Should steroids be administered to a patient with HELLP (Hemolysis, Elevated Liver enzymes, and Low Platelet count) syndrome at 5cm dilation?

Steroids in HELLP Syndrome at 5cm Dilation

Corticosteroid treatment should NOT be given to improve maternal outcomes in HELLP syndrome, but high-dose dexamethasone or betamethasone should be administered to improve fetal lung maturity if delivery will occur before 35 weeks' gestation. 1

Maternal Corticosteroid Use in HELLP Syndrome

The 2023 European Association for the Study of the Liver (EASL) clinical practice guidelines provide clear direction regarding corticosteroid use in HELLP syndrome:

• Corticosteroids should not be administered to improve maternal outcomes in HELLP syndrome (Level of Evidence 1; strong recommendation) 1
• However, high-dose dexamethasone or betamethasone should be given according to national guidance to improve fetal lung maturity if delivery will occur before 35 weeks' gestation (Level of Evidence 1; strong recommendation) 1

Management Approach for HELLP Syndrome at 5cm Dilation

At 5cm dilation, the patient is in active labor and delivery is imminent. Management should focus on:

1. Delivery planning:

   • Women with HELLP syndrome should be delivered promptly once maternal coagulopathy and severe hypertension have been corrected 1
   • At 5cm dilation, vaginal delivery is preferable if there are no other obstetric contraindications 2

2. Blood pressure control:

   • For non-severe hypertension (140-159/90-109 mmHg): oral labetalol, nifedipine, or methyldopa 1, 3
   • For severe hypertension (>160/110 mmHg): urgent treatment with oral labetalol, nifedipine, or IV labetalol/hydralazine in a monitored setting 1, 3
   • Target diastolic BP of 85 mmHg (systolic 110-140 mmHg) 3

3. Seizure prophylaxis:

   • Magnesium sulfate should be administered to prevent eclamptic seizures, especially with co-existing severe hypertension 1, 3
   • Loading dose: 4-5g IV over 15-20 minutes, followed by maintenance of 1-2g/hour continuous infusion 3

4. Platelet management:

   • Consider platelet transfusion if count is <50,000/mm³, especially if delivery is imminent 1
   • Monitor coagulation parameters and correct any coagulopathy before delivery 1

Corticosteroids for Fetal Lung Maturity

If the pregnancy is <35 weeks' gestation:

• Administer betamethasone (2 doses of 12 mg, 24 hours apart) or dexamethasone (4 doses of 6 mg, 12 hours apart) for fetal lung maturation 1, 2
• This is a standard recommendation for any preterm delivery, not specific to HELLP syndrome

Common Pitfalls to Avoid

1. Confusing maternal and fetal indications for steroids:

   • Despite some older studies suggesting maternal benefits 4, 5, the most recent high-quality evidence does not support corticosteroid use for maternal improvement in HELLP syndrome 1, 6
   • The 2004 Cochrane review concluded there was insufficient evidence that adjunctive steroid use decreases maternal and perinatal mortality or major morbidity 6

2. Delaying delivery inappropriately:

   • At 5cm dilation with HELLP syndrome, delivery should not be significantly delayed
   • HELLP syndrome is a progressive condition with serious complications 2
   • Delivery is the definitive treatment for HELLP syndrome 1, 3

3. Inadequate maternal monitoring:

   • Close surveillance should continue for at least 48 hours after delivery 2
   • Monitor for worsening liver function, decreasing platelet counts, and signs of hepatic hemorrhage 1

By following these evidence-based recommendations, you can optimize outcomes for both mother and baby in this high-risk situation.