A 34‑week pregnant woman with severe hypertension (180/110 mmHg) and proteinuria, now controlled to 140/90 mmHg with oral nifedipine, has elevated alanine aminotransferase (ALT) 140 U/L, aspartate aminotransferase (AST) 170 U/L, and thrombocytopenia (platelet count 46 ×10⁹/L). What is the appropriate next step in management?

Immediate Delivery After Maternal Stabilization

This patient has HELLP syndrome (a severe manifestation of preeclampsia) at 34 weeks' gestation with severe thrombocytopenia (platelets 46,000/µL) and elevated liver enzymes (AST 170, ALT 140), requiring immediate delivery after maternal stabilization with magnesium sulfate for seizure prophylaxis and continued blood pressure control. 1, 2

Critical Recognition: HELLP Syndrome Diagnosis

This patient meets full criteria for HELLP syndrome, which is not a separate disorder but rather a severe manifestation of preeclampsia requiring urgent intervention:

• Hemolysis – Presumed present (requires confirmation with LDH, haptoglobin, or peripheral smear) 2
• Elevated Liver enzymes – AST 170 U/L and ALT 140 U/L (both >2× upper limit of normal) 2
• Low Platelets – 46,000/µL, indicating severe thrombocytopenia and active disease with significant maternal risk 2, 3

The platelet count of 46,000/µL is particularly concerning because it correlates directly with severity of liver dysfunction and predicts adverse maternal outcomes. 2

Immediate Stabilization Protocol (Before Delivery)

1. Magnesium Sulfate for Seizure Prophylaxis

• Initiate immediately – All patients with HELLP syndrome and severe hypertension require magnesium sulfate to prevent eclamptic seizures 1, 2
• Loading dose: 4–5 g IV over 5 minutes (diluted in 250 mL dextrose 5% or normal saline) 1
• Maintenance infusion: 1–2 g/hour continuous IV 1
• Continue for 24 hours postpartum 1

2. Blood Pressure Management

• Current BP 140/90 mmHg is acceptable but requires continued monitoring and maintenance therapy 4, 1
• Target BP: Systolic 110–140 mmHg, diastolic ≈85 mmHg (minimum goal <160/105 mmHg) 1, 5
• Continue oral nifedipine as currently prescribed 4
• Have IV labetalol ready if BP rises ≥160/110 mmHg (20 mg bolus, then 40 mg after 10 min, then 80 mg every 10 min up to 220 mg cumulative) 1, 5

3. Critical Monitoring Requirements

• Continuous BP monitoring until hemodynamically stable 1
• Hourly urine output via Foley catheter (target ≥100 mL per 4 hours or >35 mL/hour) 1, 2
• Monitor for magnesium toxicity: Check deep tendon reflexes before each dose, respiratory rate (watch for depression), oxygen saturation 1, 2
• Fluid restriction: Limit IV fluids to 60–80 mL/hour to prevent pulmonary edema 1, 5
• Neurological assessment: Watch for severe headache, visual changes, confusion, right upper quadrant pain 1, 2

4. Urgent Laboratory and Imaging Assessment

• Immediate labs: Complete blood count with peripheral smear (confirm hemolysis), comprehensive metabolic panel, LDH, haptoglobin, coagulation studies (PT/PTT, fibrinogen) 1, 2
• Abdominal imaging (ultrasound or CT) – Mandatory to rule out subcapsular liver hematoma or hepatic rupture, especially given the elevated liver enzymes and platelet count <50,000/µL 2, 6
  • 65% of symptomatic HELLP patients have right upper quadrant or epigastric pain, which should trigger immediate imaging 2
  • Hepatic hemorrhage risk is significantly elevated with platelets <20,000/µL but can occur at higher counts 2

5. Platelet Transfusion Preparation

• Platelet transfusion is mandatory before cesarean section with platelets <50,000/µL 2
• Order platelets now and have them available in the operating room 2
• Target platelet count >50,000/µL before any surgical intervention to reduce bleeding risk 2
• Fresh frozen plasma should be available to correct any coagulopathy 7

Delivery Decision: Immediate After Stabilization

At 34 weeks' gestation with HELLP syndrome, delivery is indicated immediately after maternal stabilization—this is non-negotiable. 4, 1, 5, 3

Rationale for Immediate Delivery

• Gestational age ≥34 weeks with preeclampsia/HELLP syndrome is an absolute indication for delivery 4, 1, 5
• HELLP syndrome only resolves after delivery—delayed intervention carries a 3.4% maternal mortality risk 2, 3
• Progressive thrombocytopenia (platelets 46,000/µL and likely declining) is itself an absolute indication for immediate delivery at any gestational age 4, 1
• Elevated liver enzymes that are progressively worsening mandate delivery 4, 5

Mode of Delivery

• Cesarean section is strongly recommended in this case given: 3, 7
  • Severe thrombocytopenia (46,000/µL) with high bleeding risk
  • Unfavorable cervix likely at 34 weeks
  • Full-blown HELLP syndrome requiring expedited delivery
  • Need to minimize maternal stress and time to delivery
• General anesthesia may be required because platelets <100,000/µL preclude safe regional anesthesia (risk of epidural hematoma) 2
• Vaginal delivery is theoretically preferable if the cervix is favorable and maternal/fetal status allows, but cesarean section rate is typically >70% in HELLP syndrome due to obstetric indications 2, 3

Critical Pitfalls to Avoid

• Do NOT delay delivery waiting for laboratory values to normalize—they will not improve until after delivery 2, 3
• Do NOT attempt regional anesthesia (epidural/spinal) with platelets <100,000/µL due to epidural hematoma risk 2
• Do NOT use corticosteroids to improve maternal HELLP outcomes—they are ineffective for maternal disease (only indicated for fetal lung maturity if delivery can be safely delayed 24–48 hours, which it cannot in this case) 2, 3
• Do NOT reduce antihypertensives if diastolic BP falls <80 mmHg—maintain uteroplacental perfusion 4, 1
• Do NOT use diuretics—they further reduce plasma volume, which is already contracted in preeclampsia 1, 5
• Do NOT miss hepatic complications—failure to obtain abdominal imaging with these liver enzyme elevations and severe thrombocytopenia is a critical error 2, 6

Postpartum Management

• Continue magnesium sulfate for 24 hours postpartum 1
• Monitor BP every 4 hours for at least 3 days postpartum (eclampsia can first occur postpartum) 1, 5
• Continue antihypertensive therapy postpartum; replace methyldopa with alternative if used 1, 5
• Repeat labs every 6–12 hours for at least 24–48 hours postpartum (30% of HELLP cases occur or worsen postpartum) 2, 3
• Avoid NSAIDs for postpartum analgesia unless alternatives ineffective, especially with renal impairment 1, 5
• Transfer to ICU or high-dependency unit for continuous monitoring given severe thrombocytopenia and HELLP syndrome 2, 7

Long-Term Counseling

• Recurrence risk in future pregnancies ranges from 27–48% for hypertensive disorders 8
• Low-dose aspirin (75–162 mg daily) should be started before 16 weeks (ideally before 12 weeks) in any subsequent pregnancy 5
• Comprehensive follow-up at 3 months postpartum to confirm normalization of BP, proteinuria, and laboratory values 1, 5
• Lifelong increased cardiovascular risk—annual medical review recommended 5