How should a pregnant woman in the third trimester with preeclampsia who develops HELLP syndrome be managed?

Management of HELLP Syndrome in Third Trimester Preeclampsia

Women with HELLP syndrome in the third trimester should be delivered promptly once maternal coagulopathy and severe hypertension are corrected, as delayed delivery carries a 3.4% maternal mortality risk and the syndrome only resolves after delivery. 1

Immediate Stabilization and Monitoring

Upon diagnosis, transfer the patient immediately to a high-dependency unit or intensive care for continuous monitoring. 2 This includes:

• Continuous blood pressure monitoring with ECG and oxygen saturation 2
• Central venous pressure monitoring via internal jugular or subclavian catheter, as these patients are typically hypovolemic despite appearing fluid overloaded 3
• Hourly urinary output monitoring via indwelling catheter (oliguria <400 mL/24h indicates severe disease) 2, 3
• Serial laboratory monitoring every 6-12 hours: complete blood count, liver enzymes (AST, ALT, LDH), coagulation profile, and renal function 2, 3

Blood Pressure Management

Initiate magnesium sulfate immediately for all women with HELLP syndrome and severe hypertension to prevent eclamptic seizures. 1 This is a Level 1 evidence, strong recommendation. 1

For hypertension control:

• Non-severe hypertension (140-159/90-109 mmHg): Start oral labetalol, nifedipine, or methyldopa 1
• Severe hypertension (≥160/110 mmHg): Treat urgently with oral agents first; escalate to IV labetalol or hydralazine if needed 1
• Target mean arterial pressure: 100-105 mmHg to reduce eclampsia and intracranial hemorrhage risk 3

Correction of Coagulopathy

Platelet transfusion is mandatory when platelets fall below 50,000/mm³ before any surgical intervention, and should be strongly considered at <100,000/mm³ given the increased risk of abnormal coagulation. 1, 2

Additional blood product management:

• Fresh frozen plasma: Administer 400 mL cautiously (guided by CVP target 3-8 mmHg) to correct coagulopathy 3
• Packed red blood cells: Transfuse if hemoglobin <10 g/dL 2, 3

Timing and Mode of Delivery

At ≥34 weeks gestation: Deliver immediately after maternal stabilization. 2 This is non-negotiable regardless of laboratory values, as HELLP only resolves after delivery. 2

At <34 weeks gestation: Expectant management may be considered ONLY if all of the following criteria are met: 2

• Stable maternal condition with no worsening laboratory values
• No severe symptoms
• Reassuring fetal status
• Intensive monitoring capability in a tertiary center

However, deliver immediately at any gestational age if: 2

• Maternal deterioration (worsening labs, severe symptoms)
• Fetal compromise (non-reassuring status, abnormal Doppler)
• Hepatic complications identified on imaging

Mode of delivery: Expect a high cesarean section rate (>70%) due to unfavorable cervix, fetal distress, and maternal deterioration. 2 Vaginal delivery is preferable if cervical conditions are favorable. 4, 5

Antenatal Corticosteroids

For fetal lung maturity (<35 weeks): Give high-dose dexamethasone or betamethasone per national guidance. 1 This is for fetal benefit only.

Critical caveat: Do NOT give corticosteroids to improve maternal HELLP outcomes—they are ineffective for maternal disease. 1, 2 This is a Level 1 evidence, strong recommendation. 1

Hepatic Complication Surveillance

Perform abdominal ultrasound immediately if the patient reports right upper quadrant pain, epigastric pain, or right shoulder pain, as these suggest hepatic hematoma or rupture. 1, 2

Risk is particularly high when platelets <20×10⁹/L. 1 If hepatic failure signs develop, make early referral to a transplant center. 1

Anesthetic Considerations

Regional anesthesia (epidural/spinal) is contraindicated when platelets <100,000/mm³ due to epidural hematoma risk. 2 General anesthesia will be required for cesarean section in these cases. 2

Postpartum Management

Continue intensive monitoring for at least 24-48 hours postpartum, as 30% of HELLP cases occur or worsen after delivery. 2, 4, 5

• Continue magnesium sulfate for 24 hours post-delivery 1, 3
• Maintain strict fluid balance to avoid pulmonary edema 1, 3
• Serial laboratory monitoring every 6-12 hours for 24-48 hours 2
• Monitor for complications: hepatic hemorrhage, acute renal failure, pulmonary edema 3

The syndrome typically peaks 24 hours after delivery. 3

Critical Pitfalls to Avoid

• Never delay delivery waiting for laboratory values to normalize—this increases maternal mortality to 3.4% 2
• Never use regional anesthesia with platelets <100,000/mm³ 2
• Never give corticosteroids for maternal HELLP improvement 1, 2
• Never aggressively fluid resuscitate—this significantly increases pulmonary edema risk 3

Future Pregnancy Counseling

Women with prior HELLP syndrome have a 20% recurrence risk. 3 For future pregnancies:

• First-trimester screening to assess early-onset preeclampsia risk 1
• Aspirin prophylaxis 150 mg nightly starting before 16 weeks' gestation until 36 weeks or delivery 1, 2
• Calcium supplementation (1.5-2 g elemental calcium/day) if dietary intake <800 mg/day 1