A review of HELLP syndrome, in 17 patients

doi:10.4236/ojog.2012.23066

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Open Journal of Obstetrics and Gynecology, 2012, 2, 318-320 OJOG

http://dx.doi.org/10.4236/ojog.2012.23066 Published Online September 2012 (http://www.SciRP.org/journal/ojog/)

A review of HELLP syndrome, in 17 patients

Davut Güven1, Kadir Bakay2*, İdris Koçak1, Cazip Üstün1

1Department of Obstetrics and Gynecology, 19 Mayis University School of Medicine, Samsun, Turkey

2Private Hospital Department of Obstetrics and Gynecology, Turkey

Email: *[email protected]

Received 15 May 2012; revised 27 June 2012; accepted 9 July 2012

ABSTRACT

Introduction: Preeclampsia is a well known obstetric

complication characterized with hypertension and

proteinuria whereas HELLP syndrome (hemolysis,

elevated liver enzymes, low platelet count) which was

first stated by Prichard in 1954 and described by

Weinstein in 1982, is a multisystemic disease usually

seen in the third trimester and in the postpartum

period, usually in 48 - 72 hours following delivery [1].

Aim: In this study we aim to share our experience in

17 patients with HELLP syndrome treated in our

clinic between January 2005 and March 2008 in re-

gard of the current literature. Material and Methods:

17 patients diagnosed with HELLP syndrome between

January 2005 and March 2008 were retrospectively

re-evaluated in regard of symptoms, treatment op-

tions and prognosis. As such this is a retrospective

study focusing on case reports. Conclusion: As noted

before main focus of treatment should be on patient

stability, in other words, palliative care under in-

tensive care conditions.

Keywords: HELLP; Preeclampsia; Eclampsia; 17

Patients

1. INTRODUCTION

Preeclampsia (eclampsia; Greek, “shining forth”) is a

well known obstetric complication characterized with

hypertension and proteinuria whereas HELLP syndrome

(hemolysis, elevated liver enzymes, low platelet count)

which was first stated by Prichard in 1954 and described

by Weinstein in 1982, is a multisystemic disease usually

seen in the third trimester and in the postpartum period,

usually in 48 - 72 hours following delivery [1].

With an incidence of 0.2% - 0.8% in all pregnancies

and 10% in severe pregnancy its etiology and pathogene-

sis is still not fully revealed though it is assumed genetic

inheritance, abnormal placentation, immunologic factors

and maternal vasculo endothelial dysfunction may play a

role [2].

These factors may cause segmental vasospasms and

endothelial lesions causing fibrine deposits that result in

micro circulatory dysfunctions [3].

Changes described in HELLP syndrome can adversely

affect liver and renal functions causing elevated liver

enzymes and proteinuria [4].

There are various complications known to be associ-

ated with HELLP syndrome, including but not limited to;

ascites, pleural effusion, pulmonary edema and dissemi-

nated intravascular coagulation (DIC) [1,5,6].

In this study we aim to share our experience in 17 pa-

tients with HELLP syndrome that were treated in our

clinic between January 2005 and March 2008 in regard

of the current literature.

Of the 17 cases we have thus reviewed, 3 required in-

tensive care management, the remaining 14 recovered in

24 hours after delivery without any complications hence

were monitored in the obstetric clinic.

2. AIM

In this study we aim to share our clinical experience in

17 patients with HELLP syndrome treated in our clinic

between January 2005 and March 2008 in regard of the

current literature. We especially aim to present 3 cases

who were treated in the intensive care unit to remark

treatment options and prognosis in such extreme con-

ditions.

3. MATERIAL AND METHODS

17 patients diagnosed with HELLP syndrome between

January 2005 and March 2008 were retrospectively re-

evaluated in regard of symptoms, treatment options and

prognosis. As such this is a retrospective study focusing

on case reports. Patients who were treated in intensive

care unit are presented in detail as an example of how far

the disease could progress and how dramatically it can

fully resolve if managed right.

3.1. Case 1

A 25 years old 35 weeks twin pregnancy patient admitted

*Corresponding author.

OPEN ACCESS

D. Güven et al. / Open Journal of Obstetrics and Gynecology 2 (2012) 318-320 319

to our clinic complaining of headache and nausea. Upon

initial examination blood pressure was 170/120 mmHg

with ascites and remarkable pretibial edema. In pelvic

examination cervix was firm and closed. Ultrasonogra-

phy showed two viable fetuses. Initial laboratory results

were as follows; Hb: 9.8 g/dl, Hct: 32.9%, Platelets:

177.000, SGOT: 42 IU/l, SGPT: 48 IU/l, proteinuria was

present and coagulation parameters were in normal range.

Immediate caesarean section was performed and two

viable fetuses were delivered.

2 hours following delivery a second laparotomy was

deemed necessary due to uncontrollable vaginal bleeding.

An increase in liver enzymes and a severe drop in plate-

let count were observed right after operation with SGOT:

66 IU/l, SGPT: 81 IU/l and 89.000 respectively.

With the appearence of tonic-clonic seizures and se-

vere breathing irregularity along with persistant high

blood pressure, patient was intubated and transferred to

the intensive care unit.

While undergoing palliative therapy and close moni-

toring a one session of hemodialysis was needed because

of anuria and edema. Blood transfusion and fresh frozen

plasma had to be administered to stabilize hemodynamic

parameters and vascular stability.

With the return of renal functions, viable vital signs

and normal laboratory results patient was extubated on

the 3rd day in intensive care unit. During follow-up no

other complications were observed and the patient was

discharged 10 days after operation.

3.2. Case 2

A 31 years old 20 weeks pregnancy diagnosed with pre-

eclampsia was brought to our clinic after having suffered

a tonic-clonic seizure at home. Upon initial examination

patient was comatose with a Glascow Coma Score of 9

and blood pressure was 140/90 mmHg, fetal cardiac ac-

tivity was absent. Laboratory results were as follows; Hb:

10.9 g/dl, Hct: 34 %, Platelets: 73.000, SGOT: 81 IU/l,

SGPT: 67 IU/l and coagulation parameters were in nor-

mal range.

Immediate caesarean section was performed and the

patient transferred to the intensive care unit right after

the operation without extubation.

MgSO4 therapy was initiated closely monitoring mag-

nesium levels and urinary output along with replacement

therapy. Hemodialysis was required after stopping

MgSO4 due to anuria and edema albeit normal magne-

sium levels.

After having been intubated for 4 days in the intensive

care unit, with continuous monitoring and replacement

therapy renal functions returned to normal and liver en-

zymes were in a normal range. Patient was transferred

back to our clinic after 7 days in the intensive care unit

and discharged on the 10th day after operation without

any further complications.

3.3. Case 3

A 24 years old 33 weeks pregnancy with a previous his-

tory of caesarean section and diagnosed with preeclamp-

sia admitted to our clinic complaining of pelvic pain and

contractions. Upon initial examination blood pressure

was 150/110 mmHg pretibial edema was present. In pel-

vic examination cervix was dilated 3 cm with an efface-

ment of 70% indicating active labor. Ultrasonography

showed one viable fetus. Initial laboratory results were as

follows; Hb: 12.8 g/dl, Hct: 36%, Platelets: 141.000,

SGOT: 32 IU/l, SGPT: 37 IU/l, proteinuria was present

and coagulation parameters were in normal range.

Immediate caesarean section was performed and a

single viable fetus was delivered.

After a rise in blood pressure and liver enzymes along

with a decrease in platelet count in the post operative 8th

hour, patient was transferred to the intensive care unit for

close monitorization. Patient’s renal functions were nor-

mal and with palliative therapy vital signs and laboratory

results returned to normal range. Patient was transferred

back to our clinic after 3 days in the intensive care unit

and discharged on the 8th day after operation without

any further complications.

4. DISCUSSION

HELLP syndrome is diagnosed with hemolysis, elevated

liver enzymes and low platelets first stated by Prichard in

1954 and described by Dr. Louis Weinstein in 1982 [1].

In current literature HELLP syndrome is described as

a complication usually seen in the early post partum

period, up to 6 days, most frequently in the first 48 hours

[7].

Of the 3 cases we discussed above, 2 had acute renal

failure requiring hemodialysis. Acute renal failure in

HELLP syndrome is a very serious complication with an

incidence of 7.3% as stated by Sibai [8].

Endothelial damage, vasospasm, platelet activation

and a decrease in endothelium derived relaxing factor

activity may be blamed for acute renal failure in HELLP

syndrome [9].

Whatever the cause, acute renal failure in HELLP

syndrome is a serious condition which requires early

intervention and intensive care management. Also pa-

tients with HELLP syndrome and acute renal failure are

more susceptible to other severe complications such as

multi organ failure including lungs, brain and heart.

Hemolysis in HELLP syndrome can lead to DIC if left

unattended therefore it is fairly important to intervene

early if such a condition arises. There is no decisive

marker to foretell if hemolysis will occur in a preeclamp-

D. Güven et al. / Open Journal of Obstetrics and Gynecology 2 (2012) 318-320

320

tic patient but a review of current literature shows Hap-

toglobin to be the most sensitive parameter [10].

OPEN ACCESS

[6] Sibai, B.M., Taslimi, M.M., EL-Nazer, A., Aman, E.,

Mabie, B.C. and Ryan, G.M. (1986) Maternal-perinatal

outcome associated with the syndrome of hemolysis,

elevated liver enzymes, and low platelets in severe pre-

eclampsia, eclampsia. American Journal of Obstetrics &

Gynecology, 155, 501-509.

Even after numerous studies there is still debate on the

diagnosis and treatment of HELLP syndrome [11,12].

Main focus should be on palliative care and replacement

therapy but as shown in our study hemodialysis might be

necessary if renal failure is observed.

It is debatable whether or not to administer platelet

transfusion to patients with low platelet count to prevent

hemorrhage. But transfusion is recommended to patients

prior to labor if their platelet count is below 50.000 [13].

Rahman et al. administered steroids to patients with 24

- 34 weeks of pregnancy to further fetal maturation and

they observed that when used on patients with HELLP

syndrome their platelet count showed a tendency to rise

[13].

Also Martin et al. suggested that dexamethasone might

benefit patients with a postpartum onset HELLP syn-

drome [14].

5. CONCLUSIONS

As noted before main focus of treatment should be on

patient stability, in other words, palliative care under

intensive care conditions.

But more importantly all patients with preeclampsia

should be closely monitored both in the antepartum and

postpartum period. Awareness in these patients is what

saves lives.

REFERENCES

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liver enzymes, and low platelet count: A severe con-

sequence of hypertension in pregnancy. American Jour-

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[2] Sezik, M., Özkaya, M.O., Sezik, H.T., Yapar, E. and Kaya,

H. (2005) HELLP sendromlu hastalarda umblikal arter

doppler incelemesinin perinatal sonuçlarla ilişkisi. Per-

inatoloji Dergisi, 13, 198-202.

[3] Loos/Rath (1992) Das HELLP-syndrom-ein “gestaltwan-

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doi:10.1016/S0002-9378(97)70005-X

ABBREVIATIONS

HELLP: hemolysis, elevated liver enzymes, low platelet

count;

DIC: disseminated intravascular coagulation;

MgSO4: magnesium sulphate.