Endgames Case Review

A pregnant woman with anaemia and thrombocytopenia

BMJ 2016; 353 doi: http://dx.doi.org/10.1136/bmj.i3035 (Published 03 June 2016) Cite this as: BMJ 2016;353:i3035
  1. Muhajir Mohamed, consultant haematologist and associate professor in medicine1 2,
  2. Arsalan Mahmud, basic trainee medical registrar3
  1. 1Department of Medicine, Launceston General Hospital, Launceston, Tasmania 7250, Australia
  2. 2University of Tasmania, Launceston Clinical School, Launceston, Australia
  3. 3Department of Medicine, Launceston General Hospital
  1. Correspondence to: M Mohamed muhajirbm{at}yahoo.com

A 28 year old woman who was 31 weeks pregnant attended the emergency department of our hospital with acute onset of abdominal pain in her right upper quadrant. She had undergone regular antenatal check-ups in the midwifery clinic, with no problems reported. She had no medical history of note and was not taking any drugs. She was a non-smoker and before she was pregnant she rarely drank alcohol. Her cardiovascular, respiratory, and neurological examinations were unremarkable and she had no peripheral oedema. The fetal heart sounds were normal. Her blood pressure was high (136/104 mm Hg) and her pulse was 88 beats/min. The urine protein to creatinine ratio showed no evidence of proteinuria.

A full blood screen showed a low platelet count (25×109/L; reference range 150-400), high neutrophil count (14×109/L; 2.0-8.0), low haemoglobin (94 g/L; 130-170), and raised absolute reticulocyte count (204×109/L; 50-100). Red blood cells with morphological abnormalities were seen on the blood film (fig 1). Liver function tests showed moderately raised alanine transferase (356 U/L; 0-33) and aspartate transferase (304 U/L; 0-32), mildly deranged alkaline phosphatase and γ-glutamyl transferase values, and normal bilirubin levels. Serum lactate dehydrogenase (LDH) was high (951 U/L; 125-243) and serum haptoglobin was undetectable. A direct antiglobulin test was negative. Coagulation parameters—prothrombin time, activated partial thromboplastin time, and fibrinogen concentration—were within normal limits and D-dimer was raised. Blood glucose, serum creatinine, iron studies, vitamin B12, and folate values were within the normal ranges.

Fig 1

Questions

  1. What does the blood film show?

  2. What is the most likely diagnosis?

  3. What are the differential diagnoses in this patient?

  4. How do you diagnose this condition?

  5. How should the patient be managed and what is the prognosis?

Answers

1. What does the blood film show?

Short answer

Polychromasia, fragmented red blood cells (schistocytes), and thrombocytopenia. These features are suggestive of microangiopathic haemolytic …

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