Treatment of HELLP Syndrome
Delivery is the only definitive treatment for HELLP syndrome and should be performed promptly once maternal coagulopathy and severe hypertension have been corrected, as delaying delivery is associated with worse maternal outcomes. 1
Immediate Maternal Stabilization
Before delivery, focus on correcting life-threatening maternal conditions:
- Control severe hypertension (systolic BP >160 or diastolic BP >110 mmHg) urgently with labetalol, nifedipine, or oral methyldopa; use IV labetalol or hydralazine if oral agents are insufficient 1, 2
- Administer magnesium sulfate to prevent eclamptic seizures (level 1 evidence) and provide fetal neuroprotection if delivery occurs before 32 weeks of gestation 1, 2
- Transfuse platelets if count is <50,000/mm³ to reduce bleeding risk, particularly if cesarean delivery is planned 2, 3
- Transfuse packed red blood cells if hemoglobin is <10 g/dL 2, 3
Timing and Mode of Delivery
The decision to deliver should be made based on:
- Immediate delivery indications include worsening pre-eclampsia, deteriorating hepatic or renal function, severe thrombocytopenia, gestational age ≥32-34 weeks, evidence of fetal distress, or evidence of fetal maturity 3
- Cesarean section is frequently required (61.5-76% of cases) due to obstetric indications 3
- Before 32 weeks gestation, a brief delay for corticosteroid administration may be considered, but only for fetal lung maturation benefit, not maternal improvement 1
Critical Caveat on Corticosteroids
Do not administer corticosteroids to improve maternal outcomes in HELLP syndrome (EASL strong recommendation, level 1 evidence) 1, 2. Corticosteroids (dexamethasone or betamethasone in high doses) should only be given for fetal lung maturation when delivery is anticipated before 35 weeks of gestation, following national guidelines 1. While some older literature suggested maternal benefit, current high-quality guidelines explicitly recommend against this practice 4.
Post-Delivery Management
The immediate 24-48 hours after delivery are critical, as HELLP syndrome typically peaks 24 hours post-delivery 5:
- Continue magnesium sulfate for 24 hours post-delivery 1, 2
- Maintain strict fluid balance for 24 hours to prevent pulmonary edema—avoid aggressive fluid resuscitation that might reflexively be given to other critically ill patients 2
- Transfer to high-dependency unit or ICU for continuous monitoring of vital signs, blood pressure, oxygen saturation, ECG, and central venous pressure 2
- Insert urinary catheter for hourly output monitoring to assess renal function 2, 3
Monitoring for Complications
Laboratory Surveillance
- Serial complete blood counts to monitor platelets and hemoglobin 2
- Liver function tests to track enzyme levels 2
- Coagulation profile including fibrinogen and fibrin degradation products 2, 3
- Renal function tests (creatinine and urea) 2, 3
- Lactate dehydrogenase and platelet count are the two best tests to monitor disease course 5
Hepatic Complications
- Monitor for hepatic hemorrhage or hematoma by watching for abdominal pain, epigastric pain, or right shoulder pain 1, 2
- Perform abdominal ultrasound if symptoms suggest hepatic hematoma 2
- Markedly reduced platelet count (<20×10⁹/L) correlates with higher risk of hepatic hemorrhage 2
- Early referral to transplant center if signs of hepatic failure develop 2
Other Complications to Monitor
- Watch for eclampsia, placental abruption, disseminated intravascular coagulation, pulmonary edema, acute renal insufficiency 6
- Monitor for hypoglycemia during management 2, 3
Common Pitfalls
- Delayed diagnosis is common because symptoms may mimic acute cholecystitis, drug reactions, or idiopathic thrombocytopenia 2, 3, 7
- Delaying delivery significantly worsens maternal outcomes 1
- Aggressive fluid resuscitation dramatically increases pulmonary edema risk 2
- Using corticosteroids for maternal benefit is not supported by evidence and should be avoided 1, 2