Table of Contents
introduction
risk factors
clinical features
Mississippi staging classification
complications
DDx
ED Mx
HELLP syndrome in pregnancy
see also:
liver function tests (LFTs)
pre-eclampsia and eclampsia
introduction
HELLP is an acronym for the 3 main features:
haemolysis
elevated liver enzyme levels
low platelet level
it is a potentially life threatening complication of pregnancy
occurs in ~ 1 in 300 pregnancies, and in up to 12% of cases of
pre-eclampsia and eclampsia
(mainly older women with preeclampsia)
usually occurs between 27 weeks gestation up to the immediate post-partum period
15% to 30% of cases presenting postpartum
it is extremely rare prior to 20wks although cases have been recorded as early as 16wks.
recurrence rate in subsequent pregnancies is 2-27%
risk factors
maternal age > 34yrs
multiparity
Caucasian
PH poor pregnancy outcome
PH HELLP
clinical features
malaise, nausea, vomiting,
RUQ pain
with RUQ tenderness are very common
headache very common
peripheral oedema and weight gain, or, signs of
dehydration
over 80% have
proteinuria
80% have
hypertension
visual changes in 10-20%
jaundice in 5%
SOB if
acute pulmonary oedema (APO)
may have bruising
Mississippi staging classification
divides HELLP syndrome into 3 classes
class I (severe)
class 2 (moderate)
class 3 (mild)
platelet count
≤50,000/µL
50,000-100,000/µL
100,000-150,000/µL
AST or ALT
≥70 IU/L
≥70 IU/L
≥40 IU/L
LDH
≥600 IU/L
≥600 IU/L
≥600 IU/L
incidence of bleeding
13%
8%
no increased risk
complications
pre-eclampsia and eclampsia
preterm labour / premature labour
IUGR
placental abruption
disseminated intravascular coagulation (DIC)
intracranial haemorrhage
due to coagulopathy and hypertension is the most common cause of maternal death
acute kidney injury (AKI) / acute renal failure (ARF)
acute pulmonary oedema (APO)
hypertension
pulmonary embolism (PE)
acute myocardial infarction (AMI/STEMI/NSTEMI)
Acute Respiratory Distress Syndrome (ARDS)
cerebral_oedema
cerebral venous thrombosis
seizures
retinal detachment
rarely, large vessel vasculopathy causing hepatic infarction and hepatic subcapsular haematoma
nephrogenic diabetes insipidus
sepsis / septicaemia
cardiovascular disease
maternal mortality 1-3%
perinatal mortality ~9-24% (usually due to placental abruption, maternal death or prematurity)
DDx
pre-eclampsia and eclampsia
haemolytic anaemia
haemolytic uraemic syndrome (HUS)
thrombotic thrombocytopenic purpura (TTP)
ED Mx
iv access and take bloods for:
FBE, U&E, LFTs, coagulation studies, fibrinogen
group and hold
cautious iv fluid Mx
fetal assessment via urgent CTG
imaging as indicated
antihypertensives, corticosteroids and magnesium sulphate as per
pre-eclampsia and eclampsia
admit and expedite delivery as per O&G