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Management of HELLP Syndrome. Delivery at HELLP syndrome. Mode of delivery at HELLP syndrome. Management of preeclampsia superimposed on chronic hypertension
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Management of HELLP Syndrome
HELLP Syndrome is a variant of severe preeclampsia (Haemolysis, Elevated Liver enzymes and Low Platelet count). Maternal mortality is reported to be as high as 1- 2%.
The clinical picture of HELLP syndrome is variable and includes the following symptoms:
• Pain in epigastrium or in the upper right quadrant of the abdomen (86-90%).
• Nausea or vomiting (45-84%).
• Headache (50%).
• Sensitivity of palpation in the upper right quadrant of the abdomen (86%).
• dBP above 110 mm Hg. (67%).
• Massive proteinuria> 2+ (85-96%).
• Edema (55-67%).
• Arterial hypertension (80%).
In a woman with preeclampsia, the presence of any one of the following is an indicator of severe disease:
• a maternal platelet count of,
• a transaminase level or Lactate Dehydrogenase (LDH) more than double the normal upper limit,
• hemolysis of any quantity.
Management of HELLP syndrome, as well as severe PE, is to assess the severity, stabilization of the patient with subsequent delivery:
• immediate hospitalization,
• stabilization of the woman's condition, including prevention of thrombosis,
• evaluation of the fetus,
• ABP control,
• Mg Sulfate therapy,
• delivery planning/delivery
Antenatal management
If the platelet count is sufficiently low to present a hazard for operative delivery, a platelet transfusion should be considered.
Table 13
Delivery at HELLP syndrome
| Term of pregnancy | Timing of delivery |
| ≤ 34 weeks | Prevention of RDS and delivery within 48 hours with intensive care. |
| ≥ 34 weeks | Emergency delivery |
Table 14
Mode of delivery at HELLP syndrome
| Cesarean section | Delivery through maternal passage |
| Early term and unfavorable cervix | Favorable cervix Labor induction with medication |
| General anesthesia is preferred with platelet count < 75 x103 | |
| With the number of platelets < 50000 < 50000 - platelet transfusion (5-10 doses) Peritonization is not carried out Abdominal drainage is obligatory Monitoring of the woman's condition within the next 48 hours | Pain relief with narcotic analgesics Peridural analgesia (under control of platelets number) pudendal analgesia is contraindicated (risk of bleeding) |
Postpartum management
If there is significant bleeding attributed to preeclamptic thrombocytopenia at any time in the puerperium a platelet transfusion should be given.
Management of preeclampsia superimposed on chronic hypertension
This is of considerable concern as the risks to both mother and fetus are greater than those of chronic hypertension alone. Management of superimposed preeclampsia should be as outlined above for preeclampsia unless specific diagnostic issues, such as some secondary causes of hypertension, are present. It is recommended that all women with a hypertensive complication of pregnancy have a postpartum hypertension follow-up. Depending on the severity of the hypertension this follow-up should be 2-6 weeks after discharge from hospital.
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Management of PE: conclusions in tables 14, 15, 16, 17, 18, 19
Table 15
Management of PE in relation to the severity of the condition
| · | Moderate preeclampsia | Severe preeclampsia | Eclampsia |
| Management | Active management
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| Hospitalization | For examination (in the department of pregnancy pathology, the level 3-2 hospitals) | Mandatory hospitalization (in the ICU, the tertiary hospital, if impossible –to a level 2 hospital) | |
| Specific therapy | Antihypertensive therapy Prevention of seizures | Prevention and treatment of seizures Antihypertensive therapy | |
| Delivery | Depending on term of pregnancy | Within 6-24 hours. (Urgently - with the progression of symptoms or deterioration of the fetus) | Against the background of the stabilization of the state |
Table 16
The management of severe PE, depending on the term of pregnancy, as recommended by WHO.
| Severe PE at term22-24 wk | Termination of life-threatening pregnancy |
| Severe PE at term25-27 wk | 1. Prolongation of pregnancy in the absence of: - uncontrolled hypertension, - the progression of organ dysfunction in the mother, - fetal distress; 2. Improvement of lung maturity (steroids to increase surfactant) for prevention of RDS of a newborn |
| Severe PE at term 28-33 wk | 1. Prolongation of pregnancy in the absence of: - uncontrolled hypertension, - the progression of organ dysfunction in the mother, - fetal distress; 2. Improvement of lung maturity (steroids to increase surfactant) for prevention of RDS of a newborn 3. Preparation for probable delivery |
| Severe PE at term ≥ 34 wk | Treatment, preparation, delivery. |
Table 17
Indications for delivery
| Indications for emergency delivery (minutes): | Indications for urgent delivery (hours): |
| - bleeding from the birth canal, suspicion of placental abruption - acute fetal hypoxia, during gestation more than 22 weeks | - constant headache and visual manifestations - persistent epigastric pain, nausea, or vomiting - progressive deterioration of the liver and / or kidney function - eclampsia - arterial hypertension not amenable to drug correction - the number of platelets less than 100 x 109 / L and its progressive decrease - violation of the fetal condition, recorded according to CTG, US, marked oligohydramnios. |
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