Treatment for HELLP Syndrome
Immediate delivery after maternal stabilization is the definitive treatment for HELLP syndrome, as this condition only resolves after delivery, with maternal mortality reaching 3.4% when intervention is delayed. 1, 2
Initial Stabilization and Monitoring
Immediately initiate magnesium sulfate for seizure prophylaxis in all women with HELLP syndrome and severe hypertension. 2 This should be continued for 24 hours after delivery. 3
Blood Pressure Control
- Control hypertension using IV magnesium sulfate or hydralazine for severe elevations (>160/90 mmHg). 1
- For severe hypertension requiring urgent treatment, use IV labetalol or hydralazine in a monitored setting. 3
- For non-severe hypertension, oral labetalol, nifedipine, or methyldopa are appropriate options. 3
Critical Monitoring Requirements
- Transfer to ICU or high-dependency unit for continuous monitoring of blood pressure, central venous pressure, urinary output, ECG, and oxygen saturation. 2
- Insert urinary catheter for hourly output monitoring, with oliguria <400 mL/24h indicating severe disease. 2
- Consider central venous catheter in critically ill patients, as these patients are often relatively hypovolemic. 1, 2
Laboratory Assessment and Monitoring
Perform comprehensive laboratory investigations immediately:
- Platelet count, white blood cell count, PCV, partial thromboplastin time. 1
- Fibrinogen concentration, fibrin degradation products, peripheral blood smear. 1
- Liver function tests (AST, ALT, LDH, total bilirubin), creatinine, urea, and uric acid levels. 1, 2
- Serial monitoring every 6-12 hours for at least 24-48 hours postpartum, as 30% of HELLP cases occur or worsen postpartum. 2
The platelet count and LDH are the two best tests to monitor disease progression. 2, 4
Blood Product Management
Transfuse platelets if count is <50,000/mm³, especially if cesarean delivery is planned. 1, 2 This is mandatory before any surgical intervention at this threshold. 2
- Transfuse whole blood or packed red cells if hemoglobin is <10 g/dL. 1, 3
- Platelet transfusion should be strongly considered at levels >50,000/mm³ given the increased risk of abnormal coagulation and bleeding complications. 2
Indications for Immediate Delivery
Proceed with prompt delivery once maternal coagulopathy is corrected and severe hypertension is controlled. 2 Do not delay delivery waiting for laboratory values to normalize. 2
Specific indications include:
- Worsening pre-eclampsia or deteriorating hepatic/renal function. 1
- Severe thrombocytopenia (platelets <50,000/mm³). 1
- Gestational age at or beyond 32-34 weeks. 1
- Evidence of fetal distress or fetal maturity. 1
- Any gestational age if maternal condition deteriorates. 2
Mode of Delivery
- Expect high cesarean section rates (61.5-76%) due to obstetric indications. 1, 2
- If general anesthesia is required, use propofol (minimal hepatic/renal metabolism). 1
- Consider rapid sequence induction with suxamethonium for airway management. 1
Anesthetic Considerations and Critical Pitfall
Do NOT use regional anesthesia (epidural/spinal) with platelets <100,000/mm³ due to risk of epidural hematoma. 2 This is a critical safety threshold that must be respected.
Fluid Management
Maintain strict fluid balance to avoid pulmonary edema, continuing this approach for 24 hours after delivery. 3 Avoid aggressive fluid resuscitation that might be reflexively given in other critically ill patients, as this significantly increases pulmonary edema risk. 3
Imaging and Hepatic Complications
Perform abdominal imaging (ultrasound or CT) in all patients with right upper quadrant or epigastric pain to rule out subcapsular hematoma or hepatic rupture. 2 This occurs in 65% of symptomatic HELLP patients and requires immediate attention. 2
- If hepatic rupture is identified, proceed with expeditious delivery after maternal stabilization, regardless of gestational age. 2
- Monitor for signs of hepatic hemorrhage including abdominal pain, epigastric pain, or right shoulder pain. 3
- Early referral to a transplant center is necessary if signs of hepatic failure develop. 3
Post-Delivery Management
Continue intensive monitoring and management:
- Blood pressure control and strict fluid management. 1, 3
- Watch for complications including hemorrhage, renal failure, and pulmonary edema. 1
- Monitor for hypoglycemia during management. 1, 3
- Obtain chest X-ray to exclude pulmonary edema and ECG. 1
Important Caveats
Do NOT administer corticosteroids to improve maternal HELLP outcomes, as they are ineffective for maternal disease. 2, 3 While dexamethasone may be used in specific protocols for disease management 5, corticosteroids do not improve maternal outcomes according to major guidelines.
- Delayed diagnosis is common as symptoms may mimic acute cholecystitis, drug reactions, or idiopathic thrombocytopenia. 1, 3
- Markedly reduced platelet count (<20×10⁹/L) correlates with higher risk of hepatic hemorrhage. 3