 2.4 mmol/L despite a dextrose infusion, and her INR rises to 1.9. She remains alert. The fetal heart rate stays reassuring.
Question 3. What are your first management steps for mother and baby? How and when would you deliver, and what do you need to arrange before and after delivery? Which complications would you watch for in the first 72 hours postpartum?
Members’ discussion
EUSOM members can discuss this case below. Share your differential diagnosis, the tests you would add and your management plan. Log in to take part. Comments are reviewed by the EUSOM team before they appear, and we may join the discussion with questions or hints.
Not a member yet? Join EUSOM, or share your thoughts on LinkedIn and tag EUSOM.
Not a member yet? Join EUSOM, or share your thoughts on LinkedIn and tag EUSOM.
The diagnosis, the answers to all three questions and a short discussion follow next month.