What is the probable diagnosis for a patient with hyperbilirubinemia, hypotension, and hematemesis after an emergency Lower Segment Caesarean Section (LSCS)?

Probable Diagnosis: HELLP Syndrome

The most probable diagnosis is HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets), a life-threatening complication of severe pre-eclampsia that presents with the classic triad of hyperbilirubinemia from hemolysis, hypotension from hypovolemia and potential hemorrhage, and hematemesis from coagulopathy or upper gastrointestinal bleeding. 1

Clinical Reasoning

Why HELLP Syndrome Fits This Presentation

The constellation of symptoms after emergency LSCS strongly suggests HELLP syndrome based on:

• Raised bilirubin: Results from microangiopathic hemolytic anemia with red cell destruction, producing unconjugated hyperbilirubinemia (typically >12 mg/L) 2. The peripheral blood smear would show schistocytes indicating hemolysis 1.

• Hypotension: Occurs due to relative hypovolemia (many HELLP patients are volume depleted despite appearing edematous), potential ongoing hemorrhage from coagulopathy, or progression to shock from liver dysfunction 1. The British Journal of Anaesthesia emphasizes that these patients are often critically hypovolemic requiring central venous monitoring 1.

• Hematemesis: Results from severe thrombocytopenia (platelets <100,000/mm³, often <50,000/mm³) causing coagulopathy and gastrointestinal bleeding 1, 2. The degree of thrombocytopenia correlates directly with severity of liver dysfunction 1.

Diagnostic Confirmation Required

Immediate laboratory investigations should include 1, 3:

• Complete blood count: Expect low hemoglobin (often <10 g%), severe thrombocytopenia (<100,000/mm³), and schistocytes on peripheral smear
• Liver function tests: Elevated AST (>200 U/L), ALT (>159 U/L), and LDH (>600 IU/L) with raised bilirubin
• Coagulation studies: PT, aPTT, fibrinogen, and fibrin degradation products (may be elevated >80 µg/L)
• Renal function: Creatinine, urea, and uric acid to assess for acute kidney injury
• Lactate level: >2 mmol/L indicates shock 1

Critical Management Priorities

Immediate Stabilization (First 1-2 Hours)

• Hemodynamic support: Insert central venous catheter for volume assessment and resuscitation, as these patients are typically hypovolemic despite appearing fluid overloaded 1, 4. Cautious fluid management is essential as both hypovolemia and overload are detrimental 4.

• Blood pressure control: Use IV hydralazine infusion to prevent eclampsia or intracranial hemorrhage 1, 4.

• Blood product replacement 1, 4:

  • Platelet transfusion if count <50,000/mm³ (critical for ongoing bleeding)
  • Fresh frozen plasma to correct coagulopathy, particularly after 4 units of RBC transfusion
  • Whole blood transfusion if hemoglobin <10 g%
  • Maintain 1:1 ratio of RBC:FFP if bleeding continues

• Control GI bleeding: The hematemesis requires urgent gastroenterology consultation, but correction of coagulopathy takes priority 1.

Monitoring Requirements

Transfer to high-dependency or intensive care unit with 1, 4:

• Continuous invasive arterial pressure monitoring
• Central venous pressure monitoring
• Hourly urine output measurement (insert Foley catheter)
• ECG and oxygen saturation monitoring
• Serial laboratory assessments every 4-6 hours initially

Prognosis and Evolution

• HELLP syndrome typically resolves spontaneously after delivery, but the immediate postpartum period (24-48 hours) is most dangerous 3, 2.
• Maternal mortality ranges from 2-24% depending on severity and complications 1, 5.
• Watch for life-threatening complications including eclampsia, placental abruption, DIC, pulmonary edema, acute renal failure, and subcapsular liver hematoma 2.

Important Caveats

Do not miss alternative diagnoses: While HELLP is most likely, consider:

• Acute fatty liver of pregnancy: Also causes hyperbilirubinemia and coagulopathy but typically presents with more severe hypoglycemia
• Postpartum hemorrhage with consumptive coagulopathy: Would explain hypotension and hematemesis but less likely to cause significant hyperbilirubinemia unless massive transfusion occurred 1
• Sepsis with DIC: Could produce similar picture but would expect fever and leukocytosis

Common pitfall: Failure to recognize HELLP syndrome leads to inadequate preparation for coagulation abnormalities and delayed blood product administration 4. The diagnosis is often missed initially because symptoms mimic acute cholecystitis, drug reactions, or other non-obstetric conditions 1, 3.

Critical timing: The evolution of laboratory parameters (particularly platelet count and liver enzymes) is the major prognostic factor 2. Serial monitoring every 4-6 hours is essential to guide ongoing management.