Abstract Body: A 30-year-old Caucasian woman at 36 weeks gestation via in-vitro fertilization with history of polycystic ovary syndrome, hypothyroidism, and two prior pregnancy losses with unconfirmed antiphospholipid syndrome (APS) presented with severe hypertension, chest pain, and epigastric discomfort. Lab studies showed profound liver enzyme elevation (AST/ALT 2480/1601), progressive thrombocytopenia (platelets 86k/µL), and positive hemolysis markers. She underwent a cesarean section due to concern for preeclampsia with severe features. Postpartum her platelets dropped to 12k/µL necessitating upgrade to the intensive care unit (ICU).

After ruling out cardiopulmonary etiologies, differential diagnoses included thrombotic thrombocytopenic purpura, hemolytic uremic syndrome, acute fatty liver of pregnancy (AFLP), and catastrophic APS. While initial testing showed hemolysis, peripheral blood smear only showed rare schistocytes and ADAMTS13 activity was normal. With preserved renal function and stable mental status, AFLP was ruled out. APS was also confirmed negative based on prior testing showing just mildly elevated beta-2-glycoprotein. After liver imaging ruled out structural abnormalities, the combination of hemolysis, elevated liver enzymes, and low platelets pointed to HELLP syndrome.

In the ICU she was closely monitored and received magnesium intravenously for 24 hours to prevent eclampsia, in addition to platelets and corticosteroids. In case her liver enzymes continued to worsen, she was transferred to a tertiary center with liver transplant capability, though fortunately her labs began to improve. Her blood pressure was well-controlled after starting nifedipine and labetalol. She followed in the liver clinic and lab work showed normal liver enzymes and platelets.

Severe hypertension in pregnancy can lead to complications requiring further testing. The combination of elevated liver enzymes and thrombocytopenia can be seen in many microangiopathies, but subtle differences in labs and timing of clinical resolution differentiate conditions from each other. In this case where there had already been prior pregnancy losses, the timely delivery and close monitoring early in her hospital course helped arrive at HELLP syndrome and heavily impacted recovery. In summary, this case outlines the importance of keeping diagnostic vigilance, recognizing clinical red flags, and acting empirically when life-threatening mimics of preeclampsia are suspected.