What is the treatment for HELLP (Hemolysis, Elevated Liver enzymes, and Low Platelet count) syndrome after delivery?

Post-Delivery Treatment of HELLP Syndrome

Delivery is the definitive treatment for HELLP syndrome, but intensive post-delivery management is critical as the syndrome typically peaks 24 hours after delivery and requires continued aggressive monitoring and treatment for at least 48 hours postpartum. 1, 2, 3

Immediate Post-Delivery Monitoring (First 24-48 Hours)

Transfer to high-dependency unit or intensive care unit for continuous monitoring including: 1, 2

• Central venous pressure monitoring 1
• Continuous blood pressure monitoring 2
• Hourly urinary output via indwelling catheter 1, 2
• Continuous ECG and oxygen saturation 1

Blood Pressure Management Post-Delivery

Continue magnesium sulfate for 24 hours post-delivery to prevent eclamptic seizures (Level of Evidence 1, strong recommendation). 1, 4, 2

For severe hypertension (systolic >160 mmHg or diastolic >110 mmHg): 1

• Urgent treatment with oral labetalol, nifedipine, or methyldopa 1
• Intravenous labetalol or hydralazine if oral agents insufficient 1

For non-severe hypertension (systolic 140-159 mmHg or diastolic 90-109 mmHg): 1

• Oral labetalol, nifedipine, or methyldopa 1

Fluid Management

Strict fluid balance is essential for 24 hours post-delivery to prevent pulmonary edema, which is a major complication in the postpartum period. 4, 2 Avoid aggressive fluid resuscitation that might reflexively be given to other critically ill patients, as this significantly increases pulmonary edema risk. 2

Laboratory Monitoring

Serial laboratory monitoring should include: 2

• Complete blood count with platelet count (most reliable monitoring parameter) 5
• Liver function tests (AST, ALT, alkaline phosphatase) 2
• Lactate dehydrogenase (best test alongside platelets to monitor disease course) 5
• Coagulation profile (fibrinogen, fibrin degradation products) 2
• Renal function tests (creatinine, urea) 1, 2

Laboratory abnormalities typically resolve over the following week, with platelet count often normalizing by day 2-3 postpartum. 1

Blood Product Transfusion

Platelet transfusion should be considered if platelet count <100×10⁹/L, as this is associated with increased risk of abnormal coagulation and adverse maternal outcomes. 1 More specifically, transfuse if count <50,000/mm³ to reduce bleeding risk. 2

Transfuse whole blood or packed red cells if hemoglobin <10 g/dL. 1, 2

Fresh frozen plasma should be administered to correct coagulopathy. 6

Critical Complication Surveillance

Hepatic hemorrhage or hematoma monitoring: 1, 4, 2

• Perform abdominal ultrasound if symptoms develop: abdominal pain, epigastric pain, or right shoulder pain 1, 4
• Be especially vigilant if platelet count <20×10⁹/L, as this correlates with higher risk of hepatic hemorrhage 1, 4
• Early referral to transplant center if signs of hepatic failure develop (Level of Evidence 5, strong recommendation) 1

Monitor for other complications: 2, 7

• Acute renal failure/oliguria (<400 mL/24 hours) 1, 7
• Pulmonary edema 1
• Cerebral complications including subdural hematoma (rare but reported) 7

What NOT to Do

Do not give corticosteroids to improve maternal outcomes in HELLP syndrome (Level of Evidence 1, strong recommendation). 1, 4, 2 This is a critical point: while corticosteroids may show temporary improvement in some laboratory parameters, they are not effective for maternal outcomes and should not be used for this indication. 8, 9

The only indication for corticosteroids is fetal lung maturation if delivery occurred before 35 weeks gestation—this benefits the neonate, not the mother. 1, 4

Duration of Intensive Monitoring

Continue close surveillance for at least 48 hours after delivery, as most postpartum HELLP cases manifest within this timeframe and the syndrome intensity peaks at 24 hours post-delivery. 3, 5 Laboratory parameters typically begin improving after 24-48 hours, with complete resolution over the following week. 1

Future Pregnancy Counseling

Counsel regarding 20% recurrence risk in future pregnancies. 2 For subsequent pregnancies, recommend: 1, 4

• First-trimester screening for early-onset preeclampsia 1, 4
• Aspirin prophylaxis 150 mg nightly starting before 16 weeks gestation until 36 weeks or delivery (Level of Evidence 1, strong recommendation) 1, 4

Common Pitfalls to Avoid

• Delayed recognition of postpartum HELLP: 30% of cases occur postpartum, often within 48 hours of delivery 3
• Misdiagnosis: Symptoms may mimic acute cholecystitis, drug reactions, or idiopathic thrombocytopenia 1, 2
• Premature discontinuation of monitoring: The syndrome peaks 24 hours after delivery, not immediately 5
• Aggressive fluid resuscitation: This increases pulmonary edema risk 2
• Using corticosteroids for maternal benefit: No evidence supports this practice 1, 4