The hospital frequency of HELLP syndrome in the Gynecology and Obstetrics Department of the Borgou-Alibori Departmental University Hospital from 2019 to 2023 was 0.59%, corresponding to approximately 6 cases of HELLP syndrome per 1000 admissions.

The mean age was 27.14 ± 5.33 years, ranging from 17 to 42 years. Most women were in a common-law union (63.51%). Married women accounted for 33.78%, and 2.70% were single (Table 1).

Table 1. Distribution of women with HELLP syndrome according to age and marital status at the Borgou-Alibori Departmental University Hospital Center, from 2019 to 2023.

Nine (9) out of 74 women (12.16%) had a medical history of hypertension, and cesarean sections accounted for 28.38% of surgical histories. The mean gravidity was 3.13 ± 2.06 pregnancies, ranging from 0 to 8. Paucigravidae represented 41.89% of the women. The mean parity was 2.28 ± 1.86, with extremes ranging from 1 to 11. Women were primiparous and pauciparous in 28.38% of cases, respectively (Table 2).

Table 2. Distribution of women with HELLP syndrome according to medical, surgical, and obstetric history at the Borgou-Alibori Departmental University Hospital Center, from 2019 to 2023.

Among the 74 women, 60 were pregnant (81.08%), and the remaining 14 were admitted postpartum. The average gestational age was 32.63 ± 3.75 weeks of amenorrhea (WA), ranging from 22 WA to 40 WA + 2 days. Women with a gestational age of 32 WA or more accounted for 51.67%. The average number of antenatal care visits (ANC) was 2.63 ± 1.97, with extremes ranging from 0 to 9 visits. Nine women did not attend any ANC visits (Table 3).

Table 3. Distribution of pregnant women with HELLP syndrome according to gestational age and number of antenatal care visits at the Borgou-Alibori Departmental University Hospital Center, from 2019 to 2023.

ReasonforReferral

Preeclampsia accounted for 52.70% of the reasons for referral, and 25.68% of women were admitted for suspected HELLP syndrome (Table 4).

Table 4.Distribution of women with HELLP syndrome according to reason for admission at the Borgou-Alibori Departmental University Hospital Center, from 2019 to 2023.

WomenBasedonFunctionalSymptoms

The women reported headaches (93.24%), followed by sharp epigastric pain (37.84%) (Table 5).

Table 5. Distribution of women with HELLP syndrome according to presenting symptoms at admission at the Borgou-Alibori Departmental University Hospital Center, from 2019 to 2023.

GeneralSigns

The average systolic blood pressure of the women was 171.31 ± 27.90 mmHg, with extremes ranging from 96 to 237 mmHg, and the average diastolic blood pressure was 108.43 ± 19.43 mmHg, with extremes ranging from 49 to 161 mmHg. The women had an SBP ≥160 mmHg (64.86%) and a DBP ≥110 mmHg (47.30%). The average Glasgow Coma Scale score of the women was 14.09 ± 2.04, with extremes ranging from 8 to 15. The women had a GCS score greater than 13 (72.98%). The average heart rate was 98.71 ± 17.95 beats per minute, with extremes ranging from 60 to 140 beats per minute. The average respiratory rate was 21.54 ± 4.12 cycles per minute, with extremes ranging from 16 to 40 cycles per minute. The average body temperature of the women was 36.71 ± 0.4°C, with extremes ranging from 36°C to 37.9°C (Table 6).

Table 6.Distribution of women with HELLP syndrome according to general clinical signs at admission at the Borgou-Alibori Departmental University Hospital Center, from 2019 to 2023.

The average hemoglobin level was 8.15 ± 2.04 g/dL. Sixty-three point five one percent (63.51%) of the women had a hemoglobin level between 7 and 10 g/dL. The presence of schistocytes on the blood smear was reported in 2 women out of the 74. Seventy point two seven percent (70.27%) of the women had an ASAT level greater than 100 IU/L, and the ALAT level was greater than or equal to 40 IU/L in 79.73% of the women. Mississippi Class 2 represented 47.30% of the women. Urinary proteinuria was positive at 3 crosses in 39.19% of the women and negative in 2.70% of the women. According to the TENNESSEE classification, the HELLP syndrome was diagnosed in its complete form in 41 women out of 74, representing 55.41% (Table 7).

Table 7. Distribution of women with HELLP syndrome according to paraclinical findings at the Borgou-Alibori Departmental University Hospital Center, from 2019 to 2023.

TimingofDiagnosis

Of the 74 women, the diagnosis of HELLP syndrome was made in the prepartum period for 60 women (81.08%) and in the postpartum period for 14 women (18.92%).

MaternalPrognosis

45.95% of the women had no other complications associated with HELLP syndrome. Eclampsia was associated with HELLP syndrome in 22.97%, renal failure in 13.51%, followed by pulmonary edema and heart failure in 5.41% and 4.05%, respectively. The other 8.11% of associated complications included endometritis (1.35%), vaso-occlusive crises (4.05%), pre-rupture syndrome (1.35%), and stroke (1.35%).

FetalPrognosis

Prematurity accounted for 53.33% of fetal complications. This was followed by intrauterine growth restriction and fetal death in utero at 21.67% and 11.67%, respectively. Intrauterine growth restriction represented 3.33%, and no fetal complications were observed in 10% of the cases.

ObstetricPrognosis

Of the 60 pregnant women, 49 underwent a cesarean section (81.67%) and the rest delivered vaginally (18.33%). 71.67% of the newborns were alive at birth. Fresh stillbirths and macerated stillbirths accounted for 16.67% and 11.66%, respectively.

MaternalClinicalOutcome

The clinical outcome for the women was favorable in 94.59%. Four maternal deaths occurred in women who presented with HELLP syndrome (5.41%).

In this study, the hospital frequency of HELLP syndrome was 0.59%, or approximately 6 cases per 1000 admissions. This prevalence remains relatively low but consistent with other hospital series that report rates ranging from 0.2% to 0.9% of pregnancies [8]. According to Oparaji, HELLP syndrome is a rare but severe complication of preeclampsia, occurring in 10% to 20% of preeclamptic patients [9]. This proportion is consistent with our study, where more than half of the cases were referred for preeclampsia.

From a scientific perspective, the variability in reported rates can be explained by the diagnostic criteria used, ethnic differences, and obstetrical practices. A recent meta-analysis [10] confirmed that the incidence of HELLP heavily depends on the classification criteria used (Mississippi vs. Tennessee). Furthermore, Abdullahi etal. in 2024 observed that the prevalence of HELLP is higher in regions with limited access to prenatal care, which may explain the moderate frequency observed in our setting [11].

The average age of the patients was 27.14 ± 5.33 years, with extremes ranging from 17 to 42 years. This result aligns with several studies that report an average age of patients between 25 and 30 years [12][13]. Oparaji showed in 2024 that HELLP syndrome can occur in both young primigravidas and older multiparas [9], although cardiovascular risk factors increase with age.

This data underscores the importance of monitoring pregnant women regardless of age, although some studies, such as that of Wang etal. in 2024, have shown a more marked prevalence of HELLP after 35 years [14]. The pathophysiological explanation lies in the increased endothelial dysfunction and vascular stiffness that appear with age, making patients more vulnerable to hypertensive complications during pregnancy.

In this study, 12.16% of patients had a history of hypertension, which is lower than the 20% - 30% reported by some studies [15]. However, Müller etal. in 2024 confirmed that chronic hypertension is a predictive factor for HELLP, increasing the risk by a factor of 3 to 5 [16]. On the other hand, a previous cesarean section was reported in 28.38% of patients, which is consistent with trends observed in recent studies [17]. This link between surgical history and HELLP could be explained by a predisposition to placental dysfunction, as suggested by Costa etal. in 2024, who demonstrated an association between genetic mutations in the trophoblast and an increased risk of severe preeclampsia and HELLP [18].

The average gestational age at delivery was 32.63 ± 3.75 weeks, with 51.67% of women delivering at or after 32 weeks of gestation. This result aligns with data from Shi etal. in 2025, which showed that HELLP syndrome primarily occurs between 28 and 34 weeks, a period when the pathophysiology of the placenta reaches a critical threshold [19]. A study conducted in Canada [14] found that early forms of HELLP (<30 weeks) are associated with higher maternal and neonatal mortality. In contrast, in our study, the maternal outcome was favorable in 94.59% of cases, suggesting effective management despite limited resources.

In this series, 52.70% of women were referred for preeclampsia, and 25.68% had suspected HELLP. These figures are similar to those reported by Medeiros etal. in 2024, where preeclampsia was the primary initial diagnosis in 50% to 60% of HELLP cases [20]. This high rate of preeclampsia underscores the importance of early screening for hypertensive complications in hospital settings, especially since close monitoring is necessary to anticipate progression to HELLP, according to Rahman etal., 2024 [21]. Moreover, Jenkins etal. in 2024 emphasized the need to review HELLP diagnostic criteria, as many cases could be detected earlier with more sensitive biological markers [22].

Anemia was present in 63.51% of the patients, with an average hemoglobin level of 8.15 ± 2.04 g/dL. This frequency is higher than that reported by Frimat etal. in 2024 (50% of cases) [23]. Hemolysis in HELLP syndrome is well-documented, and a recent study [24] showed that the elevation of liver enzymes often precedes a drop in platelet count.

The presence of schistocytes in 2.7% of patients is a key diagnostic criterion for HELLP. According to Rajput etal. in 2025 [25], HELLP must be differentiated from thrombotic thrombocytopenic purpura (TTP), especially in cases with significant schistocytosis.

The maternal mortality rate was 5.41%, which is lower than the 10% - 20% reported in some African studies [11]. Maternal mortality in HELLP syndrome largely depends on early management and associated complications, such as renal failure (13.51%) and stroke (1.35%).

Regarding fetal prognosis, 53.33% of the children were premature, which aligns with data from Masuko etal. in 2024 [26], who reported prematurity in 50% - 60% of cases. The perinatal mortality rate of 28.33% (fresh and macerated stillbirths) is higher than the 20% observed in Europe [27], which may be explained by delays in management and limitations in neonatal care.