HELLP Syndrome — Diagnose, Stabilise & Deliver
HELLP = Haemolysis, Elevated Liver enzymes, Low Platelets; a severe form of pre-eclampsia, in 10 to 20% of severe pre-eclampsia, and 0.5 to 0.9% of all pregnancies [1][2]
About 70% appear before delivery (mostly 27 to 37 weeks) and about 30% after, mostly within 48 hours [1]
Up to 10 to 20% have no hypertension or proteinuria; do not wait for them [1][2]
Typical: upper abdominal or epigastric pain, nausea, vomiting, malaise, headache [1]
The treatment is stabilisation, then delivery; the timing depends on gestation and how sick she is [1][2]
The risk does not end at delivery: recurrence, hypertension, heart disease, stroke and kidney disease follow [3]
| System | Platelets (×10⁹/L) | AST / ALT | LDH |
|---|---|---|---|
| Tennessee (complete HELLP) [1] | 100 or less | AST 70 IU/L or more | 600 IU/L or more |
| Mississippi class 1 [1] | 50 or less | 70 or more | 600 or more |
| Mississippi class 2 [1] | Over 50 to 100 | 70 or more | 600 or more |
| Mississippi class 3 [1] | Over 100 to 150 | 40 or more | 600 or more |
| MSD Manual [2] | Under 100 | More than 2 times normal | 600 or more |
Haemolysis: low haptoglobin (below about 0.4 to 1 g/L) is the preferred marker; add a smear for schistocytes and the bilirubin [1]
Class 1 is the most severe; the Mississippi classes follow the lowest platelet count [1]
Repeat the tests every 6 to 12 hours while unstable (from memory)
| Condition | Pointers away from HELLP |
|---|---|
| Acute fatty liver (AFLP) [1] | Usually 30 to 38 weeks; 1 to 2 weeks of malaise and jaundice; often no hypertension or proteinuria; low glucose and long prothrombin time |
| TTP [1] | Rare in pregnancy; neurological signs, fever, abdominal pain; ADAMTS13 test, not always available |
| HUS [1] | Mainly kidney failure, usually after delivery; creatinine and smear help |
| SLE / antiphospholipid syndrome [1] | Antiphospholipid antibodies in 30 to 40% of SLE; thrombosis or pregnancy loss; HELLP can occur in APS |
| ITP [1] | Purpura and petechiae; no liver or haemolysis picture; usually low maternal risk |
| Cholestasis, hepatitis, sepsis, malaria, dengue | Fever, itch or viral serology; in India, check malaria and dengue early (from memory) |
| Item | What the sources say |
|---|---|
| Magnesium sulphate [2] | 4 g IV over 20 min, then 2 g/hour; reduce in renal impairment; continue 12 to 24 h after birth; toxicity: calcium gluconate 1 g IV |
| Blood pressure [1][2] | Treat if 160/110 or more; aim for 140-155 / 90-105; IV labetalol or hydralazine, or nifedipine |
| Fluids [1] | Careful balance; oliguria: 250 to 500 mL bolus; furosemide does not prevent or treat renal failure |
| Seizure not controlled [2] | IV diazepam or lorazepam |
| Monitoring [1] | Vital signs, fluid balance, platelets, liver tests, creatinine, clotting |
For the baby (24 to 34 weeks): betamethasone 12 mg IM twice, 24 h apart, or dexamethasone 6 mg IV every 12 h [1]
For the mother: weak evidence; Cochrane found no effect on mortality or liver and lung complications, only a faster platelet rise [1][7]
High-dose dexamethasone (10 mg every 12 h) did not reduce renal failure, pulmonary oedema or transfusion in the largest trial (n=132) [1][6]
Postpartum dexamethasone showed no benefit in an RCT of 105 women [1]
Platelets: suggested before caesarean in class 1, and for vaginal birth if below about 20 to 25 ×10⁹/L [1]
Regional block: avoid below 75 ×10⁹/L; some also avoid below 100 [1]
Plasma exchange with fresh frozen plasma if bilirubin or creatinine keep rising beyond 72 h [1]
| Situation | Plan |
|---|---|
| 34 weeks or more [1][2] | Deliver once BP is controlled and she is stable |
| 24 to under 34 weeks [1] | Stabilise, give steroids, deliver about 24 h after the last dose; expectant care only in a tertiary unit with close watch |
| HELLP or eclampsia, any gestation [2] | MSD Manual: deliver promptly after stabilisation |
| BP over 160/110 despite drugs [1] | Deliver now |
| Under 24 weeks [1] | Strongly consider termination |
Mode: vaginal birth if the cervix is favourable, otherwise ripen it; many favour caesarean under 30 weeks [1]
Stable, 24 to 34 weeks: the two sources differ on waiting; the 24-hour steroid window is the common ground [1][2]
| Complication | Reported rate [1] |
|---|---|
| Eclampsia | 4 to 9% |
| Placental abruption | 9 to 20% |
| DIC | Up to 38% in one cohort |
| Acute renal failure | 7 to 36% |
| Pulmonary oedema | 3 to 10% |
| Cerebral oedema | 1 to 8% |
| Subcapsular liver haematoma | About 1 to 2% |
| Liver rupture | About 1.8%; mortality 18 to 86% |
| Maternal death | 1 to 25%; 1.1% in the largest cohort (n=442) |
Baby: perinatal mortality 7.4 to 34%, highest before 32 weeks; neonatal thrombocytopenia 15 to 38%; outcome depends mainly on gestation [1]
Watch for at least 48 hours; platelets often keep falling after birth and rise by about day 3 [1]
Onset can be up to 7 days after birth; counsel her to return with pain, headache or vomiting [1][2]
Magnesium sulphate for 12 to 24 hours after birth [2]
Check BP often until normal; review every 1 to 2 weeks; high BP at 6 weeks suggests chronic hypertension [2]
Avoid heparin for postpartum DIC unless advised, because of bleeding in one series [1]
Contraception: oral contraceptives are considered safe after HELLP [1]
Keep the discharge summary with the diagnosis, lowest platelets and delivery details (from memory)
Recurrence: hypertensive disorders recur in more than 20% of women (range 5 to 52%) [1][3]; a HELLP-specific rate was not verified
HELLP at 28 weeks or earlier: the next pregnancy has more preterm birth, hypertension and neonatal death [1]
Next pregnancy: low-dose aspirin for previous pre-eclampsia [2]; early booking; consider thrombophilia screening after severe early-onset disease [1]
Heart and stroke: higher lifetime risk of hypertension, cardiovascular disease and stroke, especially after early-onset disease [3]
Kidney: up to 5 to 12 times the risk of end-stage renal disease [3]
Diabetes: higher risk [3]
Guidelines: AHA and ESC list pre-eclampsia and HELLP as female-specific risk factors [3]
Follow-up: at 3 to 6 months check BP, heart rate, BMI, urine, lipids, electrolytes and kidney function; then BP, glucose, BMI and lipids at least every 5 years [3]
Waiting for hypertension or proteinuria before testing the platelets and liver
Missing AFLP because glucose and clotting were not checked
Giving a regional block without a recent platelet count
Delaying delivery for steroids in a woman who is getting worse
Stopping magnesium too early or giving it with oliguria and no dose change
Discharging at 24 hours, before the postpartum platelet nadir
Giving no long-term advice: BP, heart and kidney follow-up
HELLP
[1] Haram K, Svendsen E, Abildgaard U. The HELLP syndrome: clinical issues and management. A review. BMC Pregnancy Childbirth 2009;9:8. doi:10.1186/1471-2393-9-8. PMID 19245695.
[2] Dulay AT. Preeclampsia and eclampsia. MSD Manual Professional Edition. Full review March 2024 (accessed online; page updated 2026).
[3] Palmrich P, Binder C, Zeisler H, et al. Awareness of obstetricians for long-term risks in women with a history of preeclampsia or HELLP syndrome. Arch Gynecol Obstet 2021;305(3):581-587. doi:10.1007/s00404-021-06181-w. PMID 34406457.
[4] ACOG Practice Bulletin No. 222: Gestational hypertension and preeclampsia. Obstet Gynecol 2020;135(6):e237-e260. doi:10.1097/AOG.0000000000003891. (As cited in [2]; not opened.)
[5] Martin JN Jr, et al. HELLP classification. Am J Obstet Gynecol 1999;180:1373-84. doi:10.1016/s0002-9378(99)70022-0. (As cited in [2]; not opened.)
[6] Fonseca JE, Mendez F, Catano C, Arias F. Dexamethasone treatment does not improve the outcome of women with HELLP syndrome: a double-blind, placebo-controlled RCT. Am J Obstet Gynecol 2005;193:1591-1598. doi:10.1016/j.ajog.2005.07.037. (As listed in [1]; not opened.)
[7] Matchaba P, Moodley J. Corticosteroids for HELLP syndrome in pregnancy. Cochrane Database Syst Rev 2004:CD002076. (As listed in [1]; not opened.)
