••• Chapter 13^ Hypertension and Pregnancy^125
❍ Is HELLP syndrome always associated with hypertension?
No.
❍ Hypertension may be absent in 12% to 18%. It may be only mild in 15% to 50%. Is HELLP syndrome
always associated with proteinuria?
No. It may be absent in up to 14%.
❍ What is the differential diagnosis for a patient with HELLP syndrome?
Acute fatty liver of pregnancy, thrombotic thrombocytopenic purpura, hemolytic-uremic syndrome, immune
thrombocytopenic purpura, systemic lupus erythematosis, antiphospholipid syndrome, cholecystitis, viral hepatitis,
pancreatitis, upper respiratory infection, disseminated herpes simplex, hemorrhagic or septic shock.
❍ What maternal morbidities are associated with HELLP syndrome?
Pulmonary edema, acute renal failure, DIC, placental abruption, liver hemorrhage or failure, adult respiratory
distress syndrome, sepsis, stroke, and death (1%).
❍ What is the reported perinatal mortality rate associated with HELLP?
7.4% to 20.4% mainly due to severe prematurity.
❍ What is the rate of prematurity in HELLP syndrome?
70%.
❍ How is a suspected case of HELLP syndrome managed?
Immediate hospitalization and observation. Diagnostic measures include blood tests such as CBC, a peripheral
smear, coagulation studies, AST, ALT, creatinine, glucose, bilirubin, and LDH. Therapeutic measures are those
for severe preeclampsia including magnesium for seizure prophylaxis and antihypertensives to keep blood pressure
below 160/105 mmHg.
❍ What is the definitive treatment of HELLP syndrome?
The cornerstone of treatment is delivery, especially beyond 34 weeks (and prior to 24 weeks) gestation.
❍ What is the role of expectant management in HELLP syndrome?
Some may advocate expectant management in selected stable patients prior to 34 weeks (ie, in the absence of
multiorgan dysfunction, DIC, liver infarction or hemorrhage, renal failure, placental abruption, or nonreassuring
fetal condition). This management might include delivery in 24 to 48 hours, thus allowing completion of steroid
course or may include prolonging the pregnancy even further, until other indications for delivery occur. Expectant
management for >48 hours was found to be associated with significant rate of fetal death, and no improvement in
overall perinatal outcome, compared with those who were delivered within 48 hours.
❍ What is the role of steroids in the treatment of HELLP syndrome?
As with severe preeclampsia, steroids prior to 34 weeks improve perinatal outcome, and may also be associated
with transient improvement of the thrombocytopenia.