What is HELLP?
(H)Haemolysis
(EL)Elevated Liver Enzymes
(LP)Low Platelets
What is HELLP?
A complication of pregnancy which usually presents in women with pre-eclampsia or eclampsia. Women show signs of liver damage and abnormalities in clotting (NICE 2016)
Although it’s debatable whether HELLP is a complication of severe pre-eclampsia or a totally separate disease altogether.
How often does HELLP syndrome occur?
In 0.5 - 0.9% of all pregnancies and in 10-20% of cases with severe pre-eclampsia
What are the risk factors for developing HELLP?
- Age >35
- Primip
- Previous PIH
- Multiple pregnancy
- Previous HELLP Syndrome
- Caucasian racial origin
- Antiphosphlipid Syndrome (APS) (an autoimmune condition that makes the blood more likely to clot)
In what ways can HELLP be presented?
- 70% of cases present before delivery (peaking between 27-37 weeks.
- 30% within 48h of delivery
- Rapid onset
- Headaches reported in 30-60% of women
- Visual disturbances (20% of women)
- Fatigue
- Malaise (generally feeling of illness/discomfort)
- Epigastric pain
- Tenderness over the liver
- Oedema, hypertension and proteinuria present
- Characterised by exacerbation of symptoms at night which ease during the day
If HELLP is suspected, following investigation via bloods-what would you expect to see in the blood results?
- Raised liver enzymes with AST or ALT levels >70 IU/L due to liver injury
- Platelet count <100 due to activation and increased consumption
- Raised Bilirubin levels due to haemolysis
What are the maternal complications of HELLP syndrome?
- Development of DIC
- Placental abruption
- Acute renal failure
- Pulmonary oedema
- Liver Haematoma
- Liver rupture
- Wound infection following LSCS
- Cerebral haemorrhage or stroke
- Death
What are the fetal complications?
- Perinatal Death
- IUGR
- Preterm Delivery
- Neonatal thrombocytopoenia (low platelets, bleeding)
How is HELLP managed?
- Urgent obsetric and Anaesthetic input required
- Managed as Severe Pre-eclampsia, considered treatment of Magnesium sulphate (NICE)
- Control BP with antihypertensives
- Strict fluid management
- Corticosteroids considered depending on gestation
- Consider thromboprophylaxis
- Consider blood transfusion for RBC/plasma depending on coagulation screening
- Plan for timing of birth
- Active management of 3rd stage
- ICU/HDU
What is the pathology of HELLP syndrome? (In a nut shell)
- Activation of the coagulation system resulting in increased fibrin throughout the body
- The fibrin deposits on the walls of the blood vessels, triggering the clumping of platelets, causing blood clots and reducing plasma concentration
- These clumpy deposits narrow the diameter of the blood vessels, raising the blood pressure and reducing the blood flow to the organs
- Liver is generally affected most causing abnormal liver function and distension which is why women suffer from epigastric pain/discomfort (Myles Textbook)
What does DIC stand for?
Disseminated Intravascular Coagulation
What is the pathology of DIC?
- Endothelial damage occurs
- as a result, activation of blood coagulation occurs to repair tissue damage. Although abnormally large quantities of intravascular fibrin are released.
- Blood clots form in small and medium sized blood vessels, reducing blood flow to organs
- Plasma is reduced/exhausted, resulting in haemorrhage
Why does DIC occur?
In response to other pathology present at the time- for E.g an infection, such as sepsis
Risk factors for DIC?
-Infection (occurs in 30-50% of severe sepsis cases)
- Malignancy
- Major Trauma
- Placental Abruption
- Amniotic fluid embolism
- Severe PIH
- HELLP syndrome
- Pre-Eclampsia (NICE 2020)
Incidence of 1:1000 pregnancies
Symptoms of DIC?
- Bleeding from three unrelated sites such as site of IV, ears, nose, throat or GI tract.
- Confusion
- Fever
- Haemorrhage
- Discolouration/cyanosis of extremeties
- Respiratory distress
What is the management of DIC?
- FBC, Coagulation screen and X match
- Monitor vital signs
- Insert urinary catheter and monitor fluid balance
- plan to expedite birth?
- Examine Placenta
- Take cord samples?
