HELLP Syndrome
Patient Presentation:
Mrs. SD, a 42 year old woman 25 weeks pregnant with twins, was transferred our hospital. This was her second pregnancy. With her first pregnancy, she had to be induced at 35 weeks for severe pre-eclampsia. She arrived to labor & delivery complaining of a persistent headache that was unrelieved by 1000mg of Tylenol®. She also complained of blurry vision and increased edema in her face and hands. Her past medical history was significant for chronic hypertension, type 2 diabetes, and obesity. She was taking 200mg of labetalol TID at home. She stated that her blood pressures were normally 140s/80s. In triage her vital signs were as follows: HR 98, BP 182/103, temp 36.6 degrees C, and pulse ox 96% on RA. She had 3+ pitting lower extremity edema, and 3+ deep tendon reflexes.
Differential:
Chronic Hypertension, Severe Pre-eclampsia, HELLP syndrome
Diagnosis
Multiple lab tests were sent to help confirm the diagnosis of HELLP. Her AST was 225 unit/L , ALT was 375 unit/L, platelets were 75 k/uL, LDH was 610 unit/L, and 3+ urine protein in a urinalysis. A 24 hour urine was collected from her OB in the outside hospital. The results showed 6388 mg total urine protein. The combination of these lab results and the patient’s clinical presentation resulted in the diagnosis of HELLP. The only cure for HELLP is delivery.
Treatment
The patient was immediately started on magnesium sulfate to help prevent seizures. She was given a 6 gram bolus over 20 minutes and was then started on a 2 gram/hour maintenance dose. Because of her severely elevated blood pressures, she was given both IV labetalol and hydralazine. Neither of these drugs was able to drop her blood pressures below 160s/100s. The decision was made to immediately deliver the patient by cesarean section. The patient was unable to get a spinal epidural because of her low platelet count. General anesthesia was used.
Outcome
The patient delivered a 760 gram little girl. She stayed in the NICU for six months, and was then released home. It is unknown if the baby experienced any developmental delays as she grew older. Mrs. SD’s blood pressures stabilized within hours of delivery. She stayed on magnesium for 24 hours postpartum. Her lab work gradually trended back to normal, and she was able to return home post op day 4.
Case created by Sarah Davis, 2011.