HELLP syndrome: Difference between revisions
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==Background== | ==Background== | ||
*HELLP = Hemolysis, Elevated LFTs, Low Platelets | *HELLP = [[hemolytic anemia|Hemolysis]], Elevated [[LFTs]], [[thrombocytopenia|Low Platelets]] | ||
*Clinical variant of [[preeclampsia]] | *Clinical variant of [[preeclampsia]] | ||
*Any patient >20wk gestation or <4wk postpartum complaining of abdominal pain should receive HELLP workup | *Any patient >20wk gestation or <4wk postpartum complaining of abdominal pain should receive HELLP workup | ||
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==Clinical Features== | ==Clinical Features== | ||
*RUQ or epigastric pain (40-90%) | *[[RUQ pain|RUQ]] or [[epigastric pain]] (40-90%) | ||
*Proteinuria (86-100%) | *Proteinuria (86-100%) | ||
*Hypertension (82-88%) | *[[Hypertension]] (82-88%) | ||
===Complications=== | |||
*[[Disseminated intravascular coagulation]] | |||
*[[Acute kidney injury]] | |||
*Subcapsular liver hematoma | |||
*[[Hemorrhage]] | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
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*CBC | *CBC | ||
**May see a [[microangiopathic hemolytic anemia]] (Schistocytes on microscopy) | **May see a [[microangiopathic hemolytic anemia]] (Schistocytes on microscopy) | ||
**Platelet count <150 × 10<sup>9</sup> per L (150 per mm<sup>3</sup>) | **[[thrombocytopenia|Platelet count <150]] × 10<sup>9</sup> per L (150 per mm<sup>3</sup>) | ||
*Chemistry | *Chemistry | ||
**Normal or elevated BUN/Cr | **Normal or elevated BUN/Cr | ||
*Coagulation panel (fibrinogen can be decreased and PTT elevated) | *Coagulation panel (fibrinogen can be decreased and PTT elevated) | ||
**Patients can progress towards [[DIC]] | **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 | **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) | **LDH elevation (often > 600 IU/L) | ||
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**Delivery (only definitive treatment) | **Delivery (only definitive treatment) | ||
**[[Magnesium sulfate]] | **[[Magnesium sulfate]] | ||
**BP control | **[[antihypertensives|BP control]] | ||
**[[Coagulopathy (main)|Coagulopathy correction]] | **[[Coagulopathy (main)|Coagulopathy correction]] | ||
***Transfuse [[platelets]] if < 20,000 or active, uncontrolled bleeding | ***Transfuse [[platelets]] if < 20,000 or active, uncontrolled bleeding | ||
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==Disposition== | ==Disposition== | ||
*Admit | *Admit | ||
==See Also== | ==See Also== | ||
Revision as of 19:35, 3 October 2019
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
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)
- 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