What is the appropriate workup after pregnancy for a patient with a history of HELLP (Hemolysis, Elevated Liver enzymes, and Low Platelet count) syndrome in pregnancy?

From the Guidelines

For women with a history of HELLP syndrome, postpartum follow-up should include comprehensive evaluation at 6-12 weeks after delivery, focusing on blood pressure monitoring, complete blood count, liver function tests, and renal function assessment to ensure complete resolution of abnormalities. This approach is crucial in identifying any potential long-term complications and managing them appropriately to reduce morbidity and mortality. The comprehensive evaluation should include:

• Blood pressure monitoring to assess for persistent hypertension
• Complete blood count to evaluate for any residual hematological abnormalities
• Liver function tests to ensure complete resolution of liver enzyme elevations
• Renal function assessment to monitor for any signs of renal impairment

According to the study by 1, the diagnosis of HELLP syndrome is suspected on clinical grounds and confirmed by laboratory investigations, and the condition tends to resolve soon after delivery. However, it is essential to monitor for any potential complications, such as haematuria, oliguria, acute tubular necrosis, and cortical necrosis.

In terms of management, if hypertension persists beyond 12 weeks postpartum, antihypertensive therapy should be initiated, such as labetalol 100-400 mg twice daily or nifedipine 30-90 mg daily as extended-release formulation. Additionally, screening for underlying conditions that may have contributed to HELLP syndrome is necessary, including thrombophilias, autoimmune disorders, and chronic hypertension.

It is also essential to counsel patients about future pregnancy risks, as women with prior HELLP syndrome have a 20-25% recurrence risk in subsequent pregnancies. Prophylactic low-dose aspirin (81-150 mg daily) starting at 12-16 weeks gestation is recommended for future pregnancies, along with close monitoring throughout pregnancy with more frequent prenatal visits and serial growth ultrasounds. This comprehensive approach is necessary to optimize management of both the patient's long-term health and future pregnancies.

From the Research

Post-Pregnancy Workup for HELLP Syndrome

The appropriate workup after pregnancy for a patient with a history of HELLP syndrome involves monitoring for potential complications and assessing the risk of recurrence in future pregnancies.

• Laboratory tests such as complete blood count with peripheral smear, lactate dehydrogenase, serum transaminases, and urinalysis are essential for diagnosis and follow-up 2.
• The platelet count and lactate dehydrogenase levels are the most reliable indicators for monitoring the course of the disease 2, 3.
• The intensity of the HELLP syndrome typically peaks 24 hours after delivery, and close surveillance of the mother should be continued for at least 48 hours after delivery 2, 4.
• The risk of recurrence of the HELLP syndrome in subsequent gestations is estimated to be 19% to 27% 5.

Laboratory Findings

The characteristic laboratory changes in pregnancies complicated by HELLP syndrome include:

• Significant increase in liver enzymes such as AST and LDH 3
• Low platelet count, with the nadir platelet count being a critical factor in determining the severity of the disease 4, 3
• Elevated total bilirubin levels, indicating the degree of hemolysis 3
• The AST, LDH, and bilirubin levels typically return to normal between the third and seventh days postpartum, while the platelet count may take longer to recover 3

Management and Counseling

The management of HELLP syndrome involves prompt delivery, with vaginal delivery being preferable if the cervix is favorable 4.

• Corticosteroid therapy may be considered in selected cases, but its clinical value in the maternal HELLP syndrome is uncertain 4, 6.
• Women with a history of HELLP syndrome should be counseled about the risk of recurrence in future pregnancies and the potential for adverse outcomes 5, 6.