Postpartum onset of
eclampsia and HELLP (
hemolysis, elevated liver
enzymes, low platelet count) syndrome is a rare but life-threatening complication for both mother and fetus. A case of a 38-year-old parturient (gravida 2, para 1) who was asymptomatic prior to delivery is reported. Emergency
caesarean section had to be performed due to sudden onset of fetal
bradycardia as a result of partial placental separation. The perioperative course was characterized by new onset
hypertension,
nausea and
restlessness; within 2 h the patient suffered a
generalized seizure which was treated with
magnesium sulfate and
hydralazine. Despite management in accordance with current guidelines, the condition deteriorated with
hypotension,
anemia and
renal failure. On further examination
hematomas in the abdominal cavity and walls were identified and laboratory tests confirmed
HELLP syndrome with severe coagulopathy. Explorative
laparotomy revealed diffuse
bleeding without a significant isolated source or postpartum
uterine hemorrhage. Retrospectively, the
anemia could be ascribed to severe
hemolysis and diffuse
bleeding from coagulopathy. The patient required packed red cells, platelets, fresh frozen plasma and
prothrombin complex. After admission to the intensive care unit persistent diffuse
bleeding mainly caused by hyperfibrinolysis and
renal failure occurred, which required
blood transfusion,
antifibrinolytic (
tranexamic acid) and
renal replacement therapy (
continuous veno-venous hemodiafiltration with
citrate) for 6 days. The patient recovered without any sequelae and was discharged 26 days later. Placental separation with new onset peripartum
hypertension is to be interpreted as a precursor of severe gestosis and associated complications, especially
disseminated intravascular coagulation (
DIC),
acute renal failure and
pleural effusion. A differentiation between a rapid drop in
hemoglobin concentration secondary to
hemolysis in postpartum
HELLP syndrome rather than
postpartum hemorrhage can be challenging. In addition,
HELLP syndrome can lead to rapidly developing, fulminant hyperfibrinolysis in the context of
DIC. Keys to successful management of postpartum gestosis and associated complications are early detection and perception of clinical and laboratory warning signs, a multidisciplinary approach with rapid and consistent targeted symptomatic
therapy to save the mother and fetus.