HELLP Syndrome

Suspect HELLP in a patient at 28 to 36 weeks' gestation or within 7 days postpartum who has right-upper-quadrant or epigastric pain, nausea or vomiting, headache, malaise, hypertension, proteinuria, or otherwise unexplained thrombocytopenia and transaminitis. Hypertension and proteinuria occur in up to 85% of cases, so their absence does not exclude HELLP. ScienceDirect+2ScienceDirectThe interpretation of liver function tests in pregnancyPubMedManaging hepatic complications of pregnancy: practical strategies for clinicians - PMCPubMedHELLP Syndrome - StatPearls - NCBI Bookshelf

Escalate immediately to obstetrics/MFM and a delivery-capable setting when there is eclampsia, severe hypertension, severe epigastric pain, pulmonary edema, worsening renal dysfunction, major maternal organ morbidity, or nonreassuring fetal status. These findings favor delivery over continued observation because HELLP is a severe hypertensive disorder with risk of progression and maternal morbidity. BMJ+1BMJHELLP syndrome - Management Approach | BMJ Best PracticePubMedPrevention, Diagnosis and Management of Hypertensive Disorders of Pregnancy: A Comparison of International Guidelines - PMC

Evaluate acute right-upper-quadrant pain with particular urgency when accompanied by hemodynamic instability, falling hemoglobin, or rapidly worsening liver tests, because HELLP may be complicated by hepatic hematoma, infarction, or rupture. Placental abruption should be considered with abdominal pain and a firm, painful uterus; abruption occurs in up to 10% of preeclamptic pregnancies. ScienceDirect+1ScienceDirectEclampsia and Preeclampsia - an overviewajogUnderstanding and managing HELLP syndrome: The integral role of aggressive glucocorticoids for mother and child - American Journal of Obstetrics & Gynecology

Obtain CBC with platelet count, peripheral blood smear, AST, ALT, total and indirect bilirubin, LDH, serum creatinine, and urine protein assessment in any patient with suspected HELLP. Confirm microangiopathic hemolysis with schistocytes or burr cells on smear and supportive evidence such as LDH greater than 600 IU/L, indirect hyperbilirubinemia, or low haptoglobin. ScienceDirect+2ScienceDirectEclampsia and Preeclampsia - an overviewPubMedHELLP Syndrome - StatPearls - NCBI BookshelfNeurologyClinical Reasoning: A 32-Year-Old Woman Presenting With Thunderclap Headache in the Third Trimester

Use the full triad for a firm diagnosis: platelet count below 100,000/μL, AST or ALT greater than twice the upper limit of normal, and hemolysis. Commonly used supporting thresholds include AST at least 70 IU/L, LDH above 600 IU/L, and total bilirubin above 1.2 mg/dL. Differences among Mississippi, Tennessee, and ACOG-derived criteria mean that a patient with evolving or partial disease warrants serial reassessment rather than exclusion solely because one threshold is not met. ScienceDirect+2ScienceDirectEclampsia and Preeclampsia - an overviewPubMedHypertension In Pregnancy - StatPearls - NCBI BookshelfNeurologyClinical Reasoning: A 32-Year-Old Woman Presenting With Thunderclap Headache in the Third Trimester

Classify thrombocytopenia to communicate severity and anticipate hemorrhagic risk: Mississippi class I is platelet count below 50,000/μL, class II is 50,000 to 100,000/μL, and class III is 100,000 to 150,000/μL with hemolysis and elevated liver enzymes. Partial HELLP may progress to complete disease, particularly when severe hypertension, eclampsia, severe epigastric pain, or organ morbidity is present. BMJ+1BMJHELLP syndrome - Management Approach | BMJ Best PracticeNeurologyClinical Reasoning: A 32-Year-Old Woman Presenting With Thunderclap Headache in the Third Trimester

Add coagulation testing when bleeding, abruption, hepatic injury, or severe systemic illness is present. Disseminated intravascular coagulation is a recognized HELLP complication and may manifest with elevated fibrin degradation products. ScienceDirectScienceDirectThe interpretation of liver function tests in pregnancy

TTP can have the same core findings as HELLP: thrombocytopenia, microangiopathic hemolytic anemia, renal disease, and neurologic abnormalities. In preeclampsia-associated HELLP, hypertension, proteinuria, and edema tend to precede hematologic abnormalities; in TTP, hypertension and proteinuria may follow hematologic disease. When thrombocytopenia and hemolysis are disproportionate to hepatic injury, or neurologic and renal findings dominate, involve hematology urgently and evaluate for TTP rather than relying on delivery as the sole intervention. ScienceDirect+1ScienceDirectEclampsia and Preeclampsia - an overviewScienceDirectHELLP Syndrome Developing at 14 Weeks of Gestation

Acute fatty liver of pregnancy is a key competing diagnosis in late pregnancy because it may overlap with HELLP in nausea, vomiting, liver dysfunction, thrombocytopenia, and systemic illness. Evaluate glucose, renal function, bilirubin, and coagulation status alongside HELLP laboratories when acute liver failure physiology or coagulopathy is present; AFLP and HELLP have similar clinical and laboratory presentations and require deliberate distinction. ScienceDirect+1ScienceDirectHELLP Syndrome Developing at 14 Weeks of GestationScienceDirectReview Imaging of pregnancy-related liver diseases

Consider antiphospholipid syndrome and hemolytic uremic syndrome in pregnancy-associated thrombotic microangiopathy, particularly when the timing, renal injury, thrombotic history, or laboratory pattern is atypical for hypertensive disease. These entities are specifically recognized in the differential diagnosis of HELLP. ScienceDirectScienceDirectHELLP Syndrome Developing at 14 Weeks of Gestation

Do not label isolated pruritus and cholestatic liver-test elevation as HELLP without evidence of hemolysis and thrombocytopenia. Intrahepatic cholestasis of pregnancy is a diagnosis of exclusion, and ursodeoxycholic acid is first-line therapy at 10 to 15 mg/kg maternal body weight when ICP is diagnosed. PubMedPubMedManaging hepatic complications of pregnancy: practical strategies for clinicians - PMC

Manage HELLP as preeclampsia with severe features: stabilize blood pressure, prevent eclampsia, assess volume status and pulmonary edema, correct clinically significant hemorrhagic complications, and coordinate anesthesia, obstetric, neonatal, and critical-care planning according to maternal and fetal condition. Definitive treatment of preeclampsia-spectrum disease is delivery. PubMed+2PubMedPrevention, Diagnosis and Management of Hypertensive Disorders of Pregnancy: A Comparison of International Guidelines - PMCPubMedHypertension In Pregnancy - StatPearls - NCBI BookshelfPubMedPreeclampsia - StatPearls - NCBI Bookshelf

Administer magnesium sulfate for seizure prophylaxis in women with preeclampsia with severe features during labor and delivery and continue for 24 hours postpartum. Use this pathway in HELLP because HELLP is managed as a severe preeclampsia phenotype and eclampsia can occur intrapartum or postpartum. PubMed+2PubMedPrevention, Diagnosis and Management of Hypertensive Disorders of Pregnancy: A Comparison of International Guidelines - PMCPubMedHypertension In Pregnancy - StatPearls - NCBI BookshelfPubMedPlasma exchange in severe postpartum HELLP syndrome

Treat severe hypertension pharmacologically without delay; intensive antihypertensive treatment is used to minimize severe systolic hypertension and its associated stroke risk in HELLP. Select the agent based on clinician experience, cost, and local availability; the cited guideline comparison does not establish a single preferred medication or dose. BMJ+1BMJHELLP syndrome - Management Approach | BMJ Best PracticePubMedPrevention, Diagnosis and Management of Hypertensive Disorders of Pregnancy: A Comparison of International Guidelines - PMC

Do not use corticosteroids as maternal disease-directed treatment for HELLP outside an individualized specialist plan. Guideline comparison data specifically advise against corticosteroids for treating HELLP, despite older literature describing possible maternal-fetal benefit; this disagreement does not alter the need for maternal stabilization and delivery when indicated. PubMed+1PubMedPrevention, Diagnosis and Management of Hypertensive Disorders of Pregnancy: A Comparison of International Guidelines - PMCajogUnderstanding and managing HELLP syndrome: The integral role of aggressive glucocorticoids for mother and child - American Journal of Obstetrics & Gynecology

Continue inpatient clinical and laboratory surveillance after delivery because HELLP can develop during the first postpartum week and eclampsia most often occurs from intrapartum through 72 hours postpartum. Follow blood pressure, symptoms, platelet count, hemolysis markers, liver tests, renal function, respiratory status, and bleeding risk until the trajectory is clearly improving. ScienceDirect+2ScienceDirectThe interpretation of liver function tests in pregnancyPubMedManaging hepatic complications of pregnancy: practical strategies for clinicians - PMCPubMedHypertension In Pregnancy - StatPearls - NCBI Bookshelf

Continue magnesium sulfate for 24 hours postpartum when the patient meets the severe-feature prophylaxis pathway. Treat postpartum severe hypertension pharmacologically; international guideline comparisons endorse treatment of severe hypertension during pregnancy and postpartum. PubMedPubMedPrevention, Diagnosis and Management of Hypertensive Disorders of Pregnancy: A Comparison of International Guidelines - PMC

If platelet count, hemolysis, renal injury, neurologic dysfunction, or hepatic abnormalities fail to improve as expected after delivery, reopen the differential rather than assuming persistent HELLP. TTP, hemolytic uremic syndrome, antiphospholipid syndrome, and acute fatty liver of pregnancy are competing diagnoses that require disease-specific evaluation and management. ScienceDirect+2ScienceDirectEclampsia and Preeclampsia - an overviewScienceDirectHELLP Syndrome Developing at 14 Weeks of GestationScienceDirectReview Imaging of pregnancy-related liver diseases

Arrange postpartum support and counseling after a severe hypertensive pregnancy complication; affected patients and families may have substantial psychological distress, and postpartum management should include psychological and family support. PubMedPubMedPrevention, Diagnosis and Management of Hypertensive Disorders of Pregnancy: A Comparison of International Guidelines - PMC