HELLP Syndrome

A case study

Members:

Audencial, Luis Miguel

Buenviaje, Diwata Amor P.

Centeno, Mariah Therese I.

CHAPTER I

General Objectives

The main objective of the case study is to gain more understanding of the HELLP

Syndrome.

Specific Objectives

To know what HELLP Syndrome is in terms of : definition, anatomy, physiology and

pathophysiology, its clinical manifestations and managements of medical and nursing.

To know the laboratory results implying the presence of HELLP.

To create a Nursing Care Plan, Drug Study and Recommendations for the HELLP.

Introduction

The HELLP Syndrome is a rare type of preeclampsia named from the three features of

the disease, the hemolysis, elevated liver enzyme levels, and low platelet levels which is a life

threatening condition that can potentially complicate a pregnancy. Even though HELLP is a type

of preeclampsia, it is still different from it. Preeclampsia leads to high blood pressure

(hypertension) and proteinuria (high levels of protein in the urine) while HELLP Syndrome is a

seperate disorder as the patient may not have high blood pressure or proteinuria. In the next

chapters, the HELLP Syndrome will be explained with more depth and by the end, more

understanding will be gained about the said topic.

CHAPTER II

Definition of Case

HELLP Syndrome is a life threatening pregnancy complication usually considered as a

variant of preeclampsia where it occurs during the later stages of pregnancy or soon after

childbirth. It was named by Dr. Louis Weinstein during the 1982 after its characteristics H for

Hemolysis which is the breaking down of red blood cells, EL for Elevated Liver Enzymes where

the chemicals speed up the body reactions such as the breakdown of protein and LP for Low

Platelet, the part of the blood that contributes to blood clotting.

HELLP syndrome can be difficult to diagnose, because all of the typical signs of

preeclampsia may not be apparent, such as high blood pressure and protein in the urine. Its

symptoms are sometimes mistaken for gastritis, flu, acute hepatitis, acute fatty liver disease,

gallbladder disease, or other conditions. While some of these conditions may also be present,

there is no evidence they are related.

The cause of HELLP Syndrome is currently unknown although theories in

Pathophysiology have been proposed. Some of the risk factors include the maternal age older

than 34 years, multiparity, white race/European descent and history of poor pregnancy

outcome.

It only occurs in 0.1-0.6% of pregnancies and 4-12% of patients with preeclampsia

making it a very rare case. HELLP Syndrome usually occurs between the 27th week of gestation

and delivery, or immediately postpartum in 15-30% of cases. Early diagnosis is critical because

25% of the cases can cause serious illness and even death. As a result, patient awareness of

HELLP syndrome, and how it relates to preeclampsia, is helpful to ensure the best medical care

for mother and baby. HELLP has been observed to occur in older maternal groups with an

average age of 25 years.

Anatomy and Physiology

There are not enough references for the anatomy of HELLP Syndrome, some think it is

the same as preeclampsia however it is not as some signs and symptoms are different from

preeclampsia and HELLP. For now the condition is mostly theorized specially on the

pathophysiology as not enough evidence has been seen yet.

Pathophysiology (Book Based)

HELLP is a syndrome characterized by thrombocytopenia, hemolytic anemia, and liver

dysfunction believed to result from microvascular endothelial activation and cell injury.

The pathophysiology of HELLP syndrome is ill-defined. For the reason that HELLP is a

variant of preeclampsia, it is theorized that the pathophysiology stems from a common source.

In preeclampsia, defective placental vascular remodeling during weeks 16-22 of pregnancy with

the second wave of trophoblastic invasion into the decidua results in inadequate placental

perfusion. The hypoxic placenta then releases various placental factors such as soluble vascular

endothelial growth factor receptor-1 (sVEGFR-1), which then binds vascular endothelial growth

factor (VEGF) and placental growth factor (PGF), causing endothelial cell and placental

dysfunction by preventing them from binding endothelial cell receptors where it results to

hypertension, proteinuria, and increased platelet activation and aggregation.

Furthermore, activation of the coagulation cascade causes consumption of platelets due

to adhesion onto a damaged and activated endothelium, in addition to microangiopathic

hemolysis caused by shearing of erythrocytes as they traverse through capillaries laden with

platelet-fibrin deposits. Multiorgan microvascular injury and hepatic necrosis causing liver

dysfunction contribute to the development of HELLP.

Clinical Manifestations (Signs and Symptoms)

The physical symptoms of HELLP Syndrome are Epigastric (abdominal) or substernal

(chest) pain, including abdominal or chest tenderness and upper right side pain (from liver

distention), nausea, vomiting, or indigestion with pain after eating, headache that won't go

away, even after taking medication such as acetaminophen (non-opioid analgesic and

antipyretic agent), shoulder pain or pain when breathing deeply, bleeding, changes in vision

including blurred vision, seeing double, or flashing lights or auras, swelling especially of the face

or hands, shortness of breath, difficult breathing, or gasping for air.

There are also some measurable signs to take note such as high blood pressure, protein

in urine and abnormalities in the laboratory blood results like the presence of hemolysis with at

least 2 of the findings: Peripheral smear with schistocytes and burr cells, Serum bilirubin >1.2

mg/dl, Low serum haptoglobin(<25mg/dl) or LDH> two times the upper level of the normal and

Severe anemia with hemoglobin <8 to 10 g/dl depending on the pregnancy stage, unrelated to

blood loss. Increased liver enzymes with AST or ALT > 2 times the upper level of normal, and

decreased platelets of <100,000 cells/microL.

Medical Management

Medications and other therapies instituted by the physician to reverse pregnancy

induced hypertension are the antiplatelet therapy where there is an increased tendency for

platelets to cluster along the vessel walls, so a mild antiplatelet agent is ordered by the

physician. Medicines that reduce hypertension and prevent seizures are also administered such

as hydralazine, nifedipine, and labetalol may be prescribed to reduce hypertension to avoid the

progression of the disease. Another main treatment for HELLP is to deliver the baby as soon as

possible, even if it is premature, because problems with the liver and other complications of
HELLP Syndrome can be harmful for the mother and the baby. There are quite some possible

complications after the delivery of the mother such as Disseminated intravascular coagulation

(DIC), a clotting disorder that leads to excess bleeding (hemorrhage), fluid in the lungs

(pulmonary edema), kidney failure, liver hemorrhage and failure, separation of the placenta

from the uterine wall (placental abruption), seizures, stroke, and fetal complications, including

restriction of fetal growth however, after the baby is born, HELLP Syndrome goes away for most

cases in 2-3 days.

Nursing Management

The role of the nurse is to reduce the blood pressure of the patient. These are just

simple interventions but could create a dramatic effect when applied properly. This can be

achieved through instructing the patient to have bed rest and avoid environmental stressors as

well as administering hypertensives as prescribed and preparing to deliver the baby either by

labor, induction or cesarean section.

CHAPTER III

Laboratory Data

The table below shows the list of the signs and symptoms of HELLP Syndrome and its laboratory

values that deviates from the norm.

Signs/Symptoms Laboratory values

Epigastric pain Platelets < 50,000uL

Nausea Total serum LDH> 1400 IU/L

Vomiting AST > 150 IU/L

Severe systolic hypertension ALT > 100 IU/L

Severe systolic hypertension Uric acid > 7.8 mg/dL

Placental abruption CPK > 200 IU/L

Eclampsia Serum creatinine > 1.0

CHAPTER 4

Nursing Care Plan (ADOPIE)

The following shows the recommended Nursing Care Plan for the HELLP Syndrome.

ASSESSME DIAGNOSIS OUTCOME PLANNING IMPLEMENTATIO EVALUATION

NT N

Subjective: To meet the The patient Short Term: Independent After the

diagnostic should be able nursing

N/A criteria, the to maintain After nursing - Assess vital signs, interventions

following must adequate fluid interventions, the conduct physical has been

Objective: be: volume as patient should be examinations, and completed, the

Liver evidenced by able to: commence daily patient should

- General Transaminase: blood pressure weight be able to:

Malaise >70 IU/L within normal 1. Decrease and monitoring.

- Weakness Platelet: limits. A patient maintain blood 1. Free from

- Fatigue <100,000mm³ should be able pressure within R.: Edema, signs of injury.

- Nausea Elevated total to demonstrate normal range. headaches, visual 2. Follow the

bilirubin: efficient fluid (from 140/90 disturbances, and prescribed

>1.2 mg/dL intake and mmHg down to abdominal pain pharmacologica

LDH and AST output. The 120/80 mmHg). are associated l regimen as

elevations patient should with HELLP evidenced by

Characteristic remain free 2. Verbalize Syndrome. Weight taking the

findings from knowledge of gain is an essential magnesium

(schistocytes) generalized or disease process, symptom of sulfate for

on a peripheral pulmonary individual risk preeclampsia-relat preventing

blood smear edema. factors, and ed HELLP seizures

Hematuria treatment plan. syndrome. Fluid

Worsening retention may be

anemia 3. Identify signs evident if the

Low serum of cardiac mother has a

decompensation. weight gain of

haptoglobin. more

Long Term: than 1.5kg/month

during the 2nd

After 3 days of trimester, or more

nursing than 0.5 kg/week

intervention, the during the 3rd

patient will: trimester.

1. Maintained - Instruct the

blood pressure patient to have

within normal bed rest and avoid

range. (from environmental

140/90 mmHg stressors.

down to 120/80

mmHg). R. To lower blood

pressure levels,

2. Absence of improve cardiac

paleness, and rate and enhance

cool and clammy renal-placental

skin. perfusion.
3. Reduced Dependent

non-pitting

edema on both - Administer

lower antihypertensives

extremities. as prescribed.

4. Absence of R.: To lower blood

restlessness. pressure levels.

5. Normal

capillary refill of

1-2 seconds.
CHAPTER V

Drug Study

The table below shows the drug's name and its effect to the users as well as the precautions

before using it.

DRUG MECHANIS INDICATIO CONTRAINDICATIO ADVERSE NURSING

NAME M OF NS NS REACTIO RESPONSIBILITIES

ACTION NS

Generic It is a beta High blood Contraindicated in Respirato Before:

name: blocker pressure patients with ry:

Observe the ten
that works bronchial asthma,
Labetalol Stuffy medication rights.
by relaxing overt cardiac
nose,
Classifica blood failure, cardiogenic Rehydrate dehydrated
Shortness
tion: vessels shock, and severe client before starting
of breath
and bradycardia. the therapy
Beta
slowing GI:
Blockers During
heart rate nausea,
Dosage: diarrhoea Regularly check for
to improve
blood pressure to
100mg blood flow
Skin:
and determine the
Edema
BID (Two
decrease response of the
times a
blood
day) patient in the
pressure.
medication.
Route:
PO After

(Oral Avoid driving or doing

Administr any hazardous activity

ation) until labetalol loses its

effect. Drinking alcohol

can further lower the

blood pressure and

may increase certain

side effects of

labetalol. Patients

should be monitored

for side effects, and

vital signs should be

checked
CHAPTER VI

METHODS

Medication

● Antihypertensive - are drugs that are used to treat high blood pressure.

● Corticosteroids - to help lungs of the fetus to mature.

Exercise

● Exercising moderately or as instructed by your healthcare provider.

Treatment

● Treatment is based on the severity of the condition and mostly aims at managing the

symptoms.

Examples include: blood transfusion, and medication to lower the blood pressure and prevent

seizures.

Health Teachings

● Educate the patient about the course of the disease. The risk of maternal and perinatal

complications and mortality should be explained to the patient and their family. The risk

of developing HELLP in subsequent pregnancies may be decreased by maintaining a

healthy lifestyle and preventing diseases such as hypertension and diabetes. Regular

exercise should be followed. Routine prenatal care and laboratory testing must be

initiated early in the subsequent pregnancies.

● Scheduling regular prenatal care visits.

● Sleeping at least eight hours per night.

OPD Instruction

N/A

Diet

● Eating lots of fruits and vegetables, and making half your plate fruits and veggies.
 ● Choosing whole grains like whole-wheat bread and pasta, oatmeal, and brown rice.

● Getting a mix of healthy proteins like lean meats, poultry, seafood, beans, nuts, and

eggs.

● Going for foods with healthy fats like olive oil, avocados, nuts, and fish.

● Eating a nutrient-dense diet of whole grains, lean protein, fruits and vegetables.

Spirituality

During the sessions, the following spiritual care must be provided:

1. Trust, empathy, and honesty between the nurse and mothers to establish a proper

communication during the sessions

2. Listening carefully to the physical and mental problems and worries and fears of patients

3. Providing psychological support from patients

4. Strengthening individuals’ inner hope and powers

5. Using positive energy sentences and strengthening healthy and constructive thoughts

6. Helping the patient find the meaning of life and understanding that none of the life

events is beyond the destiny; who believes in God over the whole world could be saved

from the feelings of pessimism, emptiness, and frustrated

7. Providing the necessary facilities for religious practices

8. Encouraging the patient to read holy books

9. Touching the hands of patients in order to provide them with mental support

10. Encouraging the patient to express their religious beliefs

11. Encouraging patients to visit religious clerics

12. Encouraging patients to refer to people who feel comfortable with them

13. Encouraging patients to enjoy entertainment and do light sports activities according to

their physician's opinion

14. Assuring the patient that the nurse is always available to her clients for mental and

psychological support

15. Seek forgiveness from past sins and forsaking anger against the perpetrator and guilty

person

16. Encouraging the mothers to enjoy music, singing, theater, cinema, art, etc.

17. Encouraging the patients to establish a friendly relationship with others

18. Encouraging the patients to laugh and do their favorite hobbies

19. Encouraging the patients to participate in religious services and social gatherings.