Initiate delivery within 24 hours after the last steroid dose, with continuous monitoring in the labor and delivery unit.
Although some women may demonstrate transient improvement in their blood tests (eg, increased platelet count or decreased AST levels), delivery is still indicated. Conversely, in some cases, maternal and fetal conditions may deteriorate, mandating delivery before the 2 doses of steroids are completed.
Delivery Considerations
HELLP syndrome does not justify immediate cesarean
Patients with HELLP syndrome in labor or with rupture of membranes can deliver vaginally in the absence of obstetric complications. In addition, induction or augmentation of labor is acceptable with either oxytocin infusion or prostaglandins if the fetal gestational age is 32 weeks or more and the cervical Bishop score exceeds 5.
TABLE 7 lists the indications for elective cesarean delivery and summarizes management during surgery. It is important to stabilize the maternal condition, correct coagulopathy, and have blood or blood products available before initiating surgery.
TABLE 7
Cesarean delivery: Indications and management
| Indications for cesarean |
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| Management during cesarean |
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Watch for oozing from surgical sites
In a cesarean section, generalized oozing from the surgical site can occur during the operation or immediately postpartum because of the continued drop in platelet count in some of these patients. Thus, it is advisable to insert a subfascial drain and to leave the skin incision open for at least 48 hours to avoid hematoma formation in these areas (FIGURE 1).
FIGURE 1 Insert subfascial drain at cesarean section
Because generalized oozing from the surgical site can occur intraoperatively or immediately postpartum, insert a subfascial drain and leave the skin incision open for at least 48 hours to avoid hematoma formation.
Small doses of systemic opioids are best
For maternal analgesia during labor, give small, intermittent doses of systemic opioids. For repair of episiotomy or vulvar or vaginal lacerations, use local infiltration anesthesia.
Avoid pudendal block because of the potential for bleeding and hematoma formation in this area. Epidural anesthesia may be used after consultation with the anesthesiologist if the platelet count exceeds 75,000/mm3.
Some authors report rising platelet counts after intravenous dexamethasone and, with the improved platelets, greater use of epidural anesthesia, especially in women who achieved a 24-hour latency period before delivery. However, since the platelet count may drop again, insert the epidural catheter once the desired platelet level (with anesthesiologist approval) is reached.
Suspected Liver Hematoma
A rare and potentially life-threatening complication of HELLP syndrome is subcapsular liver hematoma (FIGURE 2). Unfortunately, the rarity of this complication sometimes causes it to be overlooked.
FIGURE 2 Rare but life-threatening: Subcapsular liver hematoma
Liver hematomas can develop antepartum, intrapartum, or postpartum. Presenting symptoms may include severe epigastric or retrosternal pain in association with respiratory difficulty (pain on inspiration), with or without shoulder or neck pain.
Early signs and symptoms
Liver hematomas can develop antepartum, during labor, or in the postpartum period. Presenting symptoms may include severe epigastric or retrosternal pain in association with breathing difficulty (pain on inspiration), with or without shoulder or neck pain.
When profound hypovolemic shock occurs in a previously hypertensive patient, suspect rupture of a liver hematoma. Diagnosis can be made by ultrasound or computed tomography (CT) imaging of the liver, both of which can also confirm intraperitoneal bleeding.
In most cases, rupture involves the right lobe of the liver and is preceded by a parenchymal liver hematoma.
Mortality can exceed 50%
Maternal and fetal mortality increase substantially when a subcapsular liver hematoma is present. In fact, mortality may exceed 50% when frank rupture of the capsule involves liver tissue.
Choose conservative management whenever possible
Management of subcapsular liver hematoma depends on maternal hemodynamic status, integrity of the capsule (ruptured or intact), and the fetal condition.
Conservative management is preferable in hemodynamically stable women with an unruptured hematoma. It consists of close monitoring of the patient’s hemodynamic and coagulation status and serial assessment of the hematoma with ultrasound or CT scan.
Avoid exogenous trauma to the liver, such as frequent abdominal palpation, emesis, or convulsions. Any sudden increase in intraabdominal pressure can led to rupture of the hematoma.
When rupture occurs
This surgical emergency requires an acute multidisciplinary team, including an Ob/Gyn, anesthesiologist, highly qualified surgeon, and a representative of the hospital’s blood bank.