1420034211 hellp syndrome a therapeutic challenge case report with review of literature

8/19/2019 1420034211 HELLP Syndrome a Therapeutic Challenge Case Report With Review of Literature

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National Journal of Medical and Dental Research, April-June 2013: Volume-1, Issue-3, Page 62-65

“HELLP Syndrome - A Therapeutic Challenge – Case Report

With Review of Literature’’

Satyavir Singh Dhama A, Suchitra Malhotra A, Mohinder Kumar B, Gaurav JainC

A Associate Professor, Dept of Anaesthesia, Teerthanker Mahaveer Medical College,

Moradabad, U.P.

B Associate Professor, Dept of General Surgery, Teerthanker Mahaveer Medical

College, Moradabad, U.P.C Assistant Professor, Dept of Anaesthesia, Teerthanker Mahaveer Medical College,

Moradabad, U.P.

Abstract:

HELLP Syndrome is a life threatening obstetric emergency usually considered to be

a variant or complicaon of pre eclampsia. Both condions usually occur during the

later stages of pregnancy or somemes aer child birth. We are here, reporng a

case of 25 year old woman who presented with classical HELLP syndrome in which

prompt diagnosis and appropriate anesthec management helped us to reduce

morbidity and mortality related with HELLP syndrome. The policy that prevenon

is far more important than cure coupled with proper pre anesthec evaluaon will

help to reduce the incidence of anesthec complicaons arising during .regional

anesthesia. The role of regional anesthesia in management of HELLP syndrome is

reviewed.

Keywords: HELLP Syndrome, Spinal Anesthesia, Platelet Count

Natl J Med Dent Res 2013; 1(3) : 62-65

Manuscript Reference No.

NJMDR_107_13

Date of submission: 16 January 2013

Date of Editorial approval: 23 January 2013

Date of Peer review approval: 16 March 2013

Date of Publication: 30 June 2013

Conict of Interest: Nil; Source of support: Nil

Name and addresses of corresponding author:

Dr Satyavir Singh Dhama ,MD (Anaesthesia),

Department of Anaesthesia ,

Teerthanker Mahaveer Medical College & Research

Centre,

Moradabad, India.

Mobile: - 919719120071,

E-mail: [email protected]

view Article

Case Report:

A 25 year old primigravida with 35 weeks of

gestation was admitted in the hospital with

upper abdomen pain, nausea, vomiting and

blurred vision. On examination, her pulse

rate was 125/min, B.P was 210/112 mm Hg,

SPo2 was 95% and patient had associated

pedal edema. The diagnosis of HELLP

syndrome with severe preeclampsia was

made on the basis of complete laboratoryand radiological investigation which

showed Hb 7.3 gm/dl, TLC 9000/ml,

Blood urea 80mg/dl, creatinine 1.8 .mg/dl,

bleeding time 3.5 min, clotting time 8 min,

urine examination showed severe protein

urea ., platelet counts 63000/ml, liver

enzymes AST 1452 IU/l, ALT 1102 IU/l and

LDH 1388 IU/l, PT 18 control 13sec, INR

1.5, Serum bilirubin 1.5 D-dimer-8000.

Ultrasound showed hepatomegaly, 35

weeks+/- 1 week live fetus in uterus,

oligohydramnios, and weight of the fetus

was 2.20 kg.

Patient was advised to arrange three units

of fresh platelets and two units of fresh

blood. Based on our previous experience

and literature on HELLP syndrome, it was

decided to conduct the delivery by caesareansection (LSCS) under spinal anesthesia.

Patient was pre loaded with 1000ml of

Ringer lactate (RL) and 20 mg of labetalol

was given as intravenous (IV) bolus, along

with magnesium sulphate 5gm IV bolus and

12 mg betamethasone 12 hourly.

Spinal anesthesia was given in left lateral

position with full aseptic precautions.



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Bupivacaine heavy0.5 %, 1.75 ml was given. The course

of the anesthesia and surgery was uneventful up to the

delivery of the baby. Excessive oozing of blood from

uterus, abdominal incision and hematuria was observed

just after placental removal. Whole surgical procedure

was completed in just half an hour. Blood loss was

.approximately 1.5 liters. Two unit of fresh blood and

two units platelets transfusion were given postoperatively

the patient was shifted to intensive care unit (ICU) and

platelet transfusion continued in ICU. Blood sample sent

from ICU showed haemoglobin-6.8gm/dl, platelet -73000/

ml,sodium-148meq/dl,potassium-5.5meq/dl,Creatinine-

2.2mg/dland Urea -82mg/dl. As hemoglobin and platelets

were low it was decided to transfuse two units of fresh

platelets and two unit’s fresh blood. The patient recovered

rapidly and was shifted to obstetrics ward. On the 4th day

the repeat investigation were found to be within normal

limits and patient was discharged on the 10th day afterremoving the sutures.

Discussion:

HELLP syndrome is a life threatening obstetric

complication usually associated with pre eclampsia. Its

incidence is 0.5% to 0.9% of all pregnancies. It is related

with severe pre eclampsia (10% to 20%). Both conditions

occur after twenty weeks of gestation and may occur after

5 to 12 weeks of childbirth. HELLP is acronym for; H –

haemolysis, EL -elevated liver enzymes, LP - low platelets.

The term HELLP syndrome was rst used by Louis

Weinstein in 1982 [1]. Although the same clinical features

and investigations were noticed in 1954 by Pritchard [2].

The onset was gradual. Clinical features include severe

headache (30%), malaise (90%); nausea, vomiting (30%);

band pain around upper abdomen (65%), and edema.

Disseminated intravascular coagulation is also seen

in about 20%of all women with HELLP syndrome [3].

However, the path physiology is dynamic .Preeclampsia

is a common and severe disease in pregnancy, a major

cause of maternal and fetal morbidity and mortality. The

main features of the disease are de novo hypertension

after the 20th gestational week and proteinuria, and it is

frequently accompanied by edema and other subjective

symptoms. The origin of the disease is the placenta, but

its sequel affect multiple organ systems[4] that produce a

number of outcomes, whether the patient has evidence of

thrombocytopenia and elevated liver function tests alone or

whether fragmented RBC’s are present in the blood smear,

the serum bilirubin is elevated or other abnormalities

such as coagulopathy or renal insufciency are present

with greater involvement of the endothelium of the liver

in preeclampsia, more red cells are hemolyzed and more

hepatic ischemia resulted in higher bilirubin levels and

impaired coagulation tests. Hypertension in pregnancy is

increasing in prevalence and incidence and its treatment

becoming more common place Associated complications

of pregnancy, including end-organ damage, preeclampsia,eclampsia, and postpartum eclampsia, are leading sources

of maternal and fetal morbidity and mortality, requiring

an emergency physician to become procient with their

identication and treatment [5]. HELLP syndrome

is complicated with acute renal failure in 84% cases

.Pregnant women who present with hellp syndrome can be

misdiagnosed in the initial stages thereby increasing the

risk of liver failure and morbidity. In a patient with possible

hellp syndrome following blood tests should be performed.

Full blood count, liver function tests including enzymes,

renal function tests, coagulogram, serum electrolytes, andD-dimer .We conducted all the above investigations in our

patient and we diagnosed our patient was suffering from

HELLP syndrome as D-dimer was positive. A positive

D- dimer test in a patient of preeclampsia is predictive of

hellp syndrome [6]. D dimer is a more sensitive indicator

of sub clinical coagulopathy and may be positive before

other coagulation studies become abnormal. According to

Missisippi classication [7, 8] and Tenesse classication

the disease can be classied as mild, moderate and severe

the same is summarized in Table-1.

Table: 1

Mild Moderate Severe

Platelet count 150000to 100000 100000,>50,000 <50000

AST/ALT >40 IU >70IU/L >70 IU

LDH >600IU/L >600IU/L >600IU/L



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Sibai has proposed strict criteria for true or complete

HELLP syndrome platelet <100000, AST>70IU/L,

LDH>600IU/L [9]. Our patient fell into moderate type of

hellp syndrome. The only effective treatment of HELLP

syndrome is immediate delivery of baby either by caesarean

section or normal vaginal route [9]. Vigil De Gracia et al

recommended that neuraxial anaesthesia may be safely

administered in the patient with HELLP syndrome without

DIC or prolonged Prothrombin time [10]. We decided to

perform caesarean section under spinal anaesthesia even

though d-dimer and prothrombin time were marginally

raised because of our past experience in similar cases. Sibai

et al [9] also recommended Spinal/epidural anaesthesia in

HELLP syndrome if there is hemodynamic stability as

epidural anesthesia is risky in patients with coagulopathy.

This case was operated under spinal anesthesia because

patient was hemo- dynamically stable. Administration of

corticosteroid can minimize the degree of intravascular

endothelial injury and improve blood ow while decreasing

hepatocyte and platelet consumption in HELLP syndrome

[11]. O Brien et al assessed the benecial effects of steroids

on the frequency of complications after regional anesthesia

[12]. A study done by Keltor J G Hunter DJS reported that

only platelet count is not responsible for complication in

hellp syndrome but it was the platelet function that was

responsible ,but it is not proved till date because platelet

function is not easy to evaluate[13, 14]. Marcellver cauteren

et. al conducted a study[15,16,17,18] on HELLP syndrome

from 1993-2008 at Antwrep university They showed that

anesthesia of choice for caesarean section was combined

spinal epidural anesthesia (CSEA). Epidural anesthesia

was only given in selected cases where a catheter was

already placed for painless delivery. They made a guideline

that if platelet count was >90.000/ml any type of anesthesia

could be given. But in case of platelet count <60,000/ml

only general anesthesia should be given. If platelet count

is between 60,000/ml to 90,000/ml choice of anesthesia

depended on the anesthetist.

Conclusion:

Spinal anesthesia can be given safely in HELLP syndrome

with platelet count up to 60,000/ml as platelet functions are

not impaired and spinal anaesthesia, per say is otherwise

safer and cost effective than general anaesthesia.

References:

1. Wenstein L. Syndrome of hemolysis, elevated liver

enzymes and low platelet count: serious consequence

of hypertension in pregnancy. Am J Obstet Gynaec ol

1982 :142:159-67.

2. Prichard JA, Weisman R Jr, Ratnoff OD, Vosburgh GJ.

Intravascular hemolysis, thrombocytopenia and other

hematologic abnormalities associated with severe

toxaemia of pregnancy Engi Med 1954: 250:89-98.

3. Crosyby ET. Obstetrical anaesthesia for patients with

haemolysis elevated liver enzymes and low platelets.

Can J Anaes 1991:38:227-33.

4. Alasztics B. KuKor Z. Panczel Valents. The

pathophysiology of Pre-eclampsia in view of two stage

model. Ory Hetil 2012:29:153(30)1167-76.

5. Deak TM, Moskovitz JB. Emerg Med Clin North Am.

2012: 30(30):903-17.

6. Ezri T, Abouliesh E, Lee C. Intracranial subdural

hematoma following dural puncture in a patient with

HELLP syndrome Can J Anaesthesia 2002: 49:820-3.

7. Luire S. Saitan O. Oron G. Pedured

Pseudocholinesterase activity in patient with HELLP

syndrome Reprod Ser 2007;14:192-6.

8. Hawkins JL, Koonia L M, Palmer SK, GibbsC P.

Anaesthesia related deaths during obstetric deliveri in

the United States 1979-1990.Anaesthesiology 1997;

86:277-84.

9. Sibai B, Taslima MM, E l-Nazar A. Maternal –Perinatal

outcome associated with the syndrome of haemolysis,

elevated liver enzymes and low platelet in sever pre-

eclampsia. Amj obstet Gynaecol 1986; 1,55:501-9.

10. Vigil-De Gracia P, Silva S, Montufar C. Anaesthesia

in pregnant women with HELLP syndrome. Int j

Gynaecol obstet 2001; 74:23-7.

11. Rolbin SH, Abbot D. Musclow E. Epidural Anaesthesia

in pregnant women with low platelet counts Obstet

Gynecol 1998. 71:918-20.



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12. O. BrienJM, Shumate SA, Satchwell SL, Milligan DA,

Barton JR. Maternal benets of patients with HELLP

syndrome: impact on the rate of regional anaesthesia.

13. Sanli K, Kayaca N, Yeqin A. Application of regional

anaesthesia in hellp syndrome(Turkish) Genel Tip

Dreg 2005;15:81-4.

14. Beilin Y, Zahn J,Comerford M. Safe epidural analgesia

in thirty parturients with platlet counts between 69000

and 98000/mm3.Anesth Analg 1997;85:385-8.

15. Vigil-De Gracia P, Silva S, Montufar C. Anaesthesia

in pregnant women with HELLP syndrome. Int J

Gynaecol obstet 2001; 74:23-7.

16. Palit S, Palit G, Vercauteren M, Jacquemyn Y. The

choice of anaesthetic technique for C-section in

patients with HELLP syndrome: a retrospective

analysis .RAPM 2008; 33:S.

17. Welter P, De Buck F, Vandermeersch E. Characteristics,

obstetric and anaesthetic outcome of the syndrome of

Hemolysis, Elevated Liver enzymes , Low Platlets

(HELLP) in a tertiary care referral center. Acta

Anaesthesiol Belg 2008; 50:117.

18. Moen V, Dahlren N, Irestedt L. Severe neurogical

complications after central neuraxial blocade in

Sweden.

1420034211 hellp syndrome a therapeutic challenge case report with review of literature

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