80-85% of patients with HELLP need control of their BP to avoid significant maternal and perinatal morbidity and mortality.
Treat systolic BP when>150mmHg and avoid placental hypoperfusion maintaining the diastolic BP not less than 80-90 mmHg.
Choice of hypotensive medication
Hydralazine: Bolus of 5-10 mg IV every 20-40 min. If uneffective or unavailable, use labetalol, nifedipine o sodium nitroprussiate.
Labetalol: Initial bolus of 20 mg IV, with increases in dosage until a satisfactory BP is obtained or up to maximum dose of 300 mg.
Nifedipina oral(not sublingual) at usual dosage.
Sodium Nitroprussiate is a fast acting hypotensive agent(venous and arterial) which can be used in an hypertinsive crisis when all other hypotensive drugs have failed Loading dose: 0,25 μg/kg/min, increasing upto 10 μg/kg/min. Above this dose there is a greater risk of cyanide intoxication of the fetus. When using, remember it’s photosensitivty and sever rebound effect.
Sodium Nitroprussiate is a fast acting hypotensive agent(venous and arterial) which can be used in an hypertinsive crisis when all other hypotensive drugs have failed Loading dose: 0,25 μg/kg/min, increasing upto 10 μg/kg/min. Above this dose there is a greater risk of cyanide intoxication of the fetus. When using, remember it’s photosensitivty and sever rebound effect.
Preventing Convulsions
MgSO4: Initial bolus of 4-6g IV, followed by a continous infusion at 1,5-4g/h, individualized according to the patient. Continue 48 horas o more postpartum until clinical and laboratory signs of improvement are obtained.
If contraindications of MgSO4 exist, use Phenytoin.
Hemotherapy
The base of hemotherapy in patients with HELLP is the transfusion of platelets.
The usual dose is one unit per every 10 kg of corporal weight.
Spontaneous bleeding occurs in most cases with a platelet count of <50.000/mm3.
Hemotherapy
The aggresive use of Dexamethasone in patients with HELLP and severe thrombocytopenia has eliminated virtually all need for platelet transfusion.
(3) Well controled BP with systolic pressure 150 mmHg and diastolic pressure < 100 mmHg.
(4) Obvious clinical improvement and bsence of complications.
The absence of improvement of the thrombocytopenia within 72-96 hours postpartum indicates severe compromise of compensatory mechanisms and possibel MULTIPLE ORGAN FAILURE.
Be on the lookout for:
Signs of multiple organ failure.
Complications:
Subcapsular Hematoma
Subcapsular hepatica hemorrhage
Hepatic Rupture.
Hepatic Rupture
The incidence of hepatic rupture varies from one in 40,000 to one in 250,000 pregnancies .
Hepatic infarction is even more rare and commonly involves the right lobe.
It is believed to be a continuum of preeclampsia, in which areas of coalescing hemorrhage result in thinning of the capsule and intraperitoneal hemorrhage.
Advising on future pregnancies.
The risk of recurrence of preeclampsia -eclampsia is 42-43% and for the HELLP syndrome: 19-27%.
The risk of recurrence of preterm delivery is high, about 61%.1
Conclusions
HELLP Syndrome and its management still poses a problem in modern obstetrics
Precise diagnosis and early treatment with non-mineral corticosteroides such as Dexamethasone may help achieve favorable maternal and perinatal results.