Summary
Definition
History and exam
Key diagnostic factors
- nausea/vomiting
- hypertension
- brisk tendon reflexes
Other diagnostic factors
- right upper quadrant/epigastric pain and tenderness
- generalized malaise
- headache
- edema
- visual disturbances
- jaundice
- bleeding
Risk factors
- white ethnicity
- maternal age >35 years
- obesity
- chronic hypertension
- diabetes mellitus
- autoimmune disorders
- migraine
- multiple gestation
- abnormal placentation (e.g., molar pregnancy)
- previous pregnancy with preeclampsia with/without HELLP syndrome
Diagnostic tests
1st tests to order
- CBC with differential including platelets
- peripheral blood smear
- liver transaminases
- bilirubin level
- total serum LDH level
- uric acid level
- urinalysis and protein-to-creatinine ratio
- PT/PTT
- fibrinogen level
- fetal ultrasound
Tests to consider
- serum glucose level
- serum creatinine and electrolyte levels
- antithrombin level
- haptoglobin level
- maternal upper abdomen ultrasound, CT, or MRI
- lactate dehydrogenase (LDH)-to-aspartate aminotransferase (AST) ratio
Treatment algorithm
suspected/presumed HELLP
all patients (confirmed HELLP)
Contributors
Authors
James N. Martin, Jr, MD, FACOG, FAGOS, FAHA, F(H)RCOG
Professor Emeritus of Obstetrics, Gynecology, and Maternal-Fetal Medicine
University of Mississippi Medical Center
Jackson
MI
Disclosures
JNM Jr is an obstetrician-gynecologist and maternal-fetal medicine consultant to BlueCross & BlueShield of Mississippi and the Mississippi Perinatal Quality Collaborative. He is co-director of the Mississippi Maternal Mortality Review Committee. He serves on the Global Operations Advisory Group of the American College of Obstetricians and Gynecologists (ACOG), and in 2018-9 he chaired the ACOG Presidential Task Force on Pregnancy and Heart Disease. JNM Jr lectures, teaches, researches, and speaks nationally and internationally on the subjects of hypertensive complications of pregnancy, including HELLP syndrome. He is also the lead author and editor of "The 2015 compendium for HELLP syndrome: from bench to bedside" (Nova Biomedical Publishers). JNM Jr is an author of several references cited in this topic. He has cited his own papers in this topic.
Acknowledgements
Dr James N. Martin Jr would like to gratefully acknowledge Dr Marium G. Holland and Dr Alex C. Vidaeff, the previous contributors to this topic.
Disclosures
MGH declares that she has no competing interests. ACV is an author of a number of references cited in this topic.
Peer reviewers
Jerome Yankowitz, MD
Professor and Director
Division of Maternal-Fetal Medicine
Department of Obstetrics and Gynecology
University of Iowa Hospitals and Clinics
Iowa City
IA
Disclosures
JY declares that he has no competing interests.
Deirdre Murphy, MD, MRCOG
Professor of Obstetrics
Trinity College
University of Dublin
Consultant Obstetrician
Coombe Women and Infants University Hospital
Dublin
Ireland
Disclosures
DM declares that she has no competing interests.
References
Key articles
Martin JN Jr, Blake PG, Perry KG Jr, et al. The natural history of HELLP syndrome: patterns of disease progression and regression. Am J Obstet Gynecol. 1991 Jun;164(6 Pt 1):1500-9; discussion 1509-13. Abstract
Martin JN Jr, Brewer JM, Wallace K, et al. Hellp syndrome and composite major maternal morbidity: importance of Mississippi classification system. J Matern Fetal Neonatal Med. 2013 Aug;26(12):1201-6. Abstract
Martin JN Jr, Rinehart BK, May WL, et al. The spectrum of severe preeclampsia: comparative analysis by HELLP (hemolysis, elevated liver enzyme levels, and low platelet count) syndrome classification. Am J Obstet Gynecol. 1999 Jun;180(6 Pt 1):1373-84. Abstract
American College of Obstetricians and Gynecologists. ACOG practice bulletin no. 222: gestational hypertension and preeclampsia. Jun 2020 [internet publication].Full text
Sibai BM. Diagnosis and management of gestational hypertension and preeclampsia. Obstet Gynecol. 2003 Jul;102(1):181-92. Abstract
Martin JN Jr, Owens MY. Preeclampsia-eclampsia y syndrome de HELLP. In: Romero Arauz JF, Tena Alavez G, Jimenez Solis GA, eds. Preeclampsia - enfermedades hipertensivas del embarazo [in Spanish]. Mexico: McGraw Hill; 2012.
Sibai BL, Ramadan MK, Chari RS, et al. Pregnancies complicated by HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets): subsequent pregnancy outcome and long-term prognosis. Am J Obstet Gynecol. 1995 Jan;172(1 Pt 1):125-9. Abstract
Duley L, Meher S, Hunter KE, et al. Antiplatelet agents for preventing pre-eclampsia and its complications. Cochrane Database Syst Rev. 2019 Oct 30;2019(10):CD004659.Full text Abstract
Martin JN Jr, Owens MY, Keiser SD, et al. Standardized Mississippi Protocol treatment of 190 patients with HELLP syndrome: slowing disease progression and preventing new major maternal morbidity. Hypertens Pregnancy. 2012;31(1):79-90. Abstract
Magee LA, Pels A, Helewa M, et al; Canadian Hypertensive Disorders of Pregnancy Working Group. Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy: executive summary. J Obstet Gynaecol Can. 2014 May;36(5):416-41.Full text Abstract
Martin JN Jr. Milestones in the quest for best management of patients with HELLP syndrome (microangiopathic hemolytic anemia, hepatic dysfunction, thrombocytopenia). Int J Gynaecol Obstet. 2013 Jun;121(3):202-7. Abstract
Martin JN Jr, Thigpen BD, Moore RC, et al. Stroke and severe preeclampsia and eclampsia: a paradigm shift focusing on systolic blood pressure. Obstet Gynecol. 2005 Feb;105(2):246-54. Abstract
Sibai BM. Diagnosis, controversies, and management of the syndrome of hemolysis, elevated liver enzymes, and low platelet count. Obstet Gynecol. 2004 May;103(5 Pt 1):981-91. Abstract
O'Brien JM, Barton JR. Controversies with the diagnosis and management of HELLP syndrome. Clin Obstet Gynecol. 2005 Jun;48(2):460-77. Abstract
Sibai BL, Ramadan MK, Chari RS, et al. Pregnancies complicated by HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets): subsequent pregnancy outcome and long-term prognosis. Am J Obstet Gynecol. 1995;172:125-129. Abstract
Reference articles
A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
Differentials
- Acute fatty liver of pregnancy (AFLP)
- Thrombotic thrombocytopenic purpura (TTP)
- Atypical hemolytic uremic syndrome (aHUS)
More DifferentialsGuidelines
- ACOG practice bulletin no. 222: gestational hypertension and preeclampsia
- Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy
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Preeclampsia: what is it?
Preeclampsia: what treatments work?
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