HELLP Syndrome: An Overview for the General Surgeon

Educational Objectives

The goal of this program is to improve management of HELLP syndrome. After hearing and assimilating this program, the clinician will be better able to:

1. Optimize use of steroids in management of HELLP syndrome in pregnancy.

Summary

HELLP syndrome (HS): characterized by hemolysis, elevated liver enzymes, and low platelet count; systemic inflammatory response syndrome may occur secondary to generalized microangiopathy; laboratory findings include low hemoglobin, elevated aspartate and alanine aminotransferases, elevated lactate dehydrogenase levels, and low platelet count

Presentation: HS occurs in 0.1% to 1% of all pregnancies; it typically occurs in the third trimester (≈75%) and ≤48 hr after delivery; dysregulated complement activation and autoimmunity lead to hemolysis, disseminated intravascular coagulation (DIC), thrombocytopenia, low hemoglobin, and microthrombi in multiple organs; in patients with previous pregnancies, HS may be absent in previous pregnancies; preeclampsia is absent in ≈20% of patients with HS (may be a separate disorder); symptoms are nonspecific (eg, nausea, vomiting, abdominal pain); complaints of abdominal pain, right upper quadrant discomfort, and nausea and vomiting in the third trimester may mimic acute cholecystitis or atypical appendicitis; a high index of suspicion is necessary to diagnose HS; in such patients, abnormal laboratory tests often indicate a diagnosis of HS; if diagnosis is unclear, repeat laboratory workup

Management: prompt delivery is the definitive treatment; maternal complications include bleeding, DIC, and organ ischemia; massive hepatic rupture is a life-threatening complication; neonatal complications are related to the age of gestation, with no long-term complications or developmental delays; transfer to a specialized center is recommended; rule out emergent conditions; with severe hypertension, administer intravenous medications; with seizures, manage as usual; with abdominal pain and hypotension, focused assessment with sonography for trauma can identify free fluid; patients with hepatic rupture are thrombocytopenic; rush to the operating room, pack the liver, and deliver the baby; with DIC, pulmonary edema, or kidney injury, manage as usual

Prompt delivery: patient stratification is based on the severity of thrombocytopenia and the gestational age; prompt delivery is indicated for >34 wk of gestation; vaginal delivery is not contraindicated; indications for prompt delivery include <16 wk of gestation, fetal demise, and placental abruption; a short course of steroids (48 hr; 2 doses of betamethasone or 4 doses of dexamethasone 12 hr apart) is indicated in selected cases (eg, mild HS with stable mother and fetus) between 24 and 34 wk of gestation for fetal lung maturation (no maternal benefit) under careful monitoring; massive platelet transfusion may be necessary

Take-home points: HS is a potentially life-threatening condition; watch out for DIC, bleeding, multiple organ failure; after a brief period of supportive care (eg, for thrombocytopenia), prompt delivery is the definitive treatment

Readings

Dusse LM, Alpoim PN, Silva JT, et al. Revisiting HELLP syndrome. Clin Chim Acta. 2015;451(Pt B):117-120. doi:10.1016/j.cca.2015.10.024; Fitzpatrick KE, Hinshaw K, Kurinczuk JJ, et al. Risk factors, management, and outcomes of hemolysis, elevated liver enzymes, and low platelets syndrome and elevated liver enzymes, low platelets syndrome. Obstet Gynecol. 2014;123(3):618-627. doi:10.1097/AOG.0000000000000140; Wallace K, Harris S, Addison A, et al. HELLP syndrome: pathophysiology and current therapies. Curr Pharm Biotechnol. 2018;19(10):816-826. doi:10.2174/1389201019666180712115215.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Alam was recorded at Mattox Vegas Trauma, Critical Care & Acute Care Surgery 2023, held March 27-29, 2023, in Las Vegas, NV, and presented by the Trauma and Critical Care Foundation. For more information about upcoming CME activities from this presenter, please visit https://www.trauma-criticalcare.com. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.50 CE contact hours.

Lecture ID:

GS701603

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.