HELLP syndrome: Difference between revisions
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==Background== | ==Background== | ||
*HELLP = Hemolysis, Elevated | *HELLP = [[hemolytic anemia|Hemolysis]], Elevated [[LFTs]], [[thrombocytopenia|Low Platelets]] | ||
*Clinical variant of preeclampsia | *Clinical variant of [[preeclampsia]] | ||
*Any | *Any patient >20wk gestation or <4wk postpartum complaining of abdominal pain should receive HELLP workup | ||
* | *When occurring postpartum, typically presents within 48hr of delivery | ||
*80% of | *80% of patients have no evidence of preeclampsia before delivery | ||
== | ==Clinical Features== | ||
* | *[[RUQ pain|RUQ]] or [[epigastric pain]] (40-90%) | ||
*[[Proteinuria]] (86-100%) | |||
* | *[[Hypertension]] (82-88%) | ||
* | |||
== | ===Complications=== | ||
*[[Disseminated intravascular coagulation]] | |||
*[[Acute kidney injury]] | |||
*Subcapsular liver hematoma | |||
*[[Hemorrhage]] | |||
== | ==Differential Diagnosis== | ||
{{Postpartum emergencies DDX}} | |||
{{Hemolytic anemia DDX}} | |||
{{Jaundice DDX}} | |||
== | ==Evaluation== | ||
Evaluation is targeted at assessing the individual components of the syndrome. Labs to be drawn should include a: | |||
*CBC | |||
**May see a [[microangiopathic hemolytic anemia]] (Schistocytes on microscopy) | |||
**[[thrombocytopenia|Platelet count <150]] × 10<sup>9</sup> per L (150 per mm<sup>3</sup>) | |||
*Chemistry | |||
**Normal or elevated BUN/Cr | |||
*Coagulation panel (fibrinogen can be decreased and PTT elevated) | |||
**Patients can progress towards [[DIC]] | |||
*[[LFTs]] | |||
**AST levels > 150 IU/L and ALT levels > 100 IU/L (also often associated with bilirubin > 1.2mg/dL | |||
**LDH elevation (often > 600 IU/L) | |||
*[[UA]] ([[proteinuria]]) | |||
*CT or [[Ultrasound (main)|ultrasound]] can be considered if there is pain requiring a greater workup. | |||
**Depending on degree of [[thrombocytopenia]] are at risk for developing intraabdominal bleeding such as a hepatic hematoma | |||
==Management== | |||
*Similar to that of severe [[preeclampsia]] or [[eclampsia]] | |||
**Delivery (only definitive treatment) | |||
**[[Magnesium sulfate]] | |||
**[[antihypertensives|BP control]] | |||
**[[Coagulopathy (main)|Coagulopathy correction]] | |||
***Transfuse [[platelets]] if < 20,000 or active, uncontrolled bleeding | |||
==Disposition== | |||
*Admit | |||
==See Also== | ==See Also== | ||
*[[Post-Partum Emergencies]] | *[[Post-Partum Emergencies]] | ||
== | ==References== | ||
<references/> | |||
[[Category: | [[Category:OBGYN]] | ||
Latest revision as of 13:33, 25 November 2021
Background
- HELLP = Hemolysis, Elevated LFTs, Low Platelets
- Clinical variant of preeclampsia
- Any patient >20wk gestation or <4wk postpartum complaining of abdominal pain should receive HELLP workup
- When occurring postpartum, typically presents within 48hr of delivery
- 80% of patients have no evidence of preeclampsia before delivery
Clinical Features
- RUQ or epigastric pain (40-90%)
- Proteinuria (86-100%)
- Hypertension (82-88%)
Complications
- Disseminated intravascular coagulation
- Acute kidney injury
- Subcapsular liver hematoma
- Hemorrhage
Differential Diagnosis
3rd Trimester/Postpartum Emergencies
- Acute fatty liver of pregnancy
- Amniotic fluid embolus
- Chorioamnionitis
- Eclampsia
- HELLP syndrome
- Mastitis
- Peripartum cardiomyopathy
- Postpartum endometritis (postpartum PID)
- Postpartum headache
- Postpartum hemorrhage
- Preeclampsia
- Resuscitative hysterotomy
- Retained products of conception
- Septic abortion
- Uterine rupture
Microangiopathic Hemolytic Anemia (MAHA)
- Disseminated Intravascular Coagulation (DIC)
- Thrombotic Thrombocytopenic Purpura (TTP)
- Hemolytic Uremic Syndrome (HUS)
- HELLP syndrome
- Heparin-Induced Thrombocytopenia (HIT)
- Hereditary spherocytosis
- Paroxysmal nocturnal hemoglobinuria (PNH)
- Malignant hypertension
- Scleroderma
- Antiphospholipid Syndrome (APS)
- Other medical causes: malignancy, renal allograft rejection, vasculitides like polyarteritis nodosa and Wegener's granulomatosis
- Drugs: chemotherapy; Clopidogrel (Plavix) associated with TTP
- Nonvascular causes: prosthetic valve (more common with mechanical, more common at aortic valve), LVAD, TIPS, coil embolization, patched AV shunt, AVM
Jaundice
Indirect Hyperbilirubinemia
- Hemolytic
- G6PD
- Drug related
- Autoimmune hemolytic anemia
- Hematoma resorption
- Ineffective erythropoiesis
- Gilbert's
Direct (Conjugated) Hyperbilirubinemia
- Choledocholithiasis
- Cholecystitis
- Ascending cholangitis
- AIDS cholangiopathy
- Stricture
- Neoplasm
- Pancreatic head
- Gallbladder
- Primary liver (e.g. hepatocellular carcinoma)
- Metastatic
- Obstructing AAA
Hepatocellular damage
Patient will have severely elevated AST/ALT with often normal Alkaline Phosphatase
- Viral hepatitis
- Fulminant hepatic failure
- alcoholic hepatitis
- Ischemic hepatitis
- Toxins
- Isoniazid
- Phenytoin
- acetaminophen
- Ritonavir
- Halothane
- Sulfonamide
- Autoimmune hepatitis
- Primary biliary cirrhosis
- HELLP Syndrome
- Congestive Hepatopathy
Pregnancy Related
Transplant Related
Pediatric Related
- Inborn error of metabolism
- Neonatal jaundice (physiologic)
Additional Differential Diagnosis
- Reye syndrome
- TPN
- Heatstroke
- Budd-Chiari (with acute ascites)
- Wilson's disease
- Sarcoidosis
- Amyloidosis
Masqueraders
Only bilirubin stains the sclera
- Carotenemia
- Quinacrine ingestion
- Dinitrophenol, teryl (explosive chemicals)
Evaluation
Evaluation is targeted at assessing the individual components of the syndrome. Labs to be drawn should include a:
- CBC
- May see a microangiopathic hemolytic anemia (Schistocytes on microscopy)
- Platelet count <150 × 109 per L (150 per mm3)
- Chemistry
- Normal or elevated BUN/Cr
- Coagulation panel (fibrinogen can be decreased and PTT elevated)
- Patients can progress towards DIC
- LFTs
- AST levels > 150 IU/L and ALT levels > 100 IU/L (also often associated with bilirubin > 1.2mg/dL
- LDH elevation (often > 600 IU/L)
- UA (proteinuria)
- CT or ultrasound can be considered if there is pain requiring a greater workup.
- Depending on degree of thrombocytopenia are at risk for developing intraabdominal bleeding such as a hepatic hematoma
Management
- Similar to that of severe preeclampsia or eclampsia
- Delivery (only definitive treatment)
- Magnesium sulfate
- BP control
- Coagulopathy correction
- Transfuse platelets if < 20,000 or active, uncontrolled bleeding
Disposition
- Admit