What is the management approach for a patient with dengue who has developed Hemolysis, Elevated Liver enzymes, and Low Platelet count (HELLP) syndrome?

Management of Dengue with HELLP Syndrome

The critical first step is to definitively distinguish true HELLP syndrome from dengue-induced thrombocytopenia and liver dysfunction, as this distinction fundamentally changes management—HELLP requires expeditious delivery after maternal stabilization, while dengue requires supportive care with aggressive fluid management. 1, 2

Diagnostic Differentiation

This clinical scenario presents a diagnostic challenge because dengue and HELLP share overlapping features including thrombocytopenia, elevated liver enzymes, and potential hemolysis. 3

Key distinguishing features to assess:

• Pregnancy status and gestational age - HELLP occurs in 0.2%-0.6% of pregnancies, most commonly between weeks 27-37, with 20% occurring within 48 hours of delivery 1
• Hypertension and proteinuria - Present in 85% of HELLP cases, though 10-20% can present normotensive 1, 3
• Timing of fever - Dengue presents with fever as a primary feature, while HELLP typically does not 3, 4
• Hemoconcentration pattern - Dengue shows concurrent thrombocytopenia with hemoconcentration (rising hematocrit by 20%), while HELLP shows microangiopathic hemolytic anemia 1, 4
• Coagulation profile - HELLP shows fibrin deposition with potential DIC (10% of cases), while dengue can also cause DIC but through different mechanisms 1, 4

A critical pitfall: HELLP syndrome can masquerade in the background of dengue fever, particularly in term pregnancy with normotension, requiring strict vigilance. 3

Management Algorithm

If HELLP Syndrome is Confirmed (Pregnant Patient)

Immediate stabilization and delivery planning:

• Expeditious delivery is recommended after maternal stabilization, regardless of gestational age 1, 2
• Perform abdominal imaging (ultrasound) immediately to rule out hepatic hemorrhage, infarct, or rupture 1, 2
• Transfer to high-dependency unit or ICU for intensive monitoring 2

Pre-delivery stabilization:

• Insert central venous catheter and urinary catheter for invasive monitoring 1, 2
• Administer magnesium sulfate to prevent eclamptic seizures and provide neuroprotection 2, 5
• Control severe hypertension urgently with IV labetalol (20 mg bolus, then 40 mg after 10 minutes, then 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) 5
• Transfuse platelets if count <50,000/mm³ before Caesarean section 1, 2, 5
• Administer fresh frozen plasma to correct coagulopathy 1

Post-delivery management:

• Continue intensive monitoring for 24-48 hours minimum, including continuous blood pressure, oxygen saturation, ECG, central venous pressure, and hourly urinary output 2
• Perform serial complete blood counts and liver function tests 2
• Monitor vigilantly for hepatic hemorrhage (abdominal pain, epigastric pain, right shoulder pain), especially with platelet count <20×10⁹/L 2
• Transfer to transplant center if signs of hepatic failure develop 1, 2

Critical caveat: Do NOT give corticosteroids to improve maternal outcomes in HELLP syndrome 2, 5

If Dengue Fever is Confirmed (Non-pregnant or Dengue Without HELLP)

Supportive management with aggressive fluid resuscitation:

• Admit to ICU only cases with shock or unstable vital signs 4
• Monitor hematocrit rise of 20% along with continuing platelet drop as indicator for onset of shock 4
• Provide rapid fluid replacement with both crystalloids and colloids for plasma losses through increased capillary permeability 4
• Give crystalloid boluses as rapidly as possible (2-3 boluses may be needed in profound shock) 4
• Add colloidal fluids (including albumin) for massive plasma leakage or when large crystalloid volumes have been given 4
• Provide mandatory oxygen in all shock cases 4
• Transfuse blood products (blood, FFP, platelets) if DIC develops 4
• Avoid drainage of pleural effusion or ascites as it can lead to severe hemorrhage and sudden circulatory collapse 4

Consider dengue-associated hemophagocytic lymphohistiocytosis (HLH) if:

• Prolonged or recurrent fever >7 days 6
• Anemia without intravascular hemolysis or massive bleeding 6
• Fulfills at least 5 of 8 HLH-2004 criteria 6
• Treatment: Short courses (3-4 days) of high-dose dexamethasone 10 mg/m² 6

If Both Conditions Coexist (Dengue in Pregnant Patient with HELLP)

Prioritize HELLP management with delivery as definitive treatment, while simultaneously addressing dengue-specific complications:

• Proceed with expeditious delivery after maternal stabilization per HELLP protocol 1, 2
• Provide aggressive fluid resuscitation accounting for both HELLP-related plasma loss and dengue-induced capillary leak 4
• Monitor even more vigilantly for hemorrhagic complications given dual pathology 4, 7
• Avoid drainage of polyserositis (pleural effusion, ascites) which is common in dengue shock syndrome 4
• Maintain strict fluid balance monitoring to prevent pulmonary edema while managing plasma losses 2, 4

Anesthetic considerations for delivery:

• Spinal anesthesia is first choice if only moderate, non-progressive thrombocytopenia 7
• If general anesthesia required, control stress response to intubation to prevent cerebral complications in severe hypertension 7
• Anticipate difficult airway and full stomach requiring rapid sequence intubation 7