HELLP Syndrome: an Often Unrecognized Complication of Preeclampsia

EDITORIAL COMMENT: We accepted this case for publication to remind readers that the HELLP Syndrome does exist and can be present in patients who do not exhibit hypertension or marked generalized oedema; it tends to occur when preeclampsia is treated conservatively. When diagnosed, prompt delivery is indicated, after commencement of the preferred drug regimen for treatment of severe preeclampsia, but Caesarean section is not necessarily the preferred route of delivery, as illustrated by the following case, courtesy of Dr Ian Maclsaac, seen 2 days after the editor read this paper. A 29-year-old primigravida presented with severe pain and tenderness under the right costal margin, at 35.5 weeks' gestation, after a normal antenatal course; she had proteinuria (urine 1/10 solid on boiling), BP120/70, platelet count 44× 109/I and elevated serum enzymes levels (aspartate aminotransferase 364 (0–31 μ/l), alanine aminotransferase 513 (0–31 μ/l); there was no haemolysis and the coagulation profile was otherwise normal. Two days later labour was induced by amniotomy and oxytocin infusion because the epigastric pain, thrombocytopenia, proteinuria and abnormal liver function tests had persisted; 8 hours after induction a 2,860 g infant was born normally in good condition. Two days later the platelet count had fallen to 19×109/l, and microscopic haematuria was present; the patient was given a 6-unit platelet transfusion; 2 days later the platelet count was 122× 109/l and there were no further problems with mother or baby. Readers may debate whether this is a genuine case of HELLP syndrome without evidence of intravascular haemolysis or abnormal coagulation profile apart from thrombocytopenia. However, this case does undoubtedly endorse the author's message that patients with preeclampsia treated conservatively, and all those with epigastric pain associated with proteinuria, should have coagulation profile, full blood examination and tests of liver function performed, in addition to renal function tests and assessment of fetal well-being by cardiotocography. Summary: We describe a case of preeclampsia with the HELLP (Haemolysis, Elevated Liver enzymes, Low Platelets) syndrome and highlight the delayed diagnosis due to its nonspecific presentation. This syndrome is associated with significant maternal and perinatal mortality and morbidity and we discuss the importance of early recognition of the condition, aggressive management and a multidisciplinary approach.