Eclampsia and HELLP syndrome — structured SAQ (15 marks)

(a) Diagnosis, criteria and grade (4 marks)

One mark for the diagnosis, one for the Tennessee criteria applied to her numbers, one for the Mississippi class, one for recognising the normotensive non-proteinuric presentation. ^[1][2]

• Diagnosis: HELLP syndrome, complete, at 31+4 weeks.^[1]
• Tennessee criteria, all three met: haemolysis (lactate dehydrogenase 1,140 IU/L, threshold above 600 IU/L, with schistocytes and a raised bilirubin); elevated liver enzymes (AST 240 IU/L, threshold 70 IU/L or more); low platelets (48 x 10^9/L, threshold under 100 x 10^9/L).^[1]
• Mississippi class 1 — nadir platelet count 50 x 10^9/L or less, with AST or ALT 70 IU/L or more and lactate dehydrogenase 600 IU/L or more. Class 2 is above 50 up to 100 x 10^9/L; class 3 is above 100 up to 150 x 10^9/L with an enzyme threshold of 40 IU/L or more.^[1][2]
• Prognostic weight: in Martin's cohort composite major maternal morbidity was 44% in class 1, against 13% in class 2, 24% in class 3, 20% in partial HELLP and 18% in severe preeclampsia without HELLP.^[2]
• The examiner's trap: she is neither hypertensive nor proteinuric. Roughly 15 to 20% of women with HELLP present this way, and the diagnosis is made on the bloods, not the blood pressure.^[1][5]

(b) Differentials and the discriminating test (3 marks)

One mark per correctly paired differential and discriminator. ^[3][4]

• Also creditable: sepsis with disseminated intravascular coagulation (fibrinogen falling, positive cultures — hers is 3.2 g/L and normal, and the INR is normal), immune thrombocytopenia (normal enzymes and lactate dehydrogenase), and viral hepatitis (serology, far higher transaminases).^[4][1]

(c) Management over the next six hours (5 marks)

One mark each for: escalation and setting; magnesium with dose; blood pressure plan and fluid restriction; corticosteroids with the controversy stated correctly; the birth decision with blood-product planning. ^[5][6][8]

• Escalate and site her correctly: obstetric consultant, obstetric physician, anaesthetist, haematologist and neonatal team; admit to a high-dependency area; group and hold with crossmatch, and alert the blood bank to a possible platelet requirement.^[5][6]
• Magnesium sulfate per the current protocol loading and maintenance doses for seizure prophylaxis, continued 24 hours after birth or the last seizure, whichever is later. Monitor hourly reflexes, respiratory rate, conscious level and urine output; calcium gluconate per the current protocol dose is the antidote.^[6][5]
• Blood pressure: currently non-severe, so no acute agent yet, but write the threshold in the notes — at 160/110 mmHg or more, treat within 30 to 60 minutes with labetalol, hydralazine, or oral nifedipine per the current protocol doses. Restrict fluid per the current protocol rate.^[5][6]
• Corticosteroids: betamethasone per current protocol dosing for fetal lung maturity. State the controversy correctly: the Cochrane review of 11 trials and 550 women found no clear effect of corticosteroids on maternal death, severe maternal morbidity or perinatal death in HELLP; the only clear effect was an improved platelet count, greater with dexamethasone than betamethasone. Steroids are therefore for the baby, or occasionally to enable neuraxial anaesthesia — not a treatment for HELLP itself.^[9][8]
• Birth: she is class 1 HELLP at 31+4 weeks. Deliver after stabilisation. A short delay of up to about 24 to 48 hours for corticosteroids is defensible only with intensive maternal monitoring and six-hourly bloods, and is abandoned immediately if she deteriorates. Anticipate general anaesthesia — at 48 x 10^9/L and falling, neuraxial block is unsafe; transfuse platelets for active bleeding or before caesarean when the count is below about 50 x 10^9/L.^[5][1]
• Serial monitoring: repeat full blood count, liver enzymes, lactate dehydrogenase and coagulation every 6 hours; image the liver if the right upper quadrant pain worsens or radiates to the shoulder, because subcapsular haematoma is confirmed by computed tomography.^[10][1]

(d) The seizure (3 marks)

One mark for the airway and positioning bundle, one for the magnesium action with dose, one for the sequencing principle. ^[7][5]

1. Call for help — obstetric consultant, anaesthetist, midwifery coordinator, neonatal team. Declare "eclampsia".^[5]
2. Protect her and the airway — remove hazards, do not restrain her, put nothing in her mouth, left lateral position and jaw thrust once the clonic phase ends, suction if needed.^[5]
3. Oxygen 15 L per minute by reservoir mask; time the seizure; bedside glucose.^[5]
4. Magnesium: she is already loaded and running on maintenance, so give a further bolus per current protocol and continue the infusion. Around a quarter of women have recurrent fits despite treatment.^[7][5]
5. Control the blood pressure with the named agents above, and restrict fluid.^[5]
6. Then the fetus. Expect a post-ictal bradycardia and let it recover with maternal oxygenation and repositioning. Mother first, then baby — deliver once she is stabilised, not during the seizure.^[5][7]