What is the management of HELLP (Hemolysis, Elevated Liver enzymes, and Low Platelet count) syndrome in a pregnant woman, typically in the third trimester, with symptoms such as abdominal pain, nausea, and vomiting, and a history of hypertension or preeclampsia?

Management of HELLP Syndrome in Pregnancy

Deliver promptly once maternal coagulopathy and severe hypertension are corrected—delayed intervention carries a 3.4% maternal mortality risk, and HELLP syndrome only resolves after delivery. 1, 2

Immediate Stabilization and Monitoring

Upon diagnosis of HELLP syndrome, transfer the patient immediately to a tertiary care center with intensive care capabilities for both mother and neonate. 1, 2

Critical monitoring requirements include:

• Insert urinary catheter for hourly output monitoring (oliguria <400 mL/24h indicates severe disease) 1, 2
• Consider central venous catheter placement for fluid management, as these patients are paradoxically hypovolemic despite potential ascites 1, 2, 3
• Continuous monitoring of blood pressure, central venous pressure, ECG, and oxygen saturation in ICU or high-dependency unit 2, 4
• Laboratory monitoring every 6-12 hours for at least 24-48 hours postpartum (30% of HELLP cases occur or worsen postpartum) 2, 4

Blood Pressure Management

For non-severe hypertension (140-159/90-109 mmHg):

• Initiate oral labetalol, nifedipine, or methyldopa 1, 4

For severe hypertension (≥160/110 mmHg):

• Treat urgently in monitored setting with oral labetalol, nifedipine, or methyldopa 1, 4
• If rapid control needed, use IV labetalol (20 mg bolus, then 40 mg at 10 minutes, then 80 mg every 10 minutes for 2 additional doses, maximum 220 mg) or IV hydralazine (5 mg bolus, then 10 mg every 20-30 minutes, maximum 25 mg) 4

Seizure Prophylaxis

Administer magnesium sulfate to all women with HELLP syndrome and severe hypertension to prevent eclamptic seizures. 1, 2, 4 Also use as neuroprotective agent if delivery required before 32 weeks' gestation. 1, 4

Correction of Coagulopathy

Platelet transfusion thresholds:

• Mandatory if platelets <50,000/mm³ before Caesarean section 1, 4, 3
• Strongly consider if platelets <100,000/mm³ due to increased risk of abnormal coagulation and adverse maternal outcomes 2, 4
• Administer fresh frozen plasma to correct coagulopathy as needed before surgical intervention 1, 3

Regional anesthesia (epidural/spinal) is contraindicated with platelets <100,000/mm³ due to risk of epidural hematoma. 2, 3 General anesthesia may be required. 2

Imaging for Hepatic Complications

Perform abdominal ultrasound immediately if the patient has:

• Right upper quadrant pain, epigastric pain, or right shoulder pain 1, 2, 4
• Severe thrombocytopenia (platelets <20×10⁹/L), which carries higher risk of hepatic hemorrhage or hematoma 1, 2

If hepatic rupture, hemorrhage, or hematoma is identified, proceed with expeditious delivery after maternal stabilization regardless of gestational age. 2

Corticosteroid Use

Do NOT give corticosteroids to improve maternal outcomes in HELLP syndrome—they are ineffective for maternal disease. 1, 2, 4

DO give high-dose dexamethasone or betamethasone for fetal lung maturity if delivery anticipated before 35 weeks' gestation. 1, 4 This is the only indication for corticosteroids in HELLP syndrome. 2

Timing and Mode of Delivery

Delivery algorithm based on gestational age and maternal/fetal status:

≥34 weeks gestation:

• Deliver immediately after maternal stabilization (correction of coagulopathy and severe hypertension control) 1, 2, 4

<34 weeks gestation:

• Deliver immediately if maternal deterioration (worsening laboratory values, severe symptoms, hepatic complications) 2
• Deliver immediately if fetal compromise (non-reassuring fetal status, IUGR with abnormal Doppler) 2
• Expectant management for 48 hours may be considered ONLY if stable maternal condition, no severe symptoms, and no fetal compromise, but this carries increased risk 2, 5, 6

Mode of delivery:

• Vaginal delivery is preferable if cervical conditions are favorable and no maternal/fetal contraindications exist 5, 6
• Expect high Caesarean section rate (typically >70%) due to unfavorable cervix, fetal distress, and maternal deterioration 2, 3

Critical Pitfalls to Avoid

Never delay delivery waiting for laboratory values to normalize—HELLP only resolves after delivery, and maternal mortality is 3.4% with delayed intervention. 2

Never use regional anesthesia with platelets <100,000/mm³ due to epidural hematoma risk. 2, 3

Never administer corticosteroids to improve maternal HELLP outcomes—they are ineffective for maternal disease and only indicated for fetal lung maturity. 1, 2, 4

Do not miss hepatic complications—maintain high index of suspicion with right upper quadrant pain or severe thrombocytopenia, and image promptly. 1, 2

Postpartum Management

Continue intensive monitoring for at least 24-48 hours postpartum in high-dependency or ICU setting, as 30% of HELLP cases occur or worsen postpartum. 2, 4 Liver function tests and platelet counts typically normalize within days to weeks after delivery. 4

If signs of hepatic failure develop that may require transplantation, make early referral to a transplant center. 1

Prevention in Future Pregnancies

For women with history of HELLP syndrome:

• First-trimester screening to assess risk of early-onset preeclampsia 4
• Aspirin prophylaxis 150 mg nightly started before 16 weeks' gestation, continued until 36 weeks, delivery, or diagnosis of preeclampsia/HELLP 4
• If low calcium intake (<800 mg/day), calcium supplementation 1.5-2 g elemental calcium/day may reduce risk 1, 4