HELLP syndrome

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HELLP syndrome

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HELLP syndrome

  1. 1. HELLP SYNDROME ` HELLP Syndrome sm during pregnancy DEFINITION: The term HELLP syndrome is used to describe preeclampsia in association with Hemolytic anemia, Elevated Liver enzyme levels, and Low Platelet count. The diagnosis is not always clear, and the syndrome may be confused with other medical conditions. Any patient diagnosed with HELLP syndrome should be considered to have severe preeclampsia. INCIDENCE:  0.5-0.9% of all pregnancies  10-20% of women with severe preeclampsia and 30% of cases associated with eclampsia  HELLP usually occurs in Caucasian women over the age of 25 in association with hypertensive disorders with pregnancy CRITERIA FOR DIAGNOSIS I. Hemolytic anemia “H”  Schizocytosis ; fragmentation of RBCS  Bilirubin > 1.2 mg/dl II. Elevated liver enzymes “EL”  SGOT > 72 IU/L  LDH > 500 IU/L III. Low plattlet count “LP”  Plattlet count < 100.000 mm3 CLASSES “GRADES”  Class I : “severe”  Plattlets<50.000 mm3  Altered liver enzymes  Evidences of hemolysis  Class II : “moderate”  Plattlets 50.000 – 100.000 mm3  Class III : “mild”  Plattlets 100.000 – 150.000 mm3 A-MOWAFY 2013 1
  2. 2. HELLP SYNDROME ` DIFFERENTIAL DIAGNOSIS HELLP syndrome may be easily confused with many other medical conditions, particularly when the patient is normotensive, differential diagnosis include: 1. Biliary colic and cholecystitis 2. ITP 3. GERD and peptic ulcer 4. Acute fatty liver of pregnancy 5. Appendicitis 6. Cerebral hemorrhage 7. Diabetes insipidus 8. Gastroenteritis 9. Glomerulonephritis 10. Hemolytic uremic syndrome 11. Hyperemesis gravidarum 12. Pancreatitis 13. Pyelonephritis 14. Systemic lupus erythematosus 15. Thrombophilias 16. Viral hepatitis MANAGEMENT Early diagnosis Class II , Class III Class I (mild to moderate) (severe) Pregnancy > 36 weeks Terminate Pregnancy < 34 weeks Completed 36 weeks Conserve + Postpartum Care A-MOWAFY 2013 2
  3. 3. HELLP SYNDROME ` I. Early Diagnosis  All cases with abnormal high blood pressure ± proteinuria should have liver enzymes and plattlet , however; HELLP syndrome may develop in the absence of signs  High risk patients include: a. Elderly multipara b. Wide pulse pressure eg; 160/90 mm/Hg c. Visual symptoms ; blurring of vision ….. etc d. Warning symptoms ; headache, epigastric and right upper quadrant pain … etc e. Mild mid-trimestric elevation of serum α feto-protein  Laboratory investigations suggesting early HELLP syndrome in high risk patients: a. LDH> 6000 IU/L b. AST > 150 IU/L c. ALT > 100 IU/L d. Bilirubin > 1.2 mg/dL e. Plattlets < 150.000 mm3 f. Uric acid > 8 mg/dL II. III. Termination of pregnancy In the following conditions: a. Class I (severe cases) irrespective of gestational age b. Pregnancy > 36 weeks c. Completing conservative management Conservative management : Indicated in mild to moderate cases < 34 weeks, conservative management includes: a. Control of blood pressure; as PET b. Prevention of eclamptic fits;  Giving magnesium sulfate to all cases of HELLPsyndrome  Action : - prevent progression of HELLP syndrome – decreases the effect on Plattlets and RBCs c. Corticosteroid therapy;  Dose: dexamethasone 10 mg tablets/twice daily  Action: - enhance lung maturity – improve Plattlets and liver functions  N.B: withdrawal should be gradual to avoid postpartum rebound effect on Plattlets and liver enzymes d. Nitric oxide donation; improves the manifestation of HELLP syndrome e. Fluid therapy (fluid and electrolyte balance)  (glucose+saline+10% ringers lactate) 100 mL/hour  Monitoring: by the following: o Fluid chart o Serum electrolyte daily A-MOWAFY 2013 3
  4. 4. HELLP SYNDROME ` o CVP; to maintain pressure between 8-12 cm/H2O and to avoid volume overload o N.B: - too little fluids → increases vasospasm → renal injury - too much fluids → pulmonary edema f. Plattlets transfusion;  When Plattlets < 50.000 m3 and patient is going to do CS Or Plattlets < 20.000 m3 and patient will deliver vaginally  Each unit increases plattlet count by 10.000 m3 So 6 – 10 units are very effective  Aggressive corticosteroid therapy decreases the need for plattlet transfusion g. Packed RBCs when haematocrite value < 30% h. Plasmapheresis:  Life-saving procedure if deterioration continue inspite of all above measure  Fresh frozen plasma is used in plasma exchange  Action: remove debris of RBCs hemolysis and Plattlets  Aggressive corticosteroid therapy decreases the need for plasmapheresis IV. Postpartum care : HELLP syndrome may be first discovered postpartum. Once discovered treatment must be in obstetric intensive care unit till: 1. Blood pressure well-contolled (dialstolic< 100 mm/Hg) 2. Urine output > 100 mL/hour 3. Maternal Plattlets increases and LDH decreases 4. Clinical improvement of any complications A-MOWAFY 2013 4

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