Bleeding Risk – Hemolysis combined with a low platelet count predisposes the patient to greater risks of the complications of bleeding. Type and cross, large bore IV’s, and blood on hand.

Neuraxial Anesthesia – One might think that neuraxial anesthesia would be contraindicated in these patients, but HELLP syndrome is normally closely followed. Provided the mother is past 33/34 weeks, the provider may elect to perform a cesarean section before platelets get too low. Provided the platelets and coagulation studies are up-to-date and within safe values, neuraxial anesthesia can be performed. Coagulation should ALWAYS be evaluated carefully before attempting neuraxial anesthesia.

Platelet levels – Thresholds for neuraxial anesthesia differ per provider. The general consensus is that platelets should be > 100K. Women with platelet levels < 50K are generally considered candidates for GETA. If less than 20K, patient should receive a platelet transfusion.

Rupture Risk – If patient exhibits severe abdominal pain (which progresses to epigastric/right upper quadrant), N&V, and headaches, emergency evaluation should be taken to rule out rupture of a subscapsular hematoma, which is a life-threatening complication.

HELLP syndrome stands for:

H – Hemolysis (bilirubin > 1.2 mg/dL)
EL – Elevated liver enzymes (AST >70 IU/L, LDH > 600 IU/L)
LP – Low platelet count (< 100,000/mm3)

Preeclampsia / Eclampsia – True HELLP syndrome is teamed with pre-eclampsia and eclampsia. The difficulty is identifying it as true HELLP syndrome and not the symptoms of another disease. 70% of these patients deliver preterm. Signs and symptoms include N&V, headache, proteinuria, hypertension and right upper quadrant pain. Patients that developed HELLP syndrome between 24 and 34 weeks of gestation should be given corticosteroids (dexamethasone) to stimulate fetal lung development. Corticosteroids may also improve the platelet count. There may be an attempt to delay labor for this reason if < 34 weeks gestation.

Treatment – The only definitive treatment for HELLP is delivery of the fetus and placenta.