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Anesthetic Considerations in HELLP Syndrome
Anesthetic Considerations in HELLP Syndrome
Correspondence
M. del-Rio-Vellosillo, Department of
Anaesthesia, University Hospital Virgen de la
Arrixaca, Ctra. Madrid-Cartagena, s/n, 30120 El
Palmar, Murcia, Spain
E-mail: monicadelriov@hotmail.com
Conflicts of interest
None for either author.
Funding
None.
Submitted 25 May 2015; accepted 3
September 2015; submission 18 February
2015.
Citation
del-Rio-Vellosillo M, Garcia-Medina JJ.
Anesthetic considerations in HELLP syndrome.
Acta Anaesthesiologica Scandinavica 2015
doi: 10.1111/aas.12639
Hemolysis, elevated liver enzymes, and low platelets HELLP syndrome continues to be a threat
to the well-being of some obstetric patients. This article provides an updated review of perioperative approaches for safest care for obstetric patients with HELLP syndrome who need urgent operative delivery.
Pregnancy-induced hypertension is a broadspectrum entity which occurs in approximately
5% of pregnancies whose physiopathology
vasculitis plays a major role. The clinical translation is high blood pressure, kidney failure by
fibrin renal deposits, and multiorgan failure by
fibrin extrarenal deposits and consumption
coagulopathy.1
HELLP syndrome (SH), described in 1982 by
Weinstein,2 is a severe manifestation of pregnancy-induced hypertension, defined by some
authors as a variation of pre-eclampsia.
Nonetheless, SH may appear alone or in association with it.3,4
Despite the improvements made in recent
years in managing this syndrome, many details
of SH remain unknown in terms of its etiology,
diagnosis, management, and treatment.
Incidence
Its incidence is between 212% of all pregnancies, and in 1020% of cases of pre-eclampsia.5
It occurs during 70% of antepartum periods and
during 30% of postpartum periods, and emerges
mostly in the first 48 h.6,7
Classification
Several classification systems are used to categorize SH. The first is based on the number of present abnormalities (hemolysis, elevated liver
enzymes, and low platelets), in such a way that
patients are classified as partial SH (they present
one or two abnormalities) or complete SH (three
abnormalities are present).4,6
Alternatively, SH may be classified based on
the number of platelets: class I, < 50 9 109/l;
class II, 50100 9 109/l; and class III, 100
150 9 109/l.8 Morbidity and mortality are high
in class I.8
Clinical manifestations
This syndrome is characterized by hemolysis,
elevated liver enzymes, and thrombocytopenia
(lactate dehydrogenase (LDH) 600 IU/l, AST
70 IU/l, platelets 100 9 109/l).9
Hemolysis is caused by microangiopathic
hemolytic anemia produced by vascular damage
and fibrin deposits. This destruction of red
blood cells causes fragmented red blood cells
and schistocytes on a blood film and increased
LDH.10 Elevated liver enzymes may reflect both
2015 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd
Corticoids
Anticonvulsants drugs
The guideline recommended by the Collaborative Eclampsia Trial is 45 g of MgSO4 administered in 5 min, and subsequently 1 g/h for 24 h.
If a recurring seizure appears, 2 g of MgSO4
should be administered.34
MgSO4 monitoring is taken by clinical parameters of urine output, breathing rate, oxygen saturation, and patellar reflexes. The normal
plasma concentration lies between 1.58 and
2.55 mg/dl. The recommended therapeutic concentrations lie between 4 and 7 mg/dl.35
Toxicity is often presented as kidney failure.
Treatment of its toxicity must be given with
10% calcium gluconate, 1 g administered in
10 min.36
Blood products transfusion
In cases with continuing hemolysis and persistent postpartum thrombocytopenia, blood and
platelet transfusion, as well as treatment with
albumin, are standard treatments.23,37
When the platelet count falls below 50 9 109/l,
it can be considered a DIC with a worse prognosis. For this reason, it is advisable to keep platelet
levels above 50 9 109/l to avoid the risk of bleeding.38 If DIC occurs, it can be treated with fresh
frozen plasma to replace clotting proteins.33
Plasmapheresis
Plasmapheresis is one of the support therapies
that offers more favorable results in patients
who are refractory to conventional treatment.39
41
The exact mechanism is unknown but, in
general, plasmapheresis removes plasma factors
and replaces new elements by encouraging
plasma from patients. However, more research
work needs to be done into this technique for it
to be recommended.42
Some SH patients, whose bilirubin or creatinine has progressively increased for more than
72 h after delivery, could benefit from plasmapheresis with fresh frozen plasma.39,43
Fluid therapy
In line with this, a restrictive therapy in these
patients could exacerbate intravascular vasoconstrictors and lead to kidney failure.44,45 Nevertheless, a non-restrictive fluid therapy is not
2015 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd
Anesthetic recommendations
Premature delivery in these patients is normal
and deliveries are often complicated by
intrauterine growth retardation or placental
abruption. Therefore, cesarean section is quite a
common practice in such cases.
Given the high incidence in delayed or missed
diagnoses among these patients, the anesthesiologist should have a high index of suspicion and
should recognize that a delivering woman with
abdominal pain, nausea and vomiting could
have SH.
The key to safe management of such patients
is to treat hypertension and eclampsia, considering the presence of liver or kidney dysfunction,
and reduce the tendency of bleeding. The determination of appropriate anesthetic management
is based on the conditions of both the delivering
woman and the fetus, and also on urgent surgery.64,65 So anesthetic treatment in these
patients is complex, and the risks and benefits
of each anesthetic technique must be contemplated, based on sound knowledge of these
patients pathophysiological conditions.
First a preoperative examination should be
performed, which should include an electrocardiogram (ECG) and a complete blood count
with a platelet count, liver function tests, serum
creatinine concentrations, urea and uric acid,
fibrin degradation products, and prothrombin
and partial thromboplastin times.14 Blood components, including cross-matched red cells, platelet concentrates, and plasma, should be
available.21
Moreover, a blood transfusion should be evaluated depending on hemoglobin levels.66 In
patients with thrombocytopenia, platelet transfusion should be considered at the time of surgery, and not before, because platelets can be
rapidly consumed.67 Urinary catheterization is
also advisable to control dieresis hourly.
An intravascular volume assessment, proper
blood pressure control, and invasive hemodynamic monitoring should be performed.
Intravascular volume depletion in SH is usually
related with hypertension severity.21 It is important to remember that excessive crystalloid
administration in patients with widespread
vasospasm, drop in colloid oncotic pressure and
2015 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd
PREOPERATIVE
Yes
REGIONAL ANESTHESIA(RA)
ADVANTAGES
ADVANTAGES
DISADVANTAGES
No
DISADVANTAGES
- A higher risk of epidural hematoma
2015 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd
REVIEW ARTICLE
Correspondence
M. del-Rio-Vellosillo, Department of
Anaesthesia, University Hospital Virgen de la
Arrixaca, Ctra. Madrid-Cartagena, s/n, 30120 El
Palmar, Murcia, Spain
E-mail: monicadelriov@hotmail.com
Conflicts of interest
None for either author.
Funding
None.
Submitted 25 May 2015; accepted 3
September 2015; submission 18 February
2015.
Citation
del-Rio-Vellosillo M, Garcia-Medina JJ.
Anesthetic considerations in HELLP syndrome.
Acta Anaesthesiologica Scandinavica 2015
doi: 10.1111/aas.12639
Hemolysis, elevated liver enzymes, and low platelets HELLP syndrome continues to be a threat
to the well-being of some obstetric patients. This article provides an updated review of perioperative approaches for safest care for obstetric patients with HELLP syndrome who need urgent operative delivery.
Pregnancy-induced hypertension is a broadspectrum entity which occurs in approximately
5% of pregnancies whose physiopathology
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2015 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd
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2015 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd