What is the management of pre-eclampsia (high blood pressure during pregnancy) and HELLP (Hemolysis, Elevated Liver enzymes, and Low Platelet count) syndrome?

Management of Pre-eclampsia and HELLP Syndrome

The definitive management of pre-eclampsia and HELLP syndrome requires prompt delivery once maternal coagulopathy and severe hypertension have been corrected, as this is the only curative approach to prevent worsening maternal outcomes. 1

Diagnosis and Assessment

• HELLP syndrome should be considered a manifestation of severe pre-eclampsia, characterized by hemolysis, elevated liver enzymes, and low platelet count 1
• Comprehensive maternal assessment should include:
  • Blood pressure monitoring and proteinuria evaluation
  • Complete blood count with platelet count
  • Liver function tests
  • Evaluation for hemolysis
  • Coagulation studies 1
• Abnormal liver tests frequently correlate with adverse maternal outcomes but should not be used in isolation to guide management 1

Antihypertensive Management

Non-severe Hypertension (140-159/90-109 mmHg)

• Initiate oral antihypertensive therapy using one of the following:
  • Labetalol (first-line)
  • Nifedipine
  • Methyldopa 1

Severe Hypertension (≥160/110 mmHg)

• Treat urgently in a monitored setting with:
  • Oral labetalol, nifedipine, or methyldopa
  • Consider intravenous labetalol or hydralazine if rapid control is needed 1
• Hydralazine dosing: 5 mg IV bolus, then 10 mg every 20-30 minutes to maximum of 25 mg 1
• Labetalol dosing: 20 mg IV bolus, then 40 mg 10 minutes later, followed by 80 mg every 10 minutes for 2 additional doses to maximum of 220 mg 1

Seizure Prophylaxis

• Magnesium sulfate should be administered to:
  • All women with HELLP syndrome with co-existing severe hypertension to prevent eclamptic seizures 1
  • As a neuroprotective agent for preterm pre-eclampsia if delivery is required before 32 weeks' gestation 1
• Dosing should follow local/national guidelines 1

Management of Coagulopathy

• Consider platelet transfusion in pregnant women with platelet count <100×10⁹/L due to increased risk of abnormal coagulation and adverse maternal outcomes 1
• For Caesarean section, platelet transfusion is recommended if platelet count is <50,000/mm³ 1
• Fresh frozen plasma may be needed to correct coagulation abnormalities 1, 2

Corticosteroid Management

• Corticosteroid treatment should NOT be given to improve maternal outcomes in HELLP syndrome 1
• High-dose dexamethasone or betamethasone should be administered to improve fetal lung maturity if delivery is anticipated before 35 weeks' gestation 1

Delivery Considerations

• Prompt delivery is indicated once maternal coagulopathy and severe hypertension have been corrected 1
• Immediate delivery is recommended in cases of:
  • HELLP syndrome ≥34 weeks' gestation
  • Worsening maternal condition (increasing blood pressure, cerebral symptoms, worsening hepatic or renal function)
  • Severe thrombocytopenia
  • Evidence of fetal distress 1, 2
• For pregnancies <34 weeks, expectant management may be possible under intensive monitoring of mother and fetus, but requires careful consideration of risks 2, 3

Monitoring and Post-delivery Care

• Patients should be monitored in a high-dependency or intensive care setting for at least 24-48 hours post-delivery 1
• Monitoring should include:
  • Central venous pressure
  • Urinary output
  • Blood pressure
  • ECG and oxygen saturation 1
• Liver function and platelet counts typically normalize within days to weeks after delivery 1

Special Considerations

• Abdominal ultrasound should be performed if symptoms suggest hepatic hematoma (abdominal pain, epigastric pain, right shoulder pain) 1
• Be vigilant for hepatic hemorrhage or hematoma in women with markedly reduced platelet count (<20×10⁹/L) 1
• Early referral to a transplant center should be made if there are signs of hepatic failure 1

Prevention in High-Risk Women

• Women with history of prior HELLP syndrome should undergo first-trimester screening to assess risk of early-onset pre-eclampsia 1
• For high-risk women, aspirin prophylaxis (150 mg nightly) should be started before 16 weeks' gestation and continued until 36 weeks, delivery, or diagnosis of pre-eclampsia/HELLP 1
• In women with low calcium intake (<800 mg/day), calcium supplementation (1.5-2 g elemental calcium/day) may reduce the risk of both early and late-onset pre-eclampsia 1

Common Pitfalls to Avoid

• Delaying delivery when indicated, as this can worsen maternal outcomes 1
• Using corticosteroids for maternal treatment of HELLP syndrome (not effective) 1
• Failing to administer magnesium sulfate for seizure prophylaxis in severe cases 1
• Overlooking the possibility of hepatic complications, especially with severe thrombocytopenia 1
• Managing severe cases outside of tertiary care centers with appropriate expertise 4, 5