How should a pregnant woman with HELLP syndrome be managed?

Management of HELLP Syndrome

Pregnant women with HELLP syndrome require immediate maternal stabilization followed by prompt delivery, as this is the only definitive treatment and delayed intervention carries a 3.4% maternal mortality risk. 1

Immediate Stabilization and Monitoring

Upon diagnosis, initiate the following critical interventions simultaneously:

• Administer magnesium sulfate immediately for seizure prophylaxis in all women with HELLP syndrome, continuing for 24 hours post-delivery 1, 2
• Transfer to ICU or high-dependency unit for continuous monitoring of blood pressure, central venous pressure, urinary output, ECG, and oxygen saturation 1, 2
• Insert urinary catheter for hourly output monitoring, with oliguria <400 mL/24h indicating severe disease 1, 2
• Consider central venous catheter for fluid management, as these patients are often relatively hypovolemic despite appearing fluid overloaded 1, 2
• Perform abdominal imaging (ultrasound or CT) immediately to rule out hepatic hemorrhage, infarct, or rupture, especially if right upper quadrant pain is present 1, 2

Blood Pressure Management

Control severe hypertension urgently to prevent maternal complications:

• Target blood pressure below 155/105 mmHg or maintain mean arterial pressure 100-105 mmHg to reduce risk of eclampsia and intracranial hemorrhage 2, 3
• For severe hypertension: Use IV labetalol or hydralazine in a monitored setting 2
• For non-severe hypertension: Oral labetalol, nifedipine, or methyldopa are appropriate 2

Laboratory Monitoring and Transfusion Thresholds

Serial laboratory monitoring is essential to guide management:

• Monitor every 6-12 hours: Complete blood count, liver enzymes (AST, ALT, LDH), platelet count, coagulation profile, and renal function 1, 2
• Transfuse platelets if <50,000/mm³ before any surgical intervention, and strongly consider at higher levels given bleeding risk 1, 2
• Transfuse packed red blood cells if hemoglobin <10 g/dL to maintain oxygen-carrying capacity 2
• Administer fresh frozen plasma to correct coagulopathy as needed 1, 2

Critical caveat: Platelet counts below 100,000/mm³ indicate severe thrombocytopenia with significant maternal risk and contraindicate regional anesthesia due to epidural hematoma risk 1

Timing and Mode of Delivery

The decision for delivery timing follows a clear algorithm based on gestational age and maternal/fetal status:

Immediate Delivery (Standard Management)

Deliver immediately after maternal stabilization in the following scenarios:

• ≥34 weeks gestation - This is the standard threshold for immediate delivery 1, 3
• Any gestational age with maternal deterioration: Worsening laboratory values, severe symptoms, or hepatic complications 1
• Any gestational age with fetal compromise: Non-reassuring fetal status or intrauterine growth restriction with abnormal Doppler 1
• Hepatic hemorrhage, infarct, or rupture identified on imaging - Requires expeditious delivery after stabilization 1

Expectant Management (<34 Weeks)

Expectant management may be considered ONLY in highly selected cases:

• Strict criteria: Gestational age <34 weeks with stable maternal condition (no worsening laboratory values, no severe symptoms) 1, 4
• Duration: Aim for 48 hours to allow corticosteroid administration for fetal lung maturation 3, 5
• Monitoring: Intensive maternal and fetal surveillance with readiness for immediate delivery if deterioration occurs 3, 4

Important caveat: This approach carries increased risk of adverse maternal outcomes and should only be attempted in tertiary centers with expertise 5

Mode of Delivery

• Cesarean section rate is typically >70% due to obstetric indications including unfavorable cervix, fetal distress, and maternal deterioration 1
• Vaginal delivery is preferable if cervix is favorable and maternal/fetal status permits 3, 5
• General anesthesia may be required if platelets <100,000/mm³ preclude regional anesthesia 1

Corticosteroid Use: Critical Distinction

There is an important distinction between fetal and maternal corticosteroid use:

• FOR FETAL LUNG MATURATION (24-34 weeks): Administer a single course of betamethasone (2 doses of 12 mg, 24 hours apart) or dexamethasone (4 doses of 6 mg, 12 hours apart) 3, 5
• FOR MATERNAL HELLP SYNDROME: Do NOT administer corticosteroids to improve maternal outcomes - they are ineffective for maternal disease 1, 2, 6

Avoid high-dose or repeated corticosteroid courses due to potential long-term adverse effects on the fetal brain 3

Postpartum Management

HELLP syndrome typically peaks 24 hours after delivery and requires continued aggressive management for at least 48 hours postpartum: 2

• Continue magnesium sulfate for 24 hours post-delivery 2
• Maintain strict fluid balance to avoid pulmonary edema, which is a significant risk in the postpartum period 2
• Continue laboratory monitoring every 6-12 hours for at least 24-48 hours, as 30% of HELLP cases occur or worsen postpartum 1
• Monitor for complications: Hepatic hemorrhage, acute renal failure, pulmonary edema, and eclampsia 2

Critical Pitfalls to Avoid

• Never delay delivery waiting for laboratory values to normalize - HELLP syndrome only resolves after delivery 1
• Do not use regional anesthesia with platelets <100,000/mm³ due to epidural hematoma risk 1
• Avoid aggressive fluid resuscitation that might reflexively be given to other critically ill patients, as this significantly increases pulmonary edema risk 2
• Do not give corticosteroids to improve maternal HELLP outcomes - they are ineffective 1, 2

Hepatic Complications: Red Flags

65% of symptomatic HELLP patients present with right upper quadrant or epigastric pain, which should immediately trigger imaging: 1

• Suspect hepatic rupture with: Persistent or worsening right upper quadrant pain, especially with platelets <20×10⁹/L 1
• Right shoulder pain may indicate diaphragmatic irritation from hepatic bleeding 1
• Immediate management: Maternal stabilization, imaging, and expeditious delivery after stabilization 1

Future Pregnancy Counseling

• Recurrence risk is approximately 20% in future pregnancies 2
• Recommend aspirin prophylaxis 150 mg nightly starting before 16 weeks gestation until 36 weeks or delivery 2
• First-trimester screening for early-onset preeclampsia should be performed 2