Question

A 28-vear-old woman in her 30th week of pregnancy was admit- ted to the emergency room with a spontaneous abortion and vaginal bleeding. Recent history suggested pre-eclampsia as a possible cause. The admission CBC results were WBC 22.0 X 10°/L; RBC 2.81 X 1012/L: Hb 9.0 g/dL; Hct 0.30 L/L; MCV 94.6 fL; MCH 31.3 pg; MCHC 33.0 g/dL; and platelets 142 x 10°/L. The differential count revealed 89% neutrophils, 2% bands, and 9% lymphocytes. RBC morphology showed a normocytic, nor- mochromic presentation with schistocytes and burr cells. Chem- istry values of interest included a blood urea nitrogen of 90 mg/ dL and elevated alanine aminotransferase (ALT), an enzyme that is found in high amounts in the liver and kidney. ALT is occasion- ally elevated in pre-eclampsia, particularly in severe cases causing the syndrome known as hemolytic anemia with elevated liver enzymes and low platelet count (HELLP). 1. Are problems such as pre-eclampsia in pregnancy known to cause microangiopathic hemolytic anemia (MAHA)? 2. What laboratory result(s) indicates hemolysis in this case? 3. Is there any relationship between the elevated alanine amino- transferase and the suggested diagnosis of pre-eclampsia? Explain briefly. 4. Since TTP is another condition associated with pregnancy that may cause a MAHA, what laboratory value in this case differentiates TTP from HELLP?

Answer 1

1. Microangiopathic hemolytic anemia (MAHA) is a microangiopathic subgroup of hemolytic anemia (loss of red blood cells through destruction) caused by factors in the small blood vessels. It is identified by the finding of anemia and schistocytes on microscopy of the blood film. preeclampsia may cause this anemia as high blood pressure causes endothelial injury that results in cascade causing MAHA.

2. Elevated level  of ALT and appearance of shistocytes show hemolysis.

3. increased blood pressure in preeclampsia causes injury to liver that results elevation of alanine transferase enzyme.this enzyme is specific to liver and get released in blood on breakdown of hepatocytes.

4. In TTP, there is severe thrombocytopenia <20000 and in present case it is not that low so taking into account other features of hemolysis, elevated ALT, HELPP is diagnosed