Massive Ascites  in Severe Preeclampsia Patient With HELLP Syndrome : A Case Report

Objective: 

Pregnancy with Severe preeclampsia especially resistant cases , may develop complications such as HELLP syndrome ( Hemolysis , elevated liver enzymes , low platelets ) not just antenatally but  even postnatally and may be more severe . Generalised  pulmonary oedema or  ascites may develop in severe cases . In our case , massive  ascites has occurred & just  started  postnatally  with a  total of 10 litres of ascitic fluid drained  in the postnatal periods..

Case Report : 

30 year old  lady gravida 2 para 1 at 38 weeks of gestation , presented with severe preeclampsia , patient was drowsy, and in distress  , BP 184 /140 , pulse  96/min, respiratory rate  20/min , urine  albumin +3 Complete blood count , bilirubin , ALT and AST were sent . Patient given Labetalol  intravenously and MgSO4 was started to prevent  impending eclampsia , continuous cardiotocogram (CTG) was kept per policy , but was non reassuring .  Admission  investigations were: haemoglobin 13g/dl, platelets 138,000,   urea and creatinine , bilirubin , AST , ALT were normal with low albumin of 3 g/dl.

Eventually Category 2 emergency cesarean section was done for fetal distress , alive  2.3 Kg boy was born with normal Apgar score , abdominal drain was kept postoperatively, patient was shifted to critical care unit for monitoring . On  day 2 , BP was still uncontrolled : 205/115 , with tachycardia 120 bpm  , tachypnea , urine albumin +3 patient , cardiac review was normal  , 24 hour urinary protein  showed 2g proteinuria , There was evidence of haemolysis on peripheral smear and  dropping haemoglobin level  to 8.8.g/dl , LDH  raised to 580 units  and platelets  fell to 98,000 ,  HELLP syndrome was diagnosed .

Patient had massive drainage of total 10 litres ascitic fluid postnatally , although intravenous albumin was replaced , ascitic cytology  showed few WBC , but no other abnormalities , drain was draining daily averagely  1.2 lites  , so patient was advised for exploratory laparotomy in view of massive drainage but she refused . Fortunately patient  was recovered spontaneously on day 12 postop , BP normalised , drain was removed and patient was discharged . 

Discussion: 

Preeclampsia contributed to 3% of maternal deaths MBRRACE ( 2020-2022 ). Complications of severe cases include HELLP syndrome ( 4-18%) , up to 30%  of HELLP occurs pospartum, laboratory abnormalities typically worsen and peak at 24 to 48 hours postpartum and resolve by three to four day but may continue for more than 10 days postpartum as in our case .

Conclusions: 

Consequences of  preeclampsia  may not end by delivery , severe complications like HELLP syndrome may start postpartum. Massive ascites may start & develop postnatally , so abdominal drain should be considered as a protocol in all patients who had cesarean section for severe preeclampsia  , to avoid  the need of drain insertion post cesarean