What is the definitive management for a pregnant woman in her third trimester with severe hypertension, thrombocytopenia, and elevated liver enzymes, but reassuring fetal status?

Definitive Management of HELLP Syndrome in Third Trimester

Prompt delivery is the definitive management once maternal coagulopathy and severe hypertension have been corrected. 1, 2

Immediate Stabilization Before Delivery

Blood Pressure Control

• Initiate urgent antihypertensive therapy immediately for severe hypertension (≥160/110 mmHg) in a monitored setting 1, 2
• Use oral labetalol, nifedipine, or methyldopa as first-line agents 1, 2
• If oral agents are insufficient, administer intravenous labetalol (20 mg bolus, then 40 mg after 10 minutes, followed by 80 mg every 10 minutes for 2 additional doses, maximum 220 mg) or hydralazine (5 mg IV bolus, then 10 mg every 20-30 minutes, maximum 25 mg) 2
• Target diastolic blood pressure of 85-100 mmHg and systolic <160 mmHg 1, 2

Seizure Prophylaxis

• Administer magnesium sulfate immediately to prevent eclamptic seizures given the severe hypertension and HELLP syndrome 1, 2
• Continue magnesium sulfate through delivery and for 24-48 hours postpartum 2

Correction of Coagulopathy

• Transfuse platelets if count <50,000/mm³ in preparation for delivery, particularly if cesarean section is anticipated 2
• Ensure availability of cross-matched blood products given the hemorrhage risk 1
• Obtain coagulation studies to assess for DIC 2

Timing and Mode of Delivery

Deliver promptly once hypertension is controlled and coagulopathy is corrected—do not delay. 1, 2 The evidence strongly supports that delayed delivery worsens maternal outcomes in HELLP syndrome 1. With severe features present (platelets 70,000/mm³, AST 420, severe hypertension), this patient meets criteria for immediate delivery after stabilization 1.

• Mode of delivery should be determined by standard obstetric indications, not by the HELLP syndrome itself 1
• The reassuring fetal tracing does not change the need for prompt delivery, as maternal indications take precedence 1, 2

Critical Monitoring

Peripartum Period

• Monitor in high-dependency or intensive care setting for at least 24-48 hours post-delivery 2
• Continuous monitoring should include central venous pressure, urinary output, blood pressure, ECG, and oxygen saturation 2
• Repeat platelet count and liver enzymes every 12-24 hours until improving 2

Hepatic Complications

• Perform abdominal ultrasound if the patient develops severe epigastric or right upper quadrant pain to evaluate for hepatic hematoma or rupture 1, 2
• Be particularly vigilant given the markedly elevated AST and low platelets, which increase risk of hepatic hemorrhage 1

What NOT to Do

• Do not administer corticosteroids to improve maternal outcomes—they are ineffective for HELLP syndrome management 1, 2
• Do not attempt expectant management or delay delivery in third trimester HELLP with severe features 1
• Do not use sodium nitroprusside (risk of fetal cyanide toxicity) 3

Postpartum Considerations

• Liver function tests and platelet counts typically normalize within days to weeks after delivery 2
• Continue antihypertensive therapy postpartum as needed 3
• Counsel regarding 19-27% recurrence risk in future pregnancies and recommend aspirin prophylaxis (150 mg nightly starting before 16 weeks) in subsequent pregnancies 2