From the Guidelines
HELLP syndrome and DIC are distinct conditions, but HELLP syndrome can progress to DIC, and the primary goal is to prevent this progression by promptly managing HELLP syndrome through delivery and supportive care, as evidenced by the most recent guidelines 1.
Key Differences
- HELLP syndrome is characterized by Hemolysis, Elevated Liver enzymes, and Low Platelets, typically occurring in the third trimester of pregnancy or immediately postpartum, often in women with preeclampsia.
- DIC is a more severe coagulation disorder characterized by widespread clotting followed by excessive bleeding due to consumption of clotting factors.
Laboratory Findings
- HELLP syndrome: moderate thrombocytopenia (20,000-100,000/μL), elevated liver enzymes (AST, ALT), and evidence of hemolysis (elevated LDH, decreased haptoglobin, schistocytes).
- DIC: more severe coagulation abnormalities including prolonged PT/PTT, severely decreased fibrinogen, elevated D-dimer, and often more profound thrombocytopenia.
Treatment
- HELLP syndrome: delivery of the fetus (the definitive treatment), blood pressure control using oral labetalol, nifedipine, or methyldopa 1, magnesium sulfate for seizure prophylaxis, and supportive care.
- DIC management: targets the underlying cause while providing supportive care with blood products (platelets, fresh frozen plasma, cryoprecipitate) to replace consumed factors.
Prevention of Progression
- Prompt recognition and management of HELLP syndrome are crucial to prevent progression to DIC, as evidenced by the recent guidelines 1.
- Women with HELLP syndrome should be delivered promptly once maternal coagulopathy and severe hypertension have been corrected, as there is evidence for worse maternal outcomes if this is not done 1.
- Corticosteroid treatment should not be given to improve maternal outcomes in HELLP syndrome, but high-dose dexamethasone or betamethasone should be given as per national guidance to improve fetal lung maturity if a pregnancy complicated by HELLP syndrome is to be delivered before 35 weeks’ gestation 1.
From the Research
Comparison of HELLP and DIC
- HELLP syndrome is a serious complication in pregnancy characterized by haemolysis, elevated liver enzymes, and low platelet count, occurring in 0.5 to 0.9% of all pregnancies and in 10-20% of cases with severe preeclampsia 2, 3.
- Disseminated intravascular coagulation (DIC) is a condition that can complicate HELLP syndrome, occurring in 15-38% of patients 4.
- The main difference between HELLP and DIC is the coagulation abnormality, with HELLP syndrome having normal prothrombin time, activated partial thromboplastin time, and serum fibrinogen levels, whereas DIC has prolonged levels of these parameters 4.
- Evaluation of more sensitive markers of DIC, such as antithrombin III, α-2 antiplasmin, plasminogens, fibrin monomer, and D-dimers, can differentiate DIC from HELLP syndrome 4.
Management of HELLP and DIC
- Aggressive treatment is indicated for patients with DIC complicating HELLP syndrome, including delivery, control of blood pressure, and coagulation abnormality 4.
- Delivery is indicated if the HELLP syndrome occurs after the 34th week or the fetal and/or maternal conditions deteriorate, with vaginal delivery being preferable 2, 3.
- Corticosteroids may be used in the treatment of HELLP syndrome, although their effectiveness is still uncertain, and they may improve platelet count but not necessarily substantive clinical outcomes 5, 6.
- Close surveillance of the mother should be continued for at least 48 hours after delivery, and recognition of HELLP syndrome and an aggressive multidisciplinary approach are required for the improvement of materno-fetal prognosis 2, 3.