Clinical Presentation of Preeclampsia and HELLP Syndrome
Preeclampsia presents with new-onset hypertension (≥140/90 mmHg) and proteinuria (≥300 mg/24 hours or ≥+ on dipstick) after 20 weeks' gestation, while HELLP syndrome characteristically presents with epigastric or right upper quadrant pain, nausea, and vomiting—often WITHOUT the classic signs of hypertension and proteinuria at initial presentation 1, 2.
Preeclampsia Clinical Features
Blood Pressure Criteria
- Mild-moderate hypertension: Diastolic ≥90 and <100 mmHg
- Severe hypertension: Systolic ≥160 mmHg OR Diastolic ≥100 mmHg 1
- Blood pressure measurement technique is critical—errors have been implicated in maternal deaths 1
Additional Signs to Assess After 20 Weeks
- Proteinuria (new onset)
- Symptoms that warrant immediate evaluation:
- Headache
- Visual disturbances
- Epigastric pain
- Vomiting 1
Severe Preeclampsia Indicators
- Arterial pressure exceeding 160/90 mmHg
- Proteinuria >5 g/24 hours
- Oliguria <400 ml/24 hours
- Cerebral signs
- Pulmonary edema 3
HELLP Syndrome Clinical Features
The Diagnostic Triad
HELLP syndrome is defined by laboratory findings, not clinical presentation alone:
- Hemolysis (microangiopathic hemolytic anemia)
- ELevated Liver enzymes
- LPlow Platelet count 2
Typical Presentation Pattern
Most patients (79-86%) present with vague, nonspecific symptoms that frequently lead to initial misdiagnosis 2, 4:
- Epigastric or right upper quadrant pain (most common presenting symptom) 4
- Nausea and vomiting 2
- Upper abdominal tenderness 3
- General malaise 5
Critical Diagnostic Pitfall
Hypertension and proteinuria are ABSENT at presentation in more than one-third of HELLP patients 4. In fact:
- 14% of patients are completely asymptomatic at diagnosis 4
- Hypertension may develop AFTER liver enzyme elevation and platelet decrease (atypical HELLP syndrome) 6
- Initial nonobstetric diagnoses (acute cholecystitis, drug reaction, idiopathic thrombocytopenia) are common 3, 2
Timing of Presentation
- Typically presents in early third trimester 2
- Can occur from 20 weeks' gestation through postpartum period 1
- Placental abruption and renal failure are more common before 32 weeks 1
- Eclampsia is most common at term 1
Progressive and Severe Manifestations
HELLP Syndrome Complications
- Intravascular coagulopathy (30% of cases) 2
- Placental abruption 2
- Acute renal failure 2
- Jaundice 3
- Hematuria, oliguria 3
- Acute tubular necrosis, cortical necrosis 3
- Rare but catastrophic: Acute liver rupture, adult respiratory distress syndrome 3
- Eclamptic seizures and PRES (posterior reversible encephalopathy syndrome) 7
- Intracerebral hemorrhage 7
Laboratory Correlation
The degree of thrombocytopenia correlates well with the degree of liver dysfunction 3. Platelet count shows the most rapid recovery postpartum 4.
Key Clinical Pearls
Suspect HELLP syndrome in ANY pregnant woman after 20 weeks presenting with:
- Right upper quadrant or epigastric pain
- Unexplained nausea/vomiting
- Unexplained jaundice 8
- Even in the absence of hypertension or proteinuria
The condition can progress from diagnosis to life-threatening situation in an average of two weeks, with substantial numbers requiring delivery within 72 hours 1. Maternal mortality ranges from 1-24% in reported cases 4, with perinatal mortality of 226/1000 2.
Women should be educated that preeclampsia can develop between antenatal assessments and must know how to contact healthcare professionals at all times 1.