Maternal resuscitation should include:
- transfusion of packed red blood cells to maintain blood pressure and tissue perfusion,
- correction of coagulopathy with fresh frozen plasma and platelets, and
- laparotomy, preferably using a cell saver.
Options at laparotomy include:
- packing and drainage (preferred),
- ligation of the hepatic lacerations,
- embolization of the hepatic artery to the affected liver segment, and
- loosely suturing omentum or surgical mesh to the liver surface.
Postpartum Care
In women who develop HELLP prior to delivery, closely monitor postpartum vital signs, intake and output, and symptoms in intensive care or a similar facility for at least 48 hours.
During this time, my practice is to give the patient intravenous magnesium sulfate and antihypertensive medications as needed to keep systolic blood pressure below 155 mm Hg (the standard is 160 mm Hg) and diastolic blood pressure below 105 mm Hg.
The rationale for this treatment is to prevent bleeding in the brain if the woman has thrombocytopenia.
When HELLP appears in the postpartum period
Several maternal complications from HELLP syndrome may not appear until immediately postpartum. Thus, all women with preeclampsia require close monitoring of vital signs, fluid intake and output, laboratory values, and pulse oximetry for at least 48 hours.
Also continue magnesium sulfate in the postpartum period and keep maternal blood pressure below 155 mm Hg systolic and 105 mm Hg diastolic.
Time to recovery
Most patients begin to improve or completely recover within 72 hours, while others deteriorate further or fail to recover for as long as 1 week after delivery. Thus, some women may require intensive monitoring for several days because of the risk of pulmonary edema, renal failure, or adult respiratory distress syndrome.
Keep in mind that, in some of these women, the cause of the postpartum deterioration may be something other than HELLP syndrome(TABLE 6).
Watch for sudden hypotension
A sudden drop in blood pressure to hypotensive levels can be an early sign of severe hemolysis or unrecognized intraperitoneal blood loss (from surgical sites or ruptured liver hematoma), as well as sepsis.
In a woman with severe hemoconcentration (ie, severe vasoconstriction), sudden hypotension also may indicate excessive vasodilation from antihypertensive drugs such as hydralazine or nifedipine, resulting in relative hypovolemia.
Such a case requires volume resuscitation, blood transfusion (if indicated), and evaluation for unrecognized bleeding.
Use of steroids
Some authors recommend giving intravenous dexamethasone (5 to 10 mg every 12 hours) for approximately 48 hours after delivery in women who develop antepartum or postpartum HELLP. They claim this treatment improves maternal blood tests, shortens recovery, and reduces maternal morbidity.
However, at present, no data indicate this approach has clinical benefit—and the risks are unknown. For these reasons, treatment with intravenous dexamethasone after delivery remains empiric.
The author reports no financial relationships relevant to this article.