What is the treatment for HELLP (Hemolysis, Elevated Liver enzymes, and Low Platelet count) syndrome?

Treatment of HELLP Syndrome

Immediate delivery is the only definitive treatment for HELLP syndrome, regardless of gestational age, with timing based on maternal condition and fetal status. 1

Diagnosis and Initial Management

HELLP syndrome is a severe form of preeclampsia characterized by:

• Hemolysis
• Elevated Liver enzymes
• Low Platelet count

Initial laboratory assessment should include:

• Complete blood count with peripheral smear
• Liver function tests (AST, ALT)
• Lactate dehydrogenase (LDH)
• Serum haptoglobin
• Coagulation studies (especially if platelets <100,000/mm³)
• Renal function tests
• Urinalysis for proteinuria 1, 2

Treatment Algorithm

Step 1: Immediate Hospitalization and Stabilization

• Admit to a monitored setting with maternal-fetal surveillance
• Monitor vital signs and fetal well-being
• Obtain baseline laboratory values
• Assess for complications (abdominal pain, neurological symptoms)

Step 2: Blood Pressure Management

• Target blood pressure: systolic 110-140 mmHg, diastolic 85 mmHg 1
• First-line medications:
  • IV labetalol: 10-20 mg initially, then 20-80 mg every 10-30 minutes (max 220 mg)
  • IV hydralazine: 5-10 mg every 15-30 minutes
  • IV nicardipine: Start at 5 mg/h, increase by 2.5 mg/h every 5-15 minutes (max 15 mg/h)
  • Oral nifedipine may be used if IV options unavailable 1

Step 3: Seizure Prophylaxis

• Magnesium sulfate is indicated for all HELLP patients:
  • Loading dose: 4-5g IV over 15-20 minutes
  • Maintenance: 1-2g/hour by continuous IV infusion
  • Continue for at least 24 hours postpartum 1

Step 4: Delivery Planning

• Delivery is the definitive treatment
• Mode of delivery considerations:
  • Cesarean section is preferred if:
    • Neurological status is deteriorating
    • Fetal distress is present
    • Maternal condition is unstable
  • Vaginal delivery may be considered if maternal and fetal conditions are stable 1, 3

Step 5: Platelet Management

• If platelet count <50,000/mm³ or active bleeding:
  • Platelet transfusion before delivery or invasive procedures
  • Consider fresh frozen plasma if coagulopathy present 4

Step 6: Postpartum Care

• Continue magnesium sulfate for at least 24 hours postpartum
• Monitor laboratory values (HELLP typically peaks 24 hours after delivery)
• Continue antihypertensive therapy as needed
• Close monitoring for complications (DIC, renal failure, pulmonary edema) 1, 2

Special Considerations

Anesthetic Management

• Neuroaxial anesthesia (spinal) is preferred if platelets >70,000-80,000/mm³ and stable
• General anesthesia may be required if:
  • Severe thrombocytopenia (<50,000/mm³)
  • Coagulopathy present
  • Neurological symptoms present 4

Severe Cases

• Consider intensive care unit admission
• Invasive monitoring may be necessary
• In rare cases of extended atypical HELLP not responding to delivery, plasma exchange has been used 2

Follow-up Care

• Review at 3 months postpartum to ensure:
  • Resolution of hypertension
  • Normalization of laboratory values
  • Resolution of proteinuria
• Counsel regarding increased risk in future pregnancies
• Consider aspirin prophylaxis (150 mg nightly) before 16 weeks' gestation in future pregnancies 1

Common Pitfalls and Caveats

• Delayed diagnosis and treatment can lead to significant maternal and fetal morbidity and mortality 3
• HELLP can present with incomplete features (partial HELLP) but should be treated with the same urgency 5, 6
• HELLP can develop postpartum (typically within 48 hours) and requires the same management approach 5
• The condition typically worsens before improving after delivery, with peak intensity at 24 hours postpartum 2
• Avoid NSAIDs for postpartum analgesia due to potential renal effects 1