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{{WBRQuestion
{{WBRQuestion
|QuestionAuthor={{Rim}}
|QuestionAuthor={{YD}} (Reviewed by Serge Korjian)
|ExamType=USMLE Step 1
|ExamType=USMLE Step 1
|MainCategory=Pathology
|MainCategory=Pathology
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|MainCategory=Pathology
|MainCategory=Pathology
|SubCategory=Reproductive
|SubCategory=Reproductive
|MainCategory=Pathology
|MainCategory=Pathology
|MainCategory=Pathology
|MainCategory=Pathology
|MainCategory=Pathology
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|MainCategory=Pathology
|MainCategory=Pathology
|SubCategory=Reproductive
|SubCategory=Reproductive
|Prompt=A 38 year old woman G3P2A0 at 34 weeks of gestation presents to the emergency department complaining of severe nausea and dull right upper abdominal pain. Her past medical history is significant for preeclampsia. Appropriate work-up shows elevated ALT and AST, thrombocytopenia, and elevated LDH and low haptoglobin. The physician informs the patient that immediate delivery of the patient is recommended. What is the most likely cause of mortality in this patient's condition?
|Prompt=A 38-year-old woman, G3P2A0, presents to the emergency department at 34 weeks gestation with complaints of severe nausea and dull right upper abdominal pain. Her past medical history is significant for preeclampsia in her previous pregnancy warranting premature delivery. On arrival, her heart rate is 94/min, blood pressure is 182/98, and temperature is 36.9 °C (98.4 °F). Initial work-up reveals thrombocytopenia, elevated ALT and AST, elevated LDH, low haptoglobin, and 4+ protein on urine dipstick. The physician informs the patient that immediate delivery of the patient is recommended. What is the most likely cause of mortality in this patient's condition?
|Explanation=The patient is most likely presenting with HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome. The disease is associated with preeclampsia and typically manifests in pregnant women between 32-34 weeks of gestation. It is considered a life-threatening form of preeclampsia. Similar to the patient's presentation, patients with HELLP syndrome typically present with right upper abdominal pain with non-specific symptoms, such as fatigue and nausea. Serum haptoglobin is important for the detection of early hemolysis. Usually an elevation in liver enzymes precedes the decrease in platelets. Patients are usually recommended to deliver as soon as the diagnosis is made when diagnosed at 32-34 weeks. The most common causes of mortality in patients with HELLP syndrome are intracranial hemorrhage and ARDS.
|Explanation=The patient in this scenario is most likely presenting with HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome. The disease is classically described as a complication of preeclampsia, despite a recent trend considering HELLP as one extreme on the pregnancy-related hypertensive disease spectrum. HELLP is a life-threatening condition that manifests in pregnant women between 32-34 weeks of gestation, classically those with diagnosed preeclampsia. Similar to this scenario, patients with HELLP syndrome present with right upper abdominal pain with non-specific symptoms, such as fatigue and nausea. Serum haptoglobin is important for the detection of early hemolysis. Usually an elevation in liver enzymes precedes the decrease in platelets. Patients who are at 32 weeks gestation or more are usually recommended to deliver as soon as the diagnosis is made. The most common causes of mortality in patients with HELLP syndrome are intracranial hemorrhage and ARDS.
 
Educational Objective:
Intracranial hemorrhage and ARDS are the most common causes of mortality in patients with HELLP syndrome.
 
Reference:
Rath W, Faridi A, Dudenhausen JW. HELLP syndrome. J Perinat Med. 2000;28(4):249-60.
 
|AnswerA=GI bleeding
|AnswerA=GI bleeding
|AnswerAExp=GI bleeding is not a very common cause of mortality in patients with HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome.
|AnswerAExp=GI bleeding is not a very common cause of mortality in patients with HELLP syndrome.
|AnswerB=Myocardial infarction
|AnswerB=Myocardial infarction
|AnswerBExp=Myocardial infarction is not a very common cause of mortality in patients with HELLP syndrome.
|AnswerBExp=Myocardial infarction is not a very common cause of mortality in patients with HELLP syndrome.
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|AnswerCExp=Uterine bleeding is not a very common cause of mortality in patients with HELLP syndrome. Uterine atony is a common cause of uterine bleeding post-delivery that may be associated with mortality.
|AnswerCExp=Uterine bleeding is not a very common cause of mortality in patients with HELLP syndrome. Uterine atony is a common cause of uterine bleeding post-delivery that may be associated with mortality.
|AnswerD=Hematologic malignancy
|AnswerD=Hematologic malignancy
|AnswerDExp=Hematologic malignancies, such as lymphomas and leukemias, are not a very common cause of mortality in patients with HELLP syndrome.
|AnswerDExp=Hematologic malignancies, such as lymphomas and leukemias, are not associated with HELLP syndrome and are not a major cause of mortality in these patients.
|AnswerE=Intracranial hemorrhage
|AnswerE=Intracranial hemorrhage
|AnswerEExp=Intracranial hemorrhage is a common cause of death in patients with HELLP syndrome.
|AnswerEExp=Intracranial hemorrhage is a common cause of death in patients with HELLP syndrome. It is thought to be due to the combination of thrombocytopenia and severe hypertension.
|EducationalObjectives=Intracranial hemorrhage and ARDS are the most common causes of mortality in patients with HELLP syndrome.
|References=Rath W, Faridi A, Dudenhausen JW. HELLP syndrome. J Perinat Med. 2000;28(4):249-60.
|RightAnswer=E
|RightAnswer=E
|WBRKeyword=intracranial, cerebral, hemorrhage, stroke, cause, of, mortality, death, pregnancy, pregnant, HELLP, syndrome, preeclampsia, pre-eclampsia, eclampsia, hypertension, high, blood, pressure, fatigue, nausea, right, abdominal, pain, upper, hemolysis, haptoglobin, LDH, low, platelet, platelets, thrombocytopenia, elevated, high, increase, increased, liver, enzyme, enzymes, AST, ALT, SGOT, SGPT
|WBRKeyword=HELLP, Syndrome, Pregnancy, Complications, Preeclampsia, Hemolysis, Thrombocytopenia, Platelets, LFTs, Liver,  
|Approved=No
|Approved=Yes
}}
}}

Revision as of 22:58, 30 August 2014
Author [[PageAuthor::Yazan Daaboul, M.D. (Reviewed by Serge Korjian)]]
Exam Type ExamType::USMLE Step 1
Main Category MainCategory::Pathology
Sub Category SubCategory::Reproductive
Prompt [[Prompt::A 38-year-old woman, G3P2A0, presents to the emergency department at 34 weeks gestation with complaints of severe nausea and dull right upper abdominal pain. Her past medical history is significant for preeclampsia in her previous pregnancy warranting premature delivery. On arrival, her heart rate is 94/min, blood pressure is 182/98, and temperature is 36.9 °C (98.4 °F). Initial work-up reveals thrombocytopenia, elevated ALT and AST, elevated LDH, low haptoglobin, and 4+ protein on urine dipstick. The physician informs the patient that immediate delivery of the patient is recommended. What is the most likely cause of mortality in this patient's condition?]]
Answer A AnswerA::GI bleeding
Answer A Explanation AnswerAExp::GI bleeding is not a very common cause of mortality in patients with HELLP syndrome.
Answer B AnswerB::Myocardial infarction
Answer B Explanation AnswerBExp::Myocardial infarction is not a very common cause of mortality in patients with HELLP syndrome.
Answer C AnswerC::Uterine bleeding
Answer C Explanation AnswerCExp::Uterine bleeding is not a very common cause of mortality in patients with HELLP syndrome. Uterine atony is a common cause of uterine bleeding post-delivery that may be associated with mortality.
Answer D AnswerD::Hematologic malignancy
Answer D Explanation AnswerDExp::Hematologic malignancies, such as lymphomas and leukemias, are not associated with HELLP syndrome and are not a major cause of mortality in these patients.
Answer E AnswerE::Intracranial hemorrhage
Answer E Explanation AnswerEExp::Intracranial hemorrhage is a common cause of death in patients with HELLP syndrome. It is thought to be due to the combination of thrombocytopenia and severe hypertension.
Right Answer RightAnswer::E
Explanation [[Explanation::The patient in this scenario is most likely presenting with HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome. The disease is classically described as a complication of preeclampsia, despite a recent trend considering HELLP as one extreme on the pregnancy-related hypertensive disease spectrum. HELLP is a life-threatening condition that manifests in pregnant women between 32-34 weeks of gestation, classically those with diagnosed preeclampsia. Similar to this scenario, patients with HELLP syndrome present with right upper abdominal pain with non-specific symptoms, such as fatigue and nausea. Serum haptoglobin is important for the detection of early hemolysis. Usually an elevation in liver enzymes precedes the decrease in platelets. Patients who are at 32 weeks gestation or more are usually recommended to deliver as soon as the diagnosis is made. The most common causes of mortality in patients with HELLP syndrome are intracranial hemorrhage and ARDS.

Educational Objective: Intracranial hemorrhage and ARDS are the most common causes of mortality in patients with HELLP syndrome.
References: Rath W, Faridi A, Dudenhausen JW. HELLP syndrome. J Perinat Med. 2000;28(4):249-60.]]

Approved Approved::Yes
Keyword WBRKeyword::HELLP, WBRKeyword::Syndrome, WBRKeyword::Pregnancy, WBRKeyword::Complications, WBRKeyword::Preeclampsia, WBRKeyword::Hemolysis, WBRKeyword::Thrombocytopenia, WBRKeyword::Platelets, WBRKeyword::LFTs, WBRKeyword::Liver
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