Leptospirosis in Pregnancy: A Rare Condition Mimicking HELLP Syndrome

Abstract

We report a case of leptospirosis in pregnancy. A 37-year-old woman of para 1, normal vaginal delivery (NVD) presented at 33 weeks with 3 days of jaundice and diarrhea and no history of fever, abdominal pain, itch or pale stools. Her pregnancy was uneventful except for gestational diabetes. On examination she had jaundice otherwise unremarkable. Investigations revealed proteinuria, hemolysis, low platelets, raised transaminases and bilirubin. Working diagnosis was of atypical hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome owing to absence of hypertension. She progressed into labour 1 day later after preterm premature rupture of membranes (PPROM), had thick meconium and pathological cardiotocography (CTG). She delivered a baby weighing 1,736 g and normal Apgar scores. Arterial cord pH was 7.275, lactate 3.04, base excess of -8.8 and venous pH was 7.316, lactate 2.93, BE -10.6. Leptospirosis EIA IgM antibody was positive and placenta histology showed focus increased perivillous fibrinoid deposits with acute intervillositis and meconium staining. Baby showed no signs of congenital leptospirosis and was discharged on day 15 of life. Patient's symptoms resolved within 2 weeks and her biochemistry normalized within 1 month. Owning to unusual presentation and rarity, leptospirosis in pregnancy is often misdiagnosed and underreported. It mimics HELLP syndrome, viral hepatitis, obstetric cholestasis and acute fatty liver of pregnancy. It has severe implications of early miscarriages, stillbirths and neonatal leptospirosis requiring high index of suspicion, need for increased awareness, early diagnosis and treatment.

Leptospirosis in pregnancy: A systematic review

“…The median maternal age was 29.5, with the interquartile range (IQR) being 9.75. Where the data was available, most pregnant patients were healthy, with only three patients having medical comorbidities, and these were obesity and dental caries for one [38], perioral herpes for another [43], and diet-controlled gestational diabetes mellitus for the other [44]. The median gestation of presentation with symptom(s) was 27 weeks, with an IQR of 10.5.…”

Diagnostic difficulties of leptospirosis during pregnancy: a maternal near miss

“…Fetal effects such as increased incidence of meconiumstained liquor pathological CTG abortions, stillbirth and low birth weight babies have been reported. 4,5 Our case also had intrapartum meconium-stained liquor and was shifted to NICU in view of prematurity and low birth weight.…”

“…The pathogen is spread by the urine of infected animals such as rodents, dogs, livestock and pigs. 4 Occupations involving direct contact with animals poses a major risk as the infected fluids enter through skin abrasions, mucous membranes and eyes. 5 Our case had a risk factor of exposure to paddy fields rat infestations by walking barefoot.…”

Leptospirosis Manifesting as HELLP (Hemolysis, Elevated Liver Enzymes, and Low Platelets) Syndrome: A Rare Case of Leptospirosis During Pregnancy

“…If leptospirosis in pregnancy is identified and treated promptly, along with thorough monitoring of the fetus, termination of pregnancy is not indicated. Infections contracted during the first trimester may lead to spontaneous abortions [ 5 ], and even a mild infection in the mother near term can result in congenital leptospirosis in the infant, as the bacterium can be transmitted through the placenta [ 7 ]. This elevates the risk of stillbirth and intrauterine death [ 8 ].…”

“…Leptospirosis presents with a wide range of symptoms, varying from nonspecific acute febrile illness to a combination of renal and liver failure, as seen in Weil's disease [ 5 ]. Common symptoms include headache, fever, myalgia (especially in the calves and lower back), conjunctival hemorrhages, nausea, vomiting, diarrhea, abdominal pain, cough, and occasionally, skin rashes.…”