HELLP SYNDROME

HELLP syndrome is a life-threatening obstetric complication usually considered to be a variant or complication of pre-eclampsia. Both conditions usually occur during the later stages of pregnancy, or sometimes after childbirth. THE CAUSAL FACTORS INDUCE: a. Thrombocytopenia b. Microangiopathic Hemolytic Anemia c. Periportal necrosis and distension of the livers Glissons capsule. DIAGNOSIS MID-II TRIMESTER FIRST DAYS POSTPARTUM Antepartum diagnosis is made in 70% between 27 and 37 weeks of gestation.

Criteria for establishing the diagnosis of the HELLP Syndrome: 1. Hemolysis Abnormal peripherical blood smear Elevated Bilirubin >1.2 mg/dl 2. Elevated liver enzymes SGOT >72 UI / L LDH >600 UI / L 3. Low Platelets Platelet Count < 100 103 /mm3 CLINICAL MANIFESTATIONS: Excessive body weight increase . Pulse pressure amplification. Systole pressure > 140 mmHg, but diastole pressure < 90 mmHg. Ophthalmic disorders Minor alterations Cortical blindness (amaurosis) Retinal detachment Vitreous hemorrhage. Elevation of Biomarkers: o HCG o Maternal alfa-fetal protein o LDH o Serum Haptoglobin

NOTE: The presence of these disorders in an hypertensive woman with epigastric and/or right hypochondrial pain, nausea, vomiting; as well as hemolysis, will help in making the right diagnosis.

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Clasification of the HELLP Syndrome based on the platelet count

Class 1 Platelet count <50 000/mm3. Class 2 - Platelet count between 50 000 y 100 000/mm3. Class 3 - Platelet count <between 100 000 y 150 000/mm3. Hemolysis + Liver dysfunction *LDH 600 UI/l *ASAT (SGOT) and/or ALAT (SGPT) 40 UI/l *ALL MUST HAVE TO BE PRESENT II. Another classification based on the partial or complete expression of the HELLP Syndrome

1. Complete HELLP *Microangiopathic hemolytic anemia in women with severe pre-eclampsia *LDH 600 UI / L *SGOT 70 UI/l * Thrombocytopenia < 100 000/mm3 2. Partial HELLP One or two of the above. DIFFERENTIAL DIAGNOSIS OF HELLP SYNDROME: 1. THROMBOTIC MICROANGIOPATHIES - Thrombotic thrombocytopenic purpura - Microangiopathic hemolytic anemia induced by sepsis or drugs - Hemolytic Uremic Syndrome 2. FIBRINOGEN CONSUMPTION DISORDERS CID -Acute fatty liver -Sepsis - Severa Hypovolemia / Hemorrhage (Abruptio/Amniotic fluid embolism) 3. CONNECTIVE TISSUE DISORDERS -Systemic Lupus Erithematosus 4. PRIMARY RENAL DISEASE Glomerulonefritis 5. OTHERS - Hepatic encephalopathies - Viral hepatitis

Hyperemesis Gravidarum Idiopathic Thrombocytopenia Renal calculi Peptic ulcer Pielonephritis Apendicitis Diabetes Mellitus

MANAGEMENT OF THE HELLP SYNDROME 1. ANTICIPATE THE DIAGNOSIS 2. EVALUATE THE MATERNAL CONDITION 3. EVALUATE THE FETAL CONDITION 4. CONTROL THE HYPERTENSION 5. PROFILAXIS OF CONVULSIONES WITH MgSO4 6. WATER AND ELECTROLITIC BALANCE 7. HEMOTHERAPY 8. MANAGEMENT OF LABOR AND DELIVERY 9. OPTIMIZE PERINATAL CARE 10.INTENSIVE POSTPARTUM TREATMENT OF THE PATIENT 11.BE ALERT FOR MULTIPLE ORGAN FAILURE 12.ADVISE ON FUTURE PREGNANCY

POSTPARTUM INTENSIVE CARE. Admision in an obstetrical intensive care unit until: (1) Sustained increase in the platelet count and a maintained decrease in LDH. (2) Diuresis >100ml/h for 2 consecutive hours without duiretics. (3) Well controled BP with systolic pressure e 150 mmHg and diastolic pressure < 100 mmHg. (4) Obvious clinical improvement and absence of complications. The absence of improvement of the thrombocytopenia within 72-96 hours postpartum indicates severe compromise of compensatory mechanisms and posible MULTIPLE ORGAN FAILURE. Postpartum Intensive Care - The use of Dexamethasone ANTEPARTUM: (0,15mg/kg)10mg IV bid - When Platelets <100.000/mm3 - If Platelets 100.000-50.000/mm3 AND Eclampsia, Severe Hypertension, Epigastric Pain POSTPARTUM: 10mg IV bid for 2 dosis, then 5mg bid for 2 additional doses:

- When steroids were used in antepartum - Suspend when there is clinical and laboratory improvement (platelets >100.000mm3, decreased LDH, diuresis >100 ml/h)

Watch out for: Signs of multiple organ failure. Complications: Subcapsular Hematoma Subcapsular hepatica hemorrhage Hepatic Rupture.

Therapeutic solutions: Conservative Procedures Surgery.

Advising on future pregnancies. The risk of recurrence of preeclampsia -eclampsia is 42-43% and for the HELLP syndrome: 19-27%. The risk of recurrence of preterm delivery is high, about 61%.1