HELLP Syndrome

(Hemolysis, Elevated Liver enzymes, Low Platelet count)

🔷 INTRODUCTION

HELLP syndrome is a severe variant of preeclampsia characterized by a triad of:

• Hemolysis
• Elevated Liver enzymes
• Low Platelet count

It occurs in approximately 0.5–0.9% of all pregnancies and up to 20% of patients with severe preeclampsia.

🔷 DEFINITION & CLASSIFICATION

HELLP is a subtype of preeclampsia, often occurring between 28–36 weeks, but can also present postpartum.

🩸 Mississippi Classification (Based on platelet count):

🔷 PATHOPHYSIOLOGY

• Endothelial dysfunction → Vasospasm → Microangiopathic hemolysis
• Liver ischemia from fibrin deposits in sinusoids → hepatocellular injury → elevated AST/ALT
• Platelet activation and consumption → thrombocytopenia

Microthrombi form in small vessels, causing multiorgan dysfunction (liver, kidneys, CNS, etc.).

🔷 CLINICAL FEATURES

⚠️ HELLP can present without hypertension or proteinuria → Maintain high suspicion!

🔷 INVESTIGATIONS

🔷 DIFFERENTIAL DIAGNOSIS

• Acute fatty liver of pregnancy
• TTP/HUS
• DIC
• Viral hepatitis
• Cholecystitis

🔷 MANAGEMENT OVERVIEW

Definitive treatment = DELIVERY OF THE BABY

🎯 Goals:

• Stabilize mother
• Prevent seizures
• Control BP
• Support organ function
• Expedite delivery (within 24–48 hrs)

🔷 MEDICAL MANAGEMENT

🔷 ANESTHETIC MANAGEMENT

📍 Pre-Anesthesia Considerations

• Review platelet count, coagulation, and LFTs
• Assess neurological status
• Plan rapid delivery if condition worsening
• Discuss with obstetrician and neonatologist

💉 Regional Anesthesia

✅ May be possible IF:

• Platelets ≥ 75,000/mm³ (some say ≥ 80,000–100,000/mm³ for spinal)
• No signs of coagulopathy
• Stable hemodynamics

Advantages:

• Less BP fluctuation
• Avoids difficult airway

⚠️ Avoid if:

• Platelets <75k
• Active bleeding, DIC, or rising LFTs

🛑 General Anesthesia

Indications:

• Coagulopathy (low platelets, ↑ PT/INR)
• Fetal distress with need for immediate delivery
• Severe hepatic/renal dysfunction
• Altered mental status (encephalopathy)

Precautions:

• Difficult airway (facial/laryngeal edema)
• Anticipate exaggerated response to laryngoscopy → use fentanyl, esmolol
• MgSO₄ potentiates NMBs (↓ dose of vecuronium, rocuronium)
• Cricoid pressure
• Rapid desaturation → preoxygenation is critical

🔷 MONITORING

• Standard ASA monitors
• Arterial line for BP monitoring, labs
• Foley catheter for U/O
• CVP if fluid management difficult
• Lab trend monitoring: platelets, LFTs, PT/INR, electrolytes

🔷 POSTPARTUM CARE

• Monitor closely for DIC, renal failure, pulmonary edema
• Continue magnesium sulfate for 24 hours
• BP control
• Platelet transfusions if count drops <50k with bleeding
• Supportive care in ICU/HDU

🔷 COMPLICATIONS

🔷 MCQ CORNER