From the Guidelines
HELLP syndrome at 36+5 weeks gestation requires immediate delivery to prevent maternal and fetal complications. This serious variant of preeclampsia is characterized by Hemolysis, Elevated Liver enzymes, and Low Platelets. Management includes stabilizing the mother with magnesium sulfate for seizure prophylaxis, as recommended by 1, and blood pressure control with labetalol or nifedipine if severe hypertension. According to 1, magnesium sulphate should be given to women with HELLP syndrome with co-existing severe hypertension to prevent eclamptic seizures.
Key Management Steps
- Stabilize the mother with magnesium sulfate for seizure prophylaxis, with a dose as per local/national guidance 1
- Control blood pressure with labetalol, nifedipine, or methyldopa, as recommended by 1
- Prepare for delivery, as women with HELLP syndrome should be delivered promptly once maternal coagulopathy and severe hypertension have been corrected 1
- Laboratory monitoring should include complete blood count, liver function tests, coagulation studies, and kidney function tests every 6-12 hours
- Platelet transfusion may be necessary if counts fall below 20,000/μL or before cesarean delivery if below 50,000/μL
- Corticosteroids, such as betamethasone, should be considered if delivery might be delayed and gestational age is earlier, as recommended by 1
Important Considerations
- Close maternal and fetal monitoring in an intensive care setting is essential, as HELLP syndrome can rapidly progress to disseminated intravascular coagulation, liver hematoma, renal failure, pulmonary edema, or placental abruption
- Abdominal ultrasound should be performed if there are symptoms suggestive of hepatic haematoma, as recommended by 1
- Early referral to a transplant centre should be made if there are signs of hepatic failure that may require transplantation, as recommended by 1
From the Research
Diagnosis and Classification of HELLP Syndrome
- HELLP syndrome is characterized by haemolysis, elevated liver enzymes, and low platelet count, occurring in 0.5 to 0.9% of all pregnancies and in 10-20% of cases with severe preeclampsia 2.
- The Tennessee Classification System diagnostic criteria for HELLP are haemolysis with increased LDH (> 600 U/L), AST (>or= 70 U/L), and platelets < 100 x 10(9)/L 2.
- The Mississippi Triple-class HELLP System further classifies the disorder by the nadir platelet counts 2.
Management and Treatment of HELLP Syndrome
- Delivery is indicated if the HELLP syndrome occurs after the 34th gestational week or the fetal and/or maternal conditions deteriorate 2, 3.
- Vaginal delivery is preferable, and if the cervix is unfavourable, it is reasonable to induce cervical ripening and then labour 2.
- Corticosteroid treatment may be considered in selected cases < 34 weeks' gestation, but its clinical value in maternal HELLP syndrome is uncertain 2, 3, 4.
- High-dose treatment and repeated doses of corticosteroids should be avoided for fear of long-term adverse effects on the fetal brain 2.
Specific Considerations for a 36+5 Pregnant Lady
- At 36+5 weeks of gestation, delivery is likely indicated due to the high risk of complications associated with HELLP syndrome 2, 3.
- The decision to deliver should be based on the individual patient's condition and the presence of any fetal or maternal distress 2, 3.
- Close surveillance of the mother should be continued for at least 48 hours after delivery to monitor for any potential complications 2.
Differential Diagnosis and Long-term Implications
- HELLP syndrome should be differentiated from other pregnancy-related disorders, such as acute fatty liver of pregnancy, thrombotic thrombocytopenic purpura, antiphospholipid syndrome, and hemolytic uremic syndrome 4, 5.
- The maternal mortality rate for HELLP syndrome in developed countries is approximately 1%, and perinatal mortality rates are 7-20% 5.
- HELLP syndrome is associated with an increased risk of developing cardiovascular, metabolic, and neurological diseases in later life 5.