Who monitors the Lactate Dehydrogenase (LDH) level in Hemolysis, Elevated Liver enzymes, and Low Platelet count (HELLP) syndrome?

Monitoring LDH Levels in HELLP Syndrome

The obstetric and anesthesiology teams are responsible for monitoring LDH levels in HELLP syndrome, as elevated LDH is a critical diagnostic marker reflecting both hemolysis severity and hepatic dysfunction in this life-threatening pregnancy complication. 1, 2

Importance of LDH Monitoring in HELLP Syndrome

• LDH (lactate dehydrogenase) is one of the key laboratory parameters used to:

  • Diagnose HELLP syndrome (values >600 U/L are diagnostic) 3
  • Track disease progression and severity 2
  • Guide treatment decisions 4
  • Determine timing of delivery 1
  • Monitor post-delivery recovery 4

• LDH levels reflect two critical aspects of HELLP syndrome:

  • Degree of hemolysis (the "H" in HELLP)
  • Extent of hepatic dysfunction (the first "L" in HELLP) 5

Monitoring Timeline and Pattern

• Initial diagnosis: LDH is measured as part of the initial laboratory assessment when HELLP syndrome is suspected 1, 6

• During disease progression: LDH should be monitored regularly (at least twice weekly) along with other parameters 6

• Post-delivery: LDH typically returns to normal between the third and seventh days postpartum 2

• Laboratory value normalization sequence:

  1. AST (first to normalize)
  2. Hemoglobin
  3. Platelet count
  4. LDH (last parameter to normalize) 4

Clinical Decision Making Based on LDH

• LDH values at admission can predict HELLP syndrome severity:

  • Elevated admission LDH has a 74% probability of predicting Class 1 (most severe) HELLP syndrome 7
  • When combined with elevated AST and ALT at admission, the predictive probability increases to 90% 7

• Persistently elevated LDH after delivery indicates ongoing disease activity requiring continued monitoring and potentially extended treatment 4

Monitoring Protocol

• Regular LDH monitoring should be performed:
  • At initial presentation with suspected HELLP
  • At least twice weekly during conservative management 6
  • Daily in severe cases or in ICU settings 1
  • For at least 48-72 hours post-delivery 6
  • Until normalization occurs (typically 3-7 days postpartum) 2

Pitfalls to Avoid

• Relying solely on platelet counts for disease monitoring - LDH is often a better indicator of disease progression 2

• Premature discontinuation of monitoring - LDH is typically the last parameter to normalize 4

• Failing to recognize that normal LDH levels post-treatment indicate successful disease resolution and may guide decisions about discharge 4

• Missing the correlation between LDH levels and disease severity - higher values correlate with more severe disease and poorer outcomes 7