A case report of HELLP syndrome

HELLP syndrome ISSN: 2394-0026 (P)Case Report ISSN: 2394-0034 (O) A case report of HELLP syndrome Aesha A. Patel1*, Tushar M. Shah2 1PG Student, Obstetrics and Gynecology Department, B.J. Medical College, Ahmedabad, India2Assistant Professor, Obstetrics and Gynecology Department, B.J. Medical College, Ahmedabad, India *Corresponding author email: [email protected] to cite this article: Aesha A. Patel, Tushar M. Shah. A case report of HELLP syndrome. IAIM,2015; 2(1): 108-111. Available online at www.iaimjournal.comReceived on: 30-12-2014 Accepted on: 07-01-2015AbstractHELLP syndrome is a serious complication in pregnancy characterized by hemolysis, elevated liverenzymes and low platelet count. This case demonstrated the importance of rapid and early diagnosisand treatment of HELLP syndrome to reduce maternal and perinatal mortality and morbidity. 26years old, 2nd gravida with 31 weeks of gestation with severe pre-eclampsia was admitted toDepartment of Obstetrics and Gynecology at Civil Hospital, Ahmedabad. Patient suddenly developedepigastric pain, blood tinge urine (not frank hematuria) and decrease urine output within 24 hours ofadmission. Investigations revealed platelet count 44,300, serum bilirubin 12, direct bilirubin 3.44,and indirect bilirubin 8.56, SGPT 193.5 and was diagnosed as a HELLP syndrome class 1. Sheunderwent cesarean section and there was dramatic improvement of her symptoms and all bloodinvestigations (S. bilirubin, Platelet count) were declined to normal limit within 48 hours postoperatively. HELLP syndrome, a variant of severe pre-eclampsia, if diagnosed and manage timelyensure favorable maternal and perinatal outcome.Key wordsHELLP syndrome, Pre-eclampsia, Hemolysis, Diagnosis, Treatment.Introduction perinatal mortality and morbidity is very high in this case. Timely diagnosis and management ofHELLP Syndrome (H – Haemolysis, EL - Elevated HELLP syndrome reduces the maternal andliver enzymes, LP - Low platelet count) is a perinatal mortality and morbidity [1].serious complication of severe pre-eclampsia. Itsincidence is reported as 0.5-0.9% of all Case reportpregnancies, and 10-20% of women with severepre-eclampsia. Incidence of maternal and 26 years old, 2nd gravida female with 31 weeks of gestation presented to us with chiefInternational Archives of Integrated Medicine, Vol. 2, Issue 1, January, 2015. Page 108Copy right © 2015, IAIM, All Rights Reserved.

HELLP syndrome ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)complaints of bilateral pedal edema since one platelet 1,1700 cells/cumm , bilirubin 3.72month. She had a history of severe pre- mg/dl, direct 1.42 and indirect 2.35, SGPT 85.6,eclampsia in past pregnancy and undergone INR 0.98. Patient was given total 5 pint PCV, 21lower section cesarean section (LSCS) for pint Platelets, 15 pint Cryoprecipitates, and 8transverse lie before three years. Her blood pint FFP.pressure was 150/100 mmHg and had bilateralpedal edema. Rest of the findings of general Discussionexamination was normal. Random urine albuminwas +2 by dip stick method. Obstetrical HELLP syndrome is a life-threatening pregnancyexamination found abdominal wall edema, complication of pre-eclampsia. The severity ofprevious cesarean section scar, 28-30 weeks size HELLP syndrome is measured according to theuterus, cephalic presentation, regular fetal heart blood platelet count of the mother and dividedsound (FHS) and relaxed, per vaginal into three categories.examination showed os closed. On admission,hemogram (Hemoglobin 9 gm/dl, Platelet count Mississippi classification of HELLP syndrome [2]3,68,000 cells/cumm), liver function test (serumbilirubin 0.71mg/dl) including liver enzymes and Platelets Class 1 Class 2 Class 3prothrombin time were within normal limit. (Severe) (Moderate) (Mild)Ultrasound for fetal well being showed 31 weeks AST or ≤50,000/ 50,000- 100,000-mature intrauterine fetus with early diastolic ALT µL 100,000/µL 150,000/µLnotch in right uterine artery on Doppler study. LDH ≥70 IU/L ≥70 IU/L ≥40 IU/LPatient was kept on antihypertensive (T. Methyl ≥600 ≥600 IU/L ≥600 IU/Ldopa and T. Nifedipin) and 2 doses of steroids IU/Lgiven for fetal lung maturity. Next day, shesuddenly developed epigastric pain, blood tinge The pathogenesis of HELLP syndrome is noturine (not frank hematuria) and decrease urineoutput. At that time, blood pressure was completely understood. Those currently160/100 mmHg and urine albumin was +2. In aview of HELLP syndrome, repeat investigations considered important includeswere sent which revealed hemoglobin 11.2gm/dl, platelet count 64,300 cells/cumm, • Placental implantation with abnormalbilirubin 12 mg/dl, direct bilirubin 3.44, indirectbilirubin 8.56, INR 1.01, SGPT 193.5. At that trophoblastic invasion of uterine vessels.time, blood components were given (1 pint PCV,8 pint FFP, 12 pint Platelets, 4 pint • Immunological maladaptive toleranceCryoprecipitates). Non stress test was donewhich was equivocal. Decision of emergency between maternal, paternal (placental)LSCS was taken. After counseling, the patientwas posted for surgery. Emergency LSCS was and fetal tissues.done, delivered a male child 1.5 kg. Peroperative blood components were given. Post • Maternal maladaptation tooperative period was uneventful. Herinvestigations revealed hemoglobin 7 gm/dl, cardiovascular or inflammatory changes of normal pregnancy. • Genetic factors including inherited predisposing genes as well as epigenetic influences. Hemolysis, one of the major characteristics of the disorder, is due to a microangiopathic hemolytic anaemia. Elevation of liver enzymesInternational Archives of Integrated Medicine, Vol. 2, Issue 1, January, 2015. Page 109Copy right © 2015, IAIM, All Rights Reserved.

HELLP syndrome ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)reflects the hemolytic process as well as liver Referencesinvolvement. Hemolysis contributessubstantially to the elevated levels of LDH, 1. Haram K, Svendsen E, Abildgaard U. The HELLP syndrome: Clinical issues andwhereas enhanced aspartate aminotransferase management. A review. BMC Pregnancy Childbirth, 2009; 9: 8.(AST) and alanine aminotransferase (ALAT) 2. Martin JN, Owens MY, Keiser SD, Parrishlevels are mostly due to liver injury. Decreased MR, Tam Tam KB, Brewer JM, Cushman JL, May WL. Standardized Mississippiplatelet count in the HELLP syndrome is due to Protocol treatment of 190 patients with HELLP syndrome: Slowing diseasetheir increased consumption. Platelets are progression and preventing new major maternal morbidity. Hypertensactivated, and adhere to damaged vascular Pregnancy, 2012; 31(1): 79–90.endothelial cells, resulting in increased platelet 3. Baxter JK, Weinstein L. HELLP syndrome: The state of the art. Obstet Gynecolturnover with shorter lifespan [3, 4, 5]. Surv., 2004; 59: 838–845.HELLP syndrome typically occurs between 27 4. Redman CW, Bonnar J, Beilin L. Earlyweeks of gestation and delivery or immediately platelet consumption in pre-eclampsia.postpartum in 15%-30% of cases [6, 7, 8, 9]. Br Med J., 1978; 1: 467–469.HELLP syndrome has been shown to occur inolder maternal age groups, with a mean age of 5. Stubbs TM, Lazarchick J, Van Dorsten JP,25 years. In contrast, pre-eclampsia is most Cox J, Loadholt CB. Evidence ofcommon in younger patients (mean age, 19 accelerated platelet production andyears) [9]. The recurrence rate is 2-27% in consumption in nonthrombocytopenisubsequent pregnancies [10, 11]. Maternal preeclampsia. Am J Obstet Gynecol.,mortality ranges from 1-3%, with a perinatal 1986; 155: 263–265.mortality rate of 35% [12]. 6. Thomas T, Jophy R, Mhaskar A, MisguithMaternal morbidity includes D. Are we increasing serious maternal • Disseminated intravascular coagulation morbidity by postponing termination of (DIC) (20%) pregnancy in severe • Placental abruption (16%) preeclampsia/eclampsia? J Obstet • Acute renal failure (7%) Gynaecol., 2005; 25(4): 347-51. • Pulmonary edema (6%) [12] 7. Martin JN Jr, Magann EF, Blake PG.Conclusion Analysis of 454 pregnancies with severe preeclampsia/eclampsia/HELLPDefinitive treatment for women with HELLP syndrome using the 3-class system ofsyndrome is delivery of the baby. Transfusion of classification. Am J Obstret Gynecol,some form of blood product (red cells, platelets, 1993; 168: 386.plasma) is often needed. Corticosteroids can beused to improve fetal lung maturation in the 8. Martin JN Jr, Magann EF. HELLPvery preterm pregnancy. Timely diagnosis and syndrome current principles andmanagement of HELLP syndrome either by recommended practice. Curr Obstetinduction and delivery by vaginal route or by Med., 1996; 4: 129-75.cesarean section is beneficial and preventscomplications in mother and fetus.International Archives of Integrated Medicine, Vol. 2, Issue 1, January, 2015. Page 110Copy right © 2015, IAIM, All Rights Reserved.

HELLP syndrome ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)9. Sibai BM, Ramamdan MK, Usta I, Salama HELLP syndrome. Clinical Obstetrics and Gynecology., 2005; 48(2): 460-477.M, Mercer BM, Friedman SA. Maternal 12. Sullivan CA, Magann EF, Perry KG Jr, et al. The recurrence risk of the syndromemorbidity and mortality in 442 of hemolysis, elevated liver enzymes, and low platelets: Subsequentpregnancies with HELLP syndrome. Am J pregnancy outcome and long term prognosis. Am J Obstet Gynecol., 1995;Obstet Gynecol., 1993; 169: 1000-6. 172: 125.10. Ukomadu C, Greenberger N, BlumbergR, Burakoff R. Hepatic Complications ofPregnancy. In: Current Diagnosis andTreatment: Gastroenterology,Hepatology and Endoscopy. McGrawHills and Company; 2009, Chapter 8.11. O'Brien JM, Barton JR. Controversieswith the diagnosis and management ofSource of support: Nil Conflict of interest: None declared.International Archives of Integrated Medicine, Vol. 2, Issue 1, January, 2015. Page 111Copy right © 2015, IAIM, All Rights Reserved.