HELLP Syndrome

Definition
Probably a severe complication of pregnancy induced hypertension
But 15-20% do not have preceding HTN > delayed diagnosis
Multigravida > Primigravida, usually comes between 28-36 weeks, sometimes presents
post partum
Stands for:
H - Hemolysis
EL - Elevated Liver enzymes
LP - Low platelets
Pathophysiology
Problem is the placenta
Defective placental vessels lead to inadequate perfusion and hypoxia
Other theories - Autoimmune, inflammation, inborn errors of fatty acid metabolism
Signs and symptoms
Malaise and Epigastric/RUQ Pain and tenderness
Nausea and Vomiting, Jaundice
Headache and visual symptoms
May or may not have other symptoms of pre eclampsia
Differentials
Pancreatitis
Gastritis, Hepatitis
Acute Cholecystitis
ITP/HUS
Acute fatty Liver of Pregnancy (elevated direct > indirect bilirubin/ deranged coagulation
parameters, hypoglycemia, encephalopathy, elevated ammonia)
Typical labs
Mild Anemia
Thrombocytopenia
Elevated bilirubin (>1.2mg/dL, indirect > direct)
Low haptoglobin and elevated LDH (hemolysis)
Elevated AST/ALT
Microangiopathic hemolytic anemia (Schistocytes i.e. damaged RBCs on peripheral blood
smear)
Treatment (All get admitted)
ABCs
Type and cross match (for PPH/?hepatic rupture)
Antihypertensives (Labetalol, Hydrazine and Nifedipine), Target BP < 160/105 mmHg

 MgSO4 seizure prophylaxis (intrapartum and postpartum up to 12-24 hours)

6gm loading dose over 20 minutes, then 2gm/hr infusion
HELLP by itself is not an indication of CS unless there are co-existing fatal/
maternal indications
High dose steroids for improving labs - Controversial
Consider for the sickest, 20mg Dexa IV q6h up to 4 doses
GA < 34wks and stable > Steroids for lung protection and deliver after 24-48 hours
GA > 34wks and stable > deliver urgently or close monitoring if planning to delay
Anytime maternal or fatal distress in any scenario - Deliver ASAP
Symptoms usually resolve spontaneously after delivery
Transfuse only if platelets < 20,000 or severe bleeding or <40,000 when going for
Caesarean Section (CS)
Complications
Pulmonary edema
Hepatic/Renal Failure
Hepatic hematoma/ rupture
DIC, ARDS
Take Home
Any pregnant lady in late second or third trimester C/O malaise - Think HELLP (BP may
be normal)

Treatment of HELLP syndrome is seizure prevention with MgSO4 and controlling BP

Getting OBGYN involved early is important to decide on the definitive treatment

HELLP by itself is not an indication for LSCS unless there are co-existing materal/fetal
indications/distress

Thank You

Further Reading:
1. Satpathy Hemant, K., Satpathy Chabi, and Donald Frey. "Hellp syndrome.
2. Mihu, Dan, et al. "HELLP syndrome-a multisystemic disorder." Journal of
Gastrointestinal and Liver Diseases 16.4 (2007): 419.
Questions/ Comments/ Feedback
Lakshay Chanana

drlakshay_em@yahoo.com

Twitter: @EMDidactic

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