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The risk factors for HELLP syndrome differ from those associated with
preeclampsia (Table 1). The syndrome generally presents in the third trimester of
pregnancy, although it occurs at less than 27 weeks of gestation in an estimated 11
percent of patients.5 The syndrome presents antepartum in 69 percent of patients
and postpartum in 31 percent of patients.2 With postpartum presentation, the
onset is typically within the first 48 hours after delivery; however, signs and
symptoms may not become apparent until as long as seven days after delivery.
TABLE 1
Multiparous Nulliparous
Maternal age greater than 25 Maternal age less than 20 years or greater than
years 45 years
:
White race Family history of preeclampsia
Diabetes mellitus
Chronic hypertension
Multiple gestation
HELLP = hemolysis, elevated liver enzyme levels and low platelet count.
Clinical Presentation
The vague nature of the presenting complaints can make the diagnosis of HELLP
syndrome frustrating to physicians. Approximately 90 percent of patients present
with generalized malaise, 65 percent with epigastric pain, 30 percent with nausea
and vomiting, and 31 percent with headache.3 Because early diagnosis of this
syndrome is critical, any pregnant woman who presents with malaise or a viral-type
illness in the third trimester should be evaluated with a complete blood cell count
and liver function tests.6
Because of the variable nature of the clinical presentation, the diagnosis of HELLP
syndrome is generally delayed for an average of eight days.7 Many woman with this
syndrome are initially misdiagnosed with other disorders, such as cholecystitis,
esophagitis, gastritis, hepatitis or idiopathic thrombocytopenia.3 In one
:
retrospective chart review of patients with HELLP syndrome, only two of 14
patients entered the hospital with the correct diagnosis.7
Diagnostic Tests
The three chief abnormalities found in HELLP syndrome are hemolysis, elevated
liver enzyme levels and a low platelet count. The hematocrit may be decreased or
normal and is typically the last of the three abnormalities to appear. The finding of a
decreased serum haptoglobin level may confirm ongoing hemolysis when the
hematocrit is normal.8 The serum transaminase levels may be elevated to as high
as 4,000 U per L, but milder elevations are typical. Platelet counts can drop to as
low as 6,000 per mm3 (6 × 109 per L), but any platelet count less than 150 per mm3
(150 × 109 per L) warrants attention. Unless DIC is present, the prothrombin time,
partial thromboplastin time and fibrinogen level are normal in patients with HELLP
syndrome. In a patient with a plasma fibrinogen level of less than 300 mg per dL (3
g per L), DIC should be suspected, especially if other laboratory abnormalities are
also present.
Classification
:
Two classification systems are used for HELLP syndrome. The first is based on the
number of abnormalities that are present. In this system, patients are classified as
having partial HELLP syndrome (one or two abnormalities) or full HELLP syndrome
(all three abnormalities). Women with full HELLP syndrome are at higher risk for
complications, including DIC, than women with the partial syndrome. Consequently,
patients with the full syndrome should be considered for delivery within 48 hours,
whereas those with partial HELLP syndrome may be candidates for more
conservative management.12
Management
Once the diagnosis of HELLP syndrome has been established, the best markers to
follow are the maternal lactate dehydrogenase level and the maternal platelet
count.14 Laboratory abnormalities typically worsen after delivery and peak at 24 to
48 hours postpartum.14 The peak lactate dehydrogenase level signals the
beginning of recovery and subsequent normalization of the platelet count.14 The
platelet count nadir is somewhat predictive for hemorrhagic complications. The
incidence of hemorrhagic complications is higher when platelet counts are less
than 40,000 per mm3 (40 × 109 per L).15 However, hepatic imaging and liver biopsy
have shown that laboratory abnormalities do not correlate with the severity of
HELLP syndrome.16,17 Therefore, patients with HELLP syndrome who complain of
severe right upper quadrant pain, neck pain or shoulder pain should be considered
for hepatic imaging regardless of the severity of the laboratory abnormalities, to
assess for subcapsular hematoma or rupture.17
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Prompt recognition of HELLP syndrome and timely initiation of therapy are vital to
ensure the best outcome for mother and fetus. When the syndrome was first
described, prompt delivery was recommended.1 Recent research suggests that
morbidity and mortality do not increase when patients with HELLP are treated
conservatively.18 The treatment approach should be based on the estimated
gestational age and the condition of the mother and fetus (Figure 1).19
FIGURE 1.
In the past, delivery in patients with HELLP syndrome was routinely accomplished
by cesarean section. Patients with severe HELLP syndrome, superimposed DIC or a
gestation of less than 32 weeks should be delivered by cesarean section. A trial of
labor is appropriate in patients with mild to moderate HELLP syndrome who are
stable, have a favorable cervix and are at 32 weeks of gestation or greater.2
3 9
:
less than 100,000 per mm3 (100 × 109 per L) and should be continued until liver
function abnormalities are resolving and the platelet count is greater than 100,000
per mm3 (100 × 109 per L).
Between 38 and 93 percent of patients with HELLP syndrome receive some form of
blood product.15 Patients with a platelet count greater than 40,000 per mm3 (40 ×
109 per L) are unlikely to bleed. These patients do not require transfusion unless the
platelet count drops to less than 20,000 per mm3 (20 × 109 per L). Patients who
undergo cesarean section should be transfused if their platelet count is less than
50,000 per mm3 (50 × 109 per L). Prophylactic transfusion of platelets at delivery
:
does not reduce the incidence of postpartum hemorrhage or hasten normalization
of the platelet count.15 Patients with DIC should be given fresh frozen plasma and
packed red blood cells.
ANESTHESIA CONSIDERATIONS
Pain relief with intravenous narcotics and local anesthesia is acceptable but
certainly not optimal for pain control. Epidural anesthesia has been controversial
but is the technique of choice when it can be accomplished safely.26 Insertion of an
epidural catheter is generally safe in patients with a platelet count greater than
100,000 per mm3 (100 × 109 per L), normal coagulation studies and a normal
bleeding time.26 General anesthesia can be used when regional anesthesia is
considered unsafe.
COMPLICATIONS
The mortality rate for women with HELLP syndrome is approximately 1.1 percent.5
From 1 to 25 percent of affected women develop serious complications such as
DIC, placental abruption, adult respiratory distress syndrome, hepatorenal failure,
pulmonary edema, subcapsular hematoma and hepatic rupture. A significant
percentage of patients receive blood products.5
:
Infant morbidity and mortality rates range from 10 to 60 percent, depending on the
severity of maternal disease.3 Infants affected by HELLP syndrome are more likely
to experience intrauterine growth retardation and respiratory distress syndrome.27
Prognosis
Patients who have had HELLP syndrome should be counseled that they have a 19
to 27 percent risk of developing the syndrome in subsequent pregnancies.28 They
also have up to a 43 percent risk of developing preeclampsia in another
pregnancy.28 Patients with class I HELLP syndrome have the highest risk of
recurrence.28 When the syndrome recurs, it tends to develop later in gestation and
is generally less severe after two episodes. Patients who have had HELLP
syndrome may subsequently use oral contraceptive pills safely.29 Patients who
develop atypical early-onset preeclampsia or HELLP syndrome should be screened
for the presence of antiphospholipid antibodies.30
Author Information
:
MAUREEN O'HARA PADDEN, LCDR, MC, USN, is a family physician in the residency
teaching program at Naval Hospital, Camp Pendleton, Calif. Dr. Padden is a
graduate of the Uniformed Services University of the Health Sciences F. Edward
Hébert School of Medicine, Bethesda, Md. She completed a residency in family
medicine at Naval Hospital, Camp Pendleton.
The author thanks Everett Magann, M.D., of the University of Mississippi, Jackson, and
Richard Emerine, M.D., and Richard Leader, Naval Hospital, Camp Pendleton, Calif., for
critical review and recommendations in the preparation of the manuscript.
The opinions and assertions contained herein are the private views of the author and are
not to be construed as official or as reflecting the views of the U.S. Navy Medical
Department or the Naval service at large.
Address correspondence to Maureen O'Hara Padden, LCDR, MC, USN, Family Practice
Residency, Naval Hospital, Camp Pendleton, CA 92055. Reprints are not available from
the author.
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