Obgyn · Year 3 · from Obgyn
Case 3: HELLP Syndrome
Patient Demographics
- Age: 31 years
- Sex: Female
- Occupation: Nurse
Chief Complaint
"I have terrible pain under my right ribs and I feel like I might throw up."
History of Present Illness
The patient is G2P1 at 35 weeks 5 days gestation. She developed right upper quadrant pain last night that is severe and persistent. She has been nauseated with two episodes of vomiting. She noticed that she feels "unwell" and more fatigued than usual. She denies headache, visual changes, or contractions. Her pregnancy has been uncomplicated until now with normal blood pressures at all prenatal visits.
Past Medical History
- Prior uncomplicated term pregnancy
- No hypertension, diabetes, or other medical conditions
Physical Examination Findings
- Vital Signs: BP 152/98 mmHg, HR 92 bpm, Temperature 98.4F
- General: Uncomfortable, slightly jaundiced sclera
- Abdomen: Right upper quadrant tenderness to palpation, liver edge tender, gravid uterus non-tender
- Extremities: 2+ pitting edema
Diagnostic Workup
- CBC:
- Hemoglobin 10.2 g/dL (was 12.0 at 28 weeks)
- Platelets 68,000/mm3 (THROMBOCYTOPENIA)
- Comprehensive Metabolic Panel:
- AST 285 IU/L (ELEVATED)
- ALT 312 IU/L (ELEVATED)
- Total bilirubin 2.1 mg/dL (elevated)
- Creatinine 1.0 mg/dL
- LDH: 680 IU/L (ELEVATED - indicative of hemolysis)
- Peripheral Smear: Schistocytes and helmet cells present (HEMOLYSIS)
- PT/PTT: Normal
- Fibrinogen: 310 mg/dL (normal, but trending)
- Urinalysis: 2+ protein
- Fetal Assessment: NST reactive, EFW 2,400 grams
Diagnosis
HELLP Syndrome - complete, meeting all criteria:
- Hemolysis: Elevated LDH, schistocytes on smear, elevated bilirubin
- Elevated Liver enzymes: AST 285, ALT 312
- Low Platelets: 68,000
Note: Blood pressure only mildly elevated (HELLP can occur with minimal hypertension)
Risk Assessment
- Hepatic hematoma/rupture risk (rare but catastrophic)
- DIC development risk
- Acute kidney injury risk
- Placental abruption risk
- Need for emergent delivery
Management Plan
Immediate Stabilization:
- Two large-bore IVs
- Type and crossmatch for 4 units PRBCs
- Platelets ordered and available
- Anesthesia consultation (regional anesthesia may be contraindicated with severe thrombocytopenia)
Magnesium Sulfate:
- For seizure prophylaxis (HELLP patients at high risk for eclampsia)
- Standard loading and maintenance doses
Blood Pressure Management:
- IV Labetalol to maintain BP <160/110
Antenatal Corticosteroids:
- Betamethasone given, but delivery will not be delayed >48 hours for HELLP
Platelet Threshold for Delivery:
- If cesarean needed and platelets <50,000: transfuse platelets
- Current platelets 68,000: acceptable for vaginal delivery or cesarean with general anesthesia
Delivery Decision:
- HELLP syndrome at 35+ weeks: DELIVERY INDICATED
- Do not delay for corticosteroids if maternal status deteriorating
- Mode: Assess cervix for induction candidacy
Delivery Course
- Cervix 1 cm, 25% effaced, high (unfavorable)
- Given thrombocytopenia and severity of HELLP: cesarean delivery chosen
- General anesthesia used (epidural contraindicated with platelets 68,000)
- Cesarean delivery uncomplicated
- Female infant, 2,380 grams, Apgar 8/9
- EBL 800 mL, no transfusion required
Postoperative Course
- Labs initially worsened (expected nadir at 24-48 hours post-delivery):
- Day 1: Platelets 52,000, AST 420
- Day 2: Platelets 78,000, AST 280 (improving)
- Day 3: Platelets 125,000, AST 98
- Liver enzymes and platelets normalized by day 4
- Discharged postoperative day 4
Counseling
- Risk of recurrence in future pregnancy: 5-25%
- Long-term liver function usually returns to normal
- Cardiovascular risk screening recommended
Clinical Image
Image Description: Peripheral blood smear demonstrating microangiopathic hemolytic anemia with schistocytes (fragmented red blood cells) and helmet cells, characteristic findings in HELLP syndrome.
Attribution: Image from Wikimedia Commons. Educational pathology image. Licensed under CC BY-SA 3.0.