A pregnant lady with 34 weeks of amenorrhea has the following findings: LDH- 700 IU/L, platelets – 75,000/mm3, serum bilirubin- 1.5mg/dL, SGOT-200 U/L, SGPT-150U/L, and BP -140/96 mm Hg. Her coagulation profile and renal function tests are normal. What is the diagnosis? LDH- Lactate dehydrogenase SGOT- Serum glutamic-oxaloacetic transaminase / AST- Asparate transaminase SGPT- Serum glutamic pyruvic transaminase / ALT- Alanine transaminase

Correct Answer: C. HELLP syndrome

HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets) is a life-threatening variant of severe preeclampsia occurring in 0.1–0.6% of pregnancies, typically in the third trimester (>34 weeks). The clinical presentation here is pathognomonic: thrombocytopenia (75,000/mm³), elevated transaminases (AST 200, ALT 150), elevated LDH (700), and hypertension (140/96). The normal coagulation profile and renal function exclude DIC and acute kidney injury, respectively. HELLP syndrome causes microangiopathic hemolytic anemia (evidenced by elevated LDH and indirect hyperbilirubinemia at 1.5 mg/dL), hepatic endothelial injury (transaminitis), and platelet consumption (thrombocytopenia). The diagnosis is confirmed by the Mississippi classification criteria: platelet count <100,000/mm³, AST/ALT >2× upper limit of normal, and LDH >600 IU/L. This patient meets all three criteria. Per Indian obstetric guidelines (FOGSI), HELLP syndrome requires immediate delivery regardless of gestational age, as maternal mortality approaches 1–2% and fetal mortality 7–10% if untreated. The normal renal function and coagulation profile distinguish this from fulminant hepatic failure or acute fatty liver, which would show coagulopathy and elevated creatinine.

Why the other options are wrong

A. Intrahepatic cholestasis — Intrahepatic cholestasis of pregnancy (ICP) presents with pruritus and elevated alkaline phosphatase/GGT, not significant transaminitis or thrombocytopenia. LDH is normal in ICP. The marked elevation of AST/ALT (200/150) and severe thrombocytopenia (75,000) are incompatible with ICP, which does not cause hemolysis or platelet consumption. This is a common NBE trap using liver enzyme elevation to misdirect. B. Viral hepatitis — Viral hepatitis causes marked transaminitis but does NOT cause thrombocytopenia or hemolysis (elevated LDH with hyperbilirubinemia pattern). Platelet count remains normal unless there is concurrent DIC or splenomegaly. The constellation of hemolysis + thrombocytopenia + hypertension in pregnancy is pathognomonic for HELLP, not viral hepatitis. Viral hepatitis also lacks the hypertensive component. D. Acute fatty liver of pregnancy — Acute fatty liver of pregnancy (AFLP) is a rare, fulminant condition presenting with severe coagulopathy (prolonged PT/INR), elevated creatinine, and hypoglycemia—all absent in this patient. AFLP typically occurs in the third trimester but is accompanied by DIC and acute renal failure. Normal coagulation profile and renal function exclude AFLP. Thrombocytopenia in AFLP is secondary to DIC, not primary platelet consumption as in HELLP.

High-Yield Facts

Mnemonics

HELLP = Hemolysis + Elevated Liver enzymes + Low Platelets Hemolysis (LDH >600, indirect bilirubin ↑, schistocytes), Elevated transaminases (AST/ALT >2× ULN), Low Platelets (<100,000/mm³). Use when you see thrombocytopenia + transaminitis + hypertension in third-trimester pregnancy. HELLP vs AFLP: 'HELLP has normal coags, AFLP has DIC' HELLP = thrombocytopenia from consumption, normal PT/INR. AFLP = thrombocytopenia from DIC, prolonged PT/INR + AKI. This single discriminator (coagulation profile) separates the two life-threatening third-trimester liver syndromes.

NBE Trap

NBE pairs elevated liver enzymes with pregnancy to lure students toward viral hepatitis or cholestasis, but the combination of hemolysis (LDH + bilirubin) + thrombocytopenia + hypertension is pathognomonic for HELLP and absent in other hepatic disorders of pregnancy.

Clinical Pearl

In Indian obstetric practice, HELLP syndrome is a leading cause of maternal ICU admission in the third trimester. A pregnant woman presenting with epigastric pain, headache, and hypertension should have immediate CBC, LFTs, and LDH checked; if thrombocytopenia + transaminitis + elevated LDH are found, delivery should not be delayed for further investigation—maternal and fetal outcomes depend on rapid intervention.

_Reference: DC Dutta's Textbook of Obstetrics (8th ed.), Ch. 21 (Hypertensive Disorders in Pregnancy); FOGSI Clinical Practice Guidelines on Preeclampsia & HELLP Syndrome_