Can HELLP Syndrome Present with Increased INR and Ascites?
Yes, HELLP syndrome can present with both increased INR and ascites, though these findings indicate severe disease with significantly elevated maternal mortality risk and should prompt immediate intensive care management.
Increased INR in HELLP Syndrome
While classic HELLP syndrome typically presents with normal prothrombin time (PT) and INR in uncomplicated cases 1, elevated INR occurs when the disease progresses to disseminated intravascular coagulation (DIC) or severe hepatic dysfunction:
- DIC complicates approximately 29% of HELLP cases requiring intensive care, making it one of the most common severe complications 2
- Elevated INR is a critical predictor of maternal mortality in HELLP syndrome patients requiring ICU admission 2
- Non-surviving patients with HELLP syndrome had significantly higher mean INR compared to survivors (p < 0.0001), along with higher AST, ALT, LDH, and bilirubin levels 2
- High INR is associated with increased risk for major complications including hemorrhage, hepatic rupture, and multi-organ failure 2
The progression from normal coagulation parameters to elevated INR represents a transition from isolated thrombocytopenia to consumptive coagulopathy, signaling critical illness 3, 2.
Ascites in HELLP Syndrome
Large-volume ascites occurs in approximately 10% of HELLP syndrome patients undergoing cesarean delivery and represents a critical warning sign for life-threatening cardiopulmonary complications 4:
Prognostic Significance of Ascites
- Patients with HELLP-associated ascites have a sixfold increased incidence of congestive heart failure compared to those without ascites 4
- These patients have a ninefold increased incidence of adult respiratory distress syndrome (ARDS) 4
- Cardiopulmonary complications typically manifest within 24 hours postpartum in patients with ascites, versus more than 24 hours in those without ascites 4
Pathophysiology
The ascites in HELLP syndrome results from:
- Endothelial dysfunction and increased capillary permeability 4
- Hypoalbuminemia from hepatic dysfunction (albumin levels can drop to 33 g/L or lower) 1
- Intravascular fibrin deposition and hypovolemia affecting hepatic perfusion 5
Critical Management Implications
When Both INR Elevation and Ascites Are Present
This combination indicates extremely high-risk disease requiring:
- Immediate transfer to ICU or high-dependency unit with continuous monitoring of blood pressure, central venous pressure, urinary output, ECG, and oxygen saturation 6, 7
- Central venous catheter placement to guide fluid management, as these patients are paradoxically hypovolemic despite ascites 1, 7
- Cautious fluid administration to avoid precipitating congestive heart failure or ARDS, particularly in the first 24 hours postpartum 4
- Fresh frozen plasma administration to correct coagulopathy before any surgical intervention 1
- Platelet transfusion if count is <50,000/mm³ before cesarean section 6, 7
Laboratory Monitoring
Monitor every 6-12 hours for at least 24-48 hours postpartum 8, 6:
- Complete blood count with platelets
- PT/INR and aPTT
- Fibrinogen levels
- AST, ALT, LDH, total bilirubin
- Renal function tests
Delivery Timing
Prompt delivery is indicated once maternal coagulopathy is corrected and severe hypertension controlled 6, 7. Do not delay delivery waiting for laboratory normalization, as HELLP syndrome only resolves after delivery and maternal mortality reaches 3.4-24% with delayed intervention 6, 3.
Common Pitfalls to Avoid
- Do not use regional anesthesia (epidural/spinal) with elevated INR or platelets <100,000/mm³ due to risk of epidural hematoma 6, 7, 3
- Do not aggressively fluid resuscitate patients with ascites without invasive hemodynamic monitoring, as this precipitates pulmonary edema 4
- Do not assume normal coagulation based on platelet count alone—INR and fibrinogen must be checked 2
- Maintain vigilance for hepatic complications including subcapsular hematoma or rupture, especially with severe thrombocytopenia and persistent right upper quadrant pain 8, 7
The presence of both elevated INR and ascites in HELLP syndrome represents a medical emergency with maternal mortality risk potentially exceeding 14-24% 3, 2, 5, requiring immediate multidisciplinary critical care management.