What is the appropriate management for a pregnant woman in her second or third trimester diagnosed with HELLP (Hemolysis, Elevated Liver enzymes, and Low Platelet count) syndrome, with a history of hypertension or preeclampsia?

Management of HELLP Syndrome in Second and Third Trimester

Prompt delivery after maternal stabilization is the definitive treatment for HELLP syndrome, regardless of gestational age, as the syndrome only resolves after delivery and delayed intervention carries a 3.4% maternal mortality risk. 1, 2

Immediate Maternal Stabilization

Before delivery, aggressive stabilization of affected organ systems is mandatory:

• Administer magnesium sulfate immediately to all women with HELLP syndrome and co-existing severe hypertension for seizure prophylaxis, continuing for 24 hours post-delivery 1, 3
• Transfer to ICU or high-dependency unit for continuous monitoring including central venous pressure, hourly urinary output via indwelling catheter, continuous blood pressure, ECG, and oxygen saturation 1, 3, 2
• Perform abdominal imaging (ultrasound or CT) urgently to rule out hepatic hemorrhage, infarct, or rupture, especially if right upper quadrant pain, epigastric pain, or right shoulder pain is present 1, 2

Blood Pressure Control

Severe hypertension requires urgent treatment in a monitored setting:

• For severe hypertension: Use IV labetalol (20 mg bolus, then 40 mg after 10 minutes, followed by 80 mg every 10 minutes for 2 additional doses to maximum 220 mg) or IV hydralazine (5 mg bolus, then 10 mg every 20-30 minutes to maximum 25 mg) 1
• For non-severe hypertension: Initiate oral labetalol, nifedipine, or methyldopa 1, 3
• Target mean arterial pressure of 100-105 mmHg to reduce risk of eclampsia and intracranial hemorrhage 3

Management of Coagulopathy

Correction of coagulopathy is essential before delivery:

• Transfuse platelets if count <50,000/mm³ before any surgical intervention, and strongly consider at higher levels given increased bleeding risk 1, 2
• Consider platelet transfusion if count <100×10⁹/L due to increased risk of abnormal coagulation and adverse maternal outcomes 1
• Administer fresh frozen plasma to correct coagulopathy as needed, with cautious volume expansion guided by CVP (target 3-8 mmHg) 3, 2
• Transfuse packed red blood cells if hemoglobin <10 g/dL to maintain oxygen-carrying capacity 3

Timing and Mode of Delivery

The decision for delivery timing follows a clear algorithm:

Immediate Delivery (Standard Management)

• ≥34 weeks gestation: Deliver promptly after maternal stabilization 2
• Any gestational age with maternal deterioration: Worsening laboratory values, severe symptoms, or hepatic complications mandate immediate delivery 2
• Any gestational age with fetal compromise: Non-reassuring fetal status or intrauterine growth restriction with abnormal Doppler requires immediate delivery 2
• Hepatic hemorrhage, infarct, or rupture on imaging: Expeditious delivery after stabilization regardless of gestational age 2

Expectant Management (<34 Weeks)

• Only at very early gestational ages (<32 weeks) and only in the absence of severe symptoms may expectant management with close monitoring be considered, though this carries increased risk of adverse maternal outcomes 4, 2
• This approach requires stable maternal condition with no worsening laboratory values and no severe symptoms 2

Mode of Delivery

• Cesarean section rate is typically >70% due to obstetric indications including unfavorable cervix, fetal distress, and maternal deterioration 2
• Vaginal delivery with expedited induction can be considered if cervix is favorable and no maternal/fetal deterioration has occurred 4
• General anesthesia may be required if platelets <100,000/mm³ preclude regional anesthesia due to risk of epidural hematoma 2

Corticosteroid Administration

The role of corticosteroids is limited and specific:

• Do NOT give corticosteroids to improve maternal outcomes in HELLP syndrome - they are ineffective for maternal disease 1, 3, 2
• DO administer high-dose dexamethasone or betamethasone for fetal lung maturity if delivery is anticipated before 35 weeks' gestation 1

Post-Delivery Intensive Monitoring

The syndrome typically peaks 24 hours after delivery, requiring continued aggressive management:

• Monitor in high-dependency or ICU setting for at least 24-48 hours post-delivery with continuous vital signs monitoring 1, 3
• Continue magnesium sulfate for 24 hours after delivery 3
• Maintain strict fluid balance for 24 hours after delivery to avoid pulmonary edema - avoid aggressive fluid resuscitation that might be reflexively given in other critically ill patients 3
• Perform serial laboratory monitoring every 6-12 hours including complete blood count with platelets, liver function tests, coagulation profile, and renal function tests, as 30% of HELLP cases occur or worsen postpartum 3, 2

Critical Pitfalls to Avoid

• Never delay delivery waiting for laboratory values to normalize - HELLP only resolves after delivery 2
• Never use regional anesthesia with platelets <100,000/mm³ due to risk of epidural hematoma 2
• Never give corticosteroids to improve maternal HELLP outcomes - they are ineffective 1, 2
• Never perform aggressive fluid resuscitation - this significantly increases pulmonary edema risk 3

Surveillance for Hepatic Complications

Hepatic rupture is a life-threatening complication requiring specific vigilance:

• 65% of symptomatic HELLP patients present with right upper quadrant or epigastric pain - this should immediately trigger imaging 2
• Platelet count <20×10⁹/L correlates with higher risk of hepatic hemorrhage 1, 2
• Perform abdominal ultrasound if symptoms suggest hepatic hematoma and refer early to transplant center if signs of hepatic failure develop 1, 3

Future Pregnancy Counseling

• Counsel regarding 20% recurrence risk in future pregnancies 3
• Recommend first-trimester screening to assess risk of early-onset preeclampsia 1
• Initiate aspirin prophylaxis (150 mg nightly) before 16 weeks' gestation and continue until 36 weeks, delivery, or diagnosis of preeclampsia/HELLP 1, 3
• Consider calcium supplementation (1.5-2 g elemental calcium/day) in women with low calcium intake (<800 mg/day) 1