A 25-year-old female presented with abdominal pain, repeated fits and profuse vaginal bleeding after delivering a dead baby at home. She was diagnosed with HELLP syndrome based on her symptoms and lab results. She was treated aggressively in the intensive care unit with magnesium sulfate to control seizures, blood transfusions, evacuation of retained placenta, antihypertensives, and hemodialysis. Her condition improved over several days and she was discharged after 10 days on oral medications. The case illustrates the importance of early detection and rapid treatment by a multidisciplinary team for successful management of HELLP syndrome.

1. 46
M Zameer Rajput*, Abdul Rehman**, Harris Baig***
*Professor of Anesthesiology, Director Intensive care unit
** Assistant Consultant Anesthesiologist
*** Consultant Anesthesiologist
Shifa International Hospital Islamabad (Pakistan).
Correspondence: Dr. M. Zameer Rajput, Professor of Anesthesiology / Director Intensive Care Unit, Shifa
International Hospital, Sector H-8/4, Islamabad (Pakistan); Phone: +92 51 4603605.
CASE REPORT
ABSTRACT
We present here successful management of a patient of severe HELLP syndrome, secondary to retained
products of conception (POC's). The management of our patient started just after her presentation in the
emergency department of our hospital. Clinical history of post-partum bleeding, fits and confusion, along
with deranged laboratory investigations lead us to an aggressive management plan, conducted by a team of
healthcare professionals and the patient was saved.
Key Words: HELLP syndrome; Fits; Hypertension
(RajputMZ,Rehman A, BaigH. Managementof HELLPsyndrome.AnaesthPain &IntensiveCare2010;14(1):46-48.)
Management of HELLP syndrome
respiratory rate 20 breaths/min, and her temperature wasINTRODUCTION
98 ºF. On obstetric examination, she was vaginally bleeding
HELLP Syndrome is a multisystemic disorder. Its and her uterus was not well contracted. She had tender
incidence is 0.17%-0.85%. Its etio-pathogenesis is not abdomen and generalized edema. Ultrasonography of the
clearly understood. A number of hypotheses have been pelvic organs revealed retained products of conception in
presented for its etiology, but none explains every clinico- the uterine cavity. Samples were taken and sent to the
patholodic phenomenon associated with it. It is frequently laboratory while large bore cannulae were being inserted
associated with sever pre-eclampsia and eclampsia. It is into her veins. She was initially managed with infusion of
diagnosed in pregnancy on the basis of following criteria; magnesiumsulphate(MgSO )2 g IV statto controlherfits;4
pain in the right upper abdominal quadrant, generalized one unit of packed RBCs and 6 units of platelets were
edema, hemolysis, altered liver enzymes, low platelet count transfused. E&C was done to evacuate the retained
and renal dysfunction. Early detection and rapid products of placenta. Her laboratory values are shown in
therapeutic intervention by a team of experts made all the Table I.
difference in our patient with this lethal syndrome, the
A diagnosis of HELLP syndrome was made on the basisreportof managementof which ispresentedhere. 1
of clinical picture and laboratory finding. After initial
management, this patient was shifted to surgical intensiveCASE REPORT
care unit for further management. Arterial line and central
A 25 years old female presented with abdominal pain,
venous lines were passed for hemodynamic monitoring
repeated fits and profuse vaginal bleeding in the
and management. Foley's catheter and nasogastric tube
emergency department. She delivered a dead baby at home
were also inserted. Convulsions were treated with inj.and went into postpartum hemorrhage. Her attendants
diazepam 3mg IV and followed by an infusion ofgavehistoryof repeatedepisodesof fitsathome.
phenytoin 1g . Phenytoin 100 mg via nasogastric tube was
On her arrival in the emergency department, she was started. To control high blood pressure, GTN infusion was
irritable and confused with GCS 12/15. Her vital signs started. Inj. Tazoin 4.5g BID was also given. Strict intake
were; heart rate 100 bpm, blood pressure 170/110 mmHg,

2. 47
Anaesth, Pain & Intensive Care Vol. 14 (1)
output record was maintained. Two more units of packed DISCUSSION
blood cells and six units of platelets were transfused as
HELLP Syndrome is a multisystemic disorder. Itsdictated by lab investigations. Daily hemodialysis was
incidence is 0.17%-0.85%. Its etio-pathogenesis is notperformed to control her renal derangement. CT scan was
clearly understood. The most widely accepted hypotheses
ordered, which showed mild cerebral edema; and a slight
are; a change in the immune feto-maternal balance,
fluid collection was revealed in the peritoneum on platelets aggregation, endothelial dysfunction or arterial
1urtrasonography. hypertension . It is frequently associated with severe pre-
eclampsia and eclampsia, Hepatic involvement can be dueTable : LaboratoryDataof thepatient.
to intravascular fibrin deposition and hypovolemia.
Maternofetal complications cause 6.7-7% peri-natal
mortality and 1-24% maternal mortality rate. Uric acid
>7.4 mg/dl is an independent risk factor for materno-fetal
2
morbidityand mortalility.
rd
Microangiopathy usually occurs in the 3 trimester of life.
There is focal liver involvement, hemolysis and
thrombocytopenia. Hepatic rupture, cerebral hemorrhage
and disseminated intravascular coagulopathy can occur.
Severe thrombocytopenia can worsen the prognosis. Early
detection and rapid therapy can bring favorable results. A
chance of recurrence in subsequent pregnancy is high
3
(14%-27%) . HELLP Syndrome can be diagnosed in
pregnancy with following presentations; Pain in the right
upper abdominal quadrant, significant weight gain,
generalized edema, hemolysis, altered liver enzymes and
3
renaldysfunction .
Management of HELLP syndrome includes rapid
initiation of therapy with induction of delivery, materno-
fetal treatment, close monitoring and management in ICU
environment. Early detection of the disease to perform a
cesarean delivery for prompt recovery of the patient and
On day 03, her kidneys started producing urine at a rate of
normalization of symptoms and pathological findings is
4approximately 10 ml/hr. Hemodynamic state and cerebral of prime importance. In our patient, it was the early
edema dictated the use of inj. omeprazole 20 mg BD, inj. detection, rapid therapeutic intervention by a team of
hydrocortisone 50mg QID, tab. amlodipine 10mg OD, tab. emergency physicians, anesthesiologists, intensivists,
hydralazine 25mg BD. Follow up investigations were Hb obstetricians and pathologists as well as ready availability
3 3
of every necessary drug that was required, were the factors10.30 g/dl, platelets 126000/mm , WBC count 15800/m ,
that produced a positive outcome in the favour of theserum creatinine 4.21 mg/dl, ALT 80 U/L and AST 43
patient. I may be pertinent to note that many of the drugsU/L,which registeredsignificantimprovement.
cited above are not readily available in most of the cities of
By day 04, the condition of the patient improved this country. The emergency department of our hospital is
well-equipped and well-staffed to receive and handleremarkably and she was transferred to high dependency
virtuallyeverytypeof emergencypatients.unit with GCS 15/15, on oral medications and normal
investigations except serum creatinine, which was still 2.5
CONCLUSIONmg/dl. Hemodialysis was continued for another three days
until urine output and laboratory investigations became HELLP Syndrome is a multisystemic disorder, with yet
normal. Then she was shifted to the ward, where she undecided etio-pathogenesis. Early detection, rapid
stayed two more days. On day 10, she was discharged on therapeutic intervention by a team of emergency
oral antihypertensivemedications. physicians, anesthesiologists, intensivists, obstetricians
and pathologists as well as ready availability of every
Value Patient Normal range
Hb (g/dl) 8.3 12 -16
LDH (U/L) 1865 110 -210
HCT (%) 23.5 36% -46
WBC’S (/mm3) 18800 4000 -11000
ALT (U/L) 192 10 -55
AST (U/L) 98 10 -40
Creatinine (mg/dl) 9.64 0.6 -1.1
Urea (mg/dl) 171 6-20
D-dimers (ug/ml) 9000 0.01 -0.05
Fibrinogen (mg/ml) 501 175 -400
INR 1.1 1.0
Calcium (mg/dl) 6.70 8.5 -10.5
uric acid (mg/dl) 13.95 2.3 -6.6

3. 48
UnitedStates.HypertensPregnancy2003;22:203-212.necessarydrugcan makethedifferencein itsoutcome.
3. Isler CM Rinehart BK, Terrone DA, May WL,Magann EF,
REFERENCES Martin JN Jr. the importance of parity to major maternal
morbidity in the eclamptic mother with HELLP syndrome.1. Sibai BM. Diagnosis, controversies, and management of the
HypertensPregnancy2003;22:287-294.syndrome of hemolysis, elevated liver enzymes, and low
plateletscount.ObestetGynecol2004;103:981-991. 4. Egerman RS, Sibai BM: HELLP Syndrome. Clin Obstet
Gynecol1999;42:381-389.2. Zhang J Meikle S, Trumble A. Severe maternal morbidity
associated with hypertensive disorder in pregnancy in the
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Management of HELLP syndrome