HELLP syndrome can be an extremely serious and complex multisystem disorder involving much more than just eclampsia. Special considerations in obstetric and anaesthetic management are necessary, to minimize the morbidity and mortality are associated with this syndrome and its complications.

1. WELCOME

2. Anaesthetic Management of a
Patient with HELLP Syndrome

3.  Amenorrhea for 32 weeks
 H/O convulsion twice
 Headache for 01 day
Chief Complaints

4. The patient was admitted to CMH Jessore on 28
July 2016 with the complaints of amenorrhea for
32 weeks with severe headache and convulsions.
She was diagnosed as a case of 32 weeks
pregnancy with severe IUGR with eclampsia.
Since, it was a case of IUGR with serious
complications like convulsions developed within
32nd
week; hence, it was decided to terminate the
pregnancy as the safer option for the mother in an
earlier opportunity. After achieving a handsome
medical control over convulsions, trials of medical
inductions were tried, but unfortunately failed.
History of Present Illness

5. Subsequently, the patient developed newer
complications like scanty of micturition, breathing
difficulties and she was found icteric. Since, the
patient developed multiple medical problems along
with her existing ailment; so, it was decided to shift
her to CMH Dhaka by helicopter for advanced
management. On 4 Aug 2016, she arrived in CMH
Dhaka at about 1330 hrs. Here, she was detected to
have developed the HELLP syndrome along with
her pregnancy and was decided to undergo
emergency Caesarean section under general
anaesthesia.
H/O Present Illness (cont..)

6. She had no previous history of Hypertension, Diabetes
Mellitus, Bronchial Asthma or Kidney disease.
She had no ante-natal check up.
Her father was a known case of HTN.
Family History
History of Past Illness
Personal History

7. Termination of pregnancy was tried at CMH
Jessore, but failed. She was managed there with
following medications –
 Tab Alpha-methyl dopa (250 mg, 2 tab 6 hourly)
 Tab Labetalol (200 mg,1 tab 12 hourly)
 Tab Misoprostole (100 mcg, 6 hourly)
 Inj magnesium sulphate (IV @ 6 drops/min for
24 hours)
 Inj Labetalol (10 mg 8 hourly)
 Inj Oxytocin (10 units)
 Inj Dexamethasone (5 mg)
Treatment History

8. Married for one and half years
Gravida - 01
Para - nil
LMP – 16 Dec 2015
EDD – 23 Sep 2016
Obstetric History

9.  Appearance - Anxious & restless
 Jaundice - ++
 Anaemia - +++
 Oedema - Generalized +++
 Pulse - 110 beats/min
 BP - 160/100 mmHg
 RR - 28 breaths/min
 Temp - 98.4 F⁰
General Examination

10.  Cardio Vascular System:
Pulse rate - 110 beats/min, regular
BP - 160/100 mmHg
 Respiratory System:
Vesicular breath sound
RR - 28 breaths/min
Breath sound - diminished on left lower zone
Percussion note - stony dull on left lower zone
No added sound
 Central Nervous System: No abnormality detected
Systemic Examination

11.  Abdominal Examination:
 Symphysio-fundal height
was corresponding to 24
weeks of pregnancy
 Foetal heart sound- not
audible
 Foetal movement was
absent
Systemic Examination (cont…)

12. Primi Gravida of 32 weeks of pregnancy with
eclampsia with IUGR and HELLP syndrome
Provisional Diagnosis

13. CBC - HB% - 7.2 gm/dL ↓↓↓
TLC - 21.9 X 109
/L ↑↑
Platelet Count - 181X109
/L
Electrolytes - Na+
- 126 mmol/L ↓
K+
- 4.8 mmol/L
Cl-
- 88 mmol/L ↓
 Renal Function Test -
Serum urea - 43 mg/dL
Serum creatinine- 1.5
mmol/L ↑
Investigations

14.  Liver Function Test -
 Serum bilirubin - 3.5 mg/dL ↑
 SGPT - 176 IU ↑
 Alkaline Phosphatase - 820 IU ↑↑
 LDH - 1540 u/L ↑↑↑
 Total Protein - 60 gm/L ↓
 Albumin - 22 gm/L ↓
 Globulin - 38 gm/L
 A/G ratio - 0.5:1
Investigations (cont…)

15.  Coagulation profile -
 APTT - Patient 48 sec
 Control 28 sec
 PT - Patient 16 sec
 Control 12 sec
 Index - 75.60
 Ratio - 1.33
 INR - 1.34
Investigations (cont…)

16.  Urine routine examination -
 Appearance – Turbid
 Reaction – Acidic
 Albumin - +
 RBC – Numerous
 WBC – 2-3 / HPA
 Epithelial cell - 8-10 / HPA
Investigations (cont…)

17.  USG of whole
abdomen (03AUG16)
- 31 wks of single foetus
with huge ascitis with left
sided pleural effusion
 Chest X-ray (03AUG16)
- Suggestive of pleural
effusion and
pneumonitis (left)
Investigations (cont…)

18. A 20-year-old female (Wife of a Snk) got admitted
at CMH Jessore on 28 Jul 2016 with the
complaints of amenorrhea for 32 weeks,
headache and convulsion. She was diagnosed as
a case of 32 weeks pregnancy with eclampsia
with IUGR associated with anaemia, ascites and
jaundice. Subsequently, the patient developed
dyspnoea and oliguria. Pharmacological
termination of pregnancy was tried there, but
failed. On 4 Aug 2016, she was evacuated to
CMH Dhaka by helicopter at 1330 hours.
Salient Features

19. The patient was received at E & C of CMH Dhaka
with dyspnoea, severe anaemia, jaundice,
generalised oedema and raised blood pressure. On
examination, there was diminished breath sound
and stony dull on percussion over the lower zone of
the left lung. Her abdominal examination revealed
severe IUGR with no foetal movement and heart
sounds. Investigations showed significant reduction
of hemoglobin, coagulation disorder, electrolyte
imbalance and hepatic & renal dysfunction.
Salient Features (cont…)

20. 32 weeks pregnancy with
HELLP Syndrome with
IUD and Acute Kidney
Injury
Final Diagnosis

21. ANAESTHETIC MANAGEMENT

22.  The patient was severely anaemic and having
altered coagulation profile.
 She was moderately icteric and having very
high liver enzyme levels & low serum protein.
 Patient developed AKI.
 She developed pleural effusion and having
respiratory distress.
 Patient was accepted as ASA grade III (E) for
general anesthesia.
Pre-anaesthetic Assessment

23.  Central venous catheter & an arterial line
were established for invasive haemodynamic
monitoring.
 Catheterization of the urinary bladder was also
done.
 The patient was connected with multi
parameter monitor.
 Inj Metoclopromide 10 mg, Inj Ranitidine 50
mg IV was administered.
Pre-operative Preparation

24.  Rapid Sequence
Induction (RSI) protocol
was followed.
 Thiopental sodium
(5 mg/kg)
 Fentanyl (1.5 mcg/kg)
 Suxamethonium 100 mg
was given and patient
was intubated under
direct laryngoscopic view
and was put on
controlled ventilation.
Induction and Intubation

25. Preparation (evaluation, monitoring, equipment,
medication, iv access, patient’s position)
Direct laryngoscopy and Intubation (Sellick’s maneuver)
Administration of rapid acting iv induction agents
Succinylcholine IV
Confirmation of endotracheal tube placement
Removal of cricoid pressure and ventilation
RSI Protocol

26. Per-operative Monitoring &
Management

27.  Anaesthesia was maintained with Inj Atracurium,
Oxygen and nitrous oxide.
 Analgesia was provided by using Fentanyl.
 Inj GTN and Inj Labetalol were used to control
BP.
 Duration of Operation: 1 hour 30 min
Per-operative Management
Input Output
Hartman’s solution-1500 ml Blood loss - 1000 ml
5% Dextrose in Aqua-500 ml Urine output – 145 ml
Whole blood- 2 units

28. As the patient had multi-organ dysfunction,
unstable haemodynamic condition and loss of
significant amount of blood with pre-existing
severe anaemia along with massive volume
replacement.
So, considering her critical clinical state and
impending instabilities…
Elective post-operative ventilation was planned
and the patient was shifted to critical care centre
(CCC).
Reversal and Extubation

29.  Patient was severely anaemic and having altered
coagulation profile.
 She was moderately icteric and having very high
liver enzyme levels & low serum protein
 Patient developed AKI
 She developed pleural effusion and having
respiratory distress
 She was not kept NPO
 Having severe metabolic acidosis (pH 6.9)
 She was carrying a dead baby
Anaesthetic Challenges (for 1st
Op)

30. On 04 Aug 1600 hours, the patient’s condition was -
On ventilator (PSIMV mode)
Pulse - 90 bpm
BP - 150/90 mmHg (Labetolol & Dobutamine infusion)
Abdominal girth were increased (10 cm).
Massive Haematuria
USG of whole abdomen revealed moderate intra-
peritoneal collection
An urgent Medical Board was held and decided to
perform Emergency Laparotomy at 2100 hrs.
Re-Laparotomy (2nd
operation)

31. Investigation findings:
Hb% - 10.5 gm/dL
Platelet count - 185X109
/L
Serum urea - 43.48 mg/dl
Serum creatinine - 2.10 mg/dl
Serum bilirubin - 4.04 mg/dL
ALT - 118 u/L
AST - 230 u/L
ALP - 599 u/L
LDH - 1726 u/L
D-dimer - Positive
INR - 2.36
VBG at 1820 hours:
pH - 6.8
PCO2- 45.4
PO2 - 85.4
HCO3
-
- 7.6 mmol/l
BE - 28 mmol/l
Na+
- 129.7 mmol/l
K+
- 4.97 mmol/l
Cl-
- 95.4 mmol/l
Lactate - 5.0 mmol/l
SvO2 - 81 %
Re-Laparotomy (2nd
operation)

32.  Considering the aforementioned critical findings, the
patient was accepted as ASA Grade- III(E) for
exploratory re-laparotomy.
 She was prepared & managed by the Senior
anaesthesiologists.
 CVP and Invasive BP were monitored continuously.
 Anaesthesia was maintained by Inj Fentanyl, Inj
Vecuronium, Oxygen, Nitrous oxide.
 Duration of Operation: 2100-2200 (1 hour)
 After operation, elective post-operative ventilation
was planned and the patient was shifted to CCC.
Re-Laparotomy (2nd
operation)

33.  Inj GTN and Inj Labetelol infusion were kept
ready to maintain haemodynamic stability.
 Inj NaHCO3, Inj Frusemide, Inj Calcium
Gluconate were given per-operatively
Input Output
Whole blood - 2 units
Sero-sanguinous fluid-
1700 ml
Hartman’s solution - 500 ml Urine output - 30 ml
Re-Laparotomy (2nd
operation)

34. Anaesthetic challenges
A critical patient was undergoing 2nd
operation 5
hours after the 1st
one.
The patient was in severely metabolic acidosis
state.
Her serum creatinine was high and having
severe hematuria.
Her serum electrolytes and coagulation
profile were deranged.
Her liver function tests were deranged.
Re-Laparotomy (2nd
operation)

35. On 05 Aug 16, the patient’s
condition was –
On ventilator (PSIMV
mode)
Pulse - 90 beats/min
BP - 130/80 mmHg
Haemodialysis was done
at 0100 hours (by SLED)
[Sustained Low Efficiency
Dialysis]
Re-Laparotomy 3rd
Operation

36.  The patient received…
 Packed Cell - 2 units
 FFP - 2 units
 Drain bag collection was - 1200 ml of blood.
 At 1900 hours, her Hb% decreased to 4.6 gm/dl.
 So, an emergency Medical Board was held and
decided to perform re-laparotomy.
 Re-laparotomy and exploration of peritoneal
cavity was done at 2130 hrs on 1st
POD.
Re-Laparotomy 3rd
Operation

37. Investigation findings:
Hb% - 4.6 gm/dl
Platelet count - 36X109
/l
Serum urea - 16.07 mg/dl
Serum creatinine - 0.91 mg/dL
Serum bilirubin - 3.86 mg/dl
ALT - 69.8 u/L
ALP - 312.2 u/L
LDH - 1064 u/L
D-dimer - Positive
INR - 1.84
VBG at 0600 hours:
pH - 7.099
PCO2 - 46.6
PO2 - 62.9
HCO-
3 - 14.4 mmol/l
BE- - 15.3 mmol/l
Lactate - 5.2 mmol/l
Na+
- 131.7 mmol/l
K+
- 4.01 mmol/l
Cl-
- 94.9 mmol/l
SvO2 - 80.4 %
Re-Laparotomy 3rd
Operation

38.  The patient was labeled as ASA Grade- IV(E)
for exploratory re-re-laparotomy.
 Patient was prepared and managed by the
Senior anaesthesiologists.
 An arterial line was re-established to monitor
Invasive BP and central venous pressure
was monitored continuously.
Re-Laparotomy 3rd
Operation

39. Input Output
Hartman’s solution - 200 ml Blood loss - 500 ml
Whole blood- 3 units Urine output - 1000 ml
Platelet concentrate - 2 units
 Anaesthesia was maintained by Inj Fentanyl, Inj
Atracurium, Oxygen, Nitrous oxide.
 Duration of Op: 2130-2345 (2 hours 15 min)
 After operation, elective post-operative ventilation
was planned and patient shifted to CCC.
Re-Laparotomy 3rd
Operation

40. Anaesthetic challenges
A moribund patient was undergoing 3rd
operation
on the 1st
POD
Severely anaemic (Hb% - 4.6 gm/l)
Patient was in severely metabolic acidotic state
(pH - 7.099).
Her renal function was impaired and having
severe haematuria.
Her electrolytes and Coagulation profile
(platelet-36X109
) were deranged.
Her liver function test was deranged.
Re-Laparotomy 3rd
Operation

41.  At CCC, the patient remained on mechanical
ventilation with multiple supports.
 After getting advanced intensive care, she was
extubated on 13 Aug 2016 (8th
POD).
Post-operative Management

42. Discussion

43.  The acronym HELLP was coined by
Weinstein in 1982 to describe a syndrome
consisting of Hemolysis, Elevated Liver
enzymes, and Low Platelet count.
 It is a syndrome that is characterized by
hepatic endothelial disruption followed by
platelet activation, aggregation and
consumption, ultimately resulting in
ischemia and hepatocyte death.
Introduction

44.  HELLP syndrome is a life-threatening obstetric
complication usually considered to be a
variant of pre-eclampsia. Both conditions
usually occur during the later stages of
pregnancy or sometimes after childbirth.
 Incidence: 0.2% to 0.6% of all pregnancy and
the maternal mortality rate is 25%.
Introduction

45.  The elevated liver enzymes are thought to
be secondary to obstruction of hepatic blood
flow by fibrin deposition in the sinusoids.
 This obstruction leads to peri-portal necrosis
and in severe cases intra-hepatic
haemorrhage, subcapsular haematoma
formation or hepatic rupture.
Pathophysiology

46.  Haemolysis is due to microangiopathic
haemolytic anaemia. Red cells become
fragmented as they pass through small vessels
with endothelial damage and fibrin deposits,
results in increase in bilirubin levels and LDH.
 Decreased platelet count is due to their
increased consumption. Platelets are activated,
and adhere to damaged vascular endothelial
cells, resulting in increased platelet turnover
with shorter lifespan.
Pathophysiology (cont..)

47.  Placental abruption
 Pulmonary edema
 Disseminated intravascular coagulation (DIC)
 Adult Respiratory distress syndrome
 Ruptured liver hematoma
 Acute renal failure
 Intrauterine Growth retardation (IUGR)
 Cerebral oedema and hemorrhage
Complications of HELLP syndrome

48. Special Considerations for
Anaesthetic Management

49.  Coagulopathy: Platelet count <1,00,000/mm3
–
regional procedures are to be avoided.
 RSI – when GA is considered.
 Attenuation of Sympathetic responses to
endotracheal intubation.
 Availability of difficult intubation cart and drugs
 Compulsory Invasive monitoring
 Proactive management of haemodynamic
alterations by vasodilators &/or vasopressors
(whenever necessary)
Special Considerations for
Anaesthetic Management

50.  Meticulous management of volume losses
 In time replacement of Blood and Plasma
 Prevention of Cerebral oedema/haemorage
 Renal protection
 Prevention of further hepatic injuries
 Last, but not the least…
 It’s an issue of two lives, both of whom are
seriously endangered and compromised.
 It demands urgent management – always.
Special Considerations for
Anaesthetic Management (cont..)

51.  Intra-arterial blood pressure monitoring
 Beat-to-beat real time BP
 Accurate- in shock
 Underlying conditions can be analysed by tracings
 Can measure any range of systolic & diastolic BP
 Use of inotropes
 Most commonly radial, femoral and brachial artery.
Management of Complications

52. Management of Complications ( cont..)
Mechanism of Intra-arterial blood pressure monitoring

53. Central venous catheter
 Central venous pressure
monitoring
 Concentrated Vasoactive drugs
 Temporary hemodialysis
 Rapid infusion of fluids
 Serial venous blood access
 We have controlled
haemodynamic status along with
metabolic acidosis.
Management of Complications (cont..)

54.  Acute renal failure
 Intake- output was maintained srtictly
 Diuretics (Frusemide), renal vasodilators (Dopamine)
were used.
 Haemodialysis was done by using modified SLED
 Liver injury
 Hepatotoxic anaesthetic agents were avoided
 Drugs with properties of self-degradation were used
Management of Complications (cont..)

55. Choice of anaesthesia depends on…
 Expertise of anaesthesiologist
 Patients condition
 Foetal condition
 Urgency of the procedure
 Patients desire to be awake during the
procedure
Choice of Anaesthesia

56.  Invasive monitoring and restoration of
haemodynamical status of the patient
 To manage metabolic acidosis state.
 Altered coagulation profile.
 Deranged liver function.
 Severe respiratory distress
General Anaesthesia

57.  Subarachnoid block - for this case it was not
chosen because it likely to have severe
hypotension due to sympathetic blockade.
 Epidural Block - this might be the choice for
the patient but avoided due to the risk for
epidural haematoma formation.
Regional Anaesthesia

58. HELLP syndrome can be an extremely
serious and complex multisystem disorder
involving much more than just eclampsia.
Special considerations in obstetric and
anaesthetic management are necessary, to
minimize the morbidity and mortality are
associated with this syndrome and its
complications.
Conclusion

59. Questions