HELLP Syndrome

What happens in HELLP syndrome

HELLP is thought to start with a problem in the placenta that triggers widespread inflammation and damage to the lining of small blood vessels. This leads to:

• hemolysis: red blood cells are damaged as they pass through injured small vessels
• elevated liver enzymes: the liver is injured, sometimes with bleeding under its capsule
• low platelets: platelets are used up, increasing bleeding risk

It is closely linked to preeclampsia, and most women with HELLP have high blood pressure and protein in the urine, but some do not, which can delay diagnosis.

How common is it

HELLP occurs in a small fraction of pregnancies, under 1 percent, and in about 10 to 20 percent of women with severe preeclampsia. Most cases occur between 27 and 37 weeks, and a significant share appear after delivery, usually within 48 hours.

Symptoms

Symptoms can be easily mistaken for flu, indigestion, gallbladder disease or a stomach bug:

• pain in the upper right belly or the upper middle belly (epigastric), sometimes spreading to the back or right shoulder
• nausea and vomiting
• headache
• tiredness and feeling generally unwell
• swelling of the face, hands or legs
• vision changes
• bleeding gums or easy bruising
• high blood pressure (in most, but not all)

Risk factors

• preeclampsia in the current pregnancy
• HELLP or preeclampsia in a previous pregnancy
• age over 35
• first pregnancy (preeclampsia), though HELLP also occurs in later pregnancies
• multiple pregnancy
• chronic high blood pressure, diabetes, kidney disease or autoimmune conditions

Diagnosis

HELLP is diagnosed by blood tests:

• complete blood count with platelet count: platelets typically below 100,000 per microliter
• liver enzymes (AST, ALT): elevated, often more than twice normal
• LDH and bilirubin: raised by red cell breakdown
• blood smear: fragmented red cells
• clotting tests to look for disseminated intravascular coagulation (DIC)
• kidney function and urine protein

Doctors also check blood pressure, monitor the baby, and may do an ultrasound of the liver if there is concern about bleeding. HELLP must be distinguished from acute fatty liver of pregnancy, thrombotic thrombocytopenic purpura, hemolytic uremic syndrome and viral hepatitis, which can look similar.

Treatment

HELLP is treated in a hospital with a high-risk obstetric team and often intensive care.

• Delivery: the definitive treatment. At 34 weeks or more, delivery usually happens soon after stabilization. Before 34 weeks, if mother and baby are stable, delivery may be delayed by 24 to 48 hours to give steroids for the baby's lungs. Vaginal birth is possible in some cases, but cesarean delivery is often needed.
• Magnesium sulfate through an IV to prevent seizures (eclampsia).
• Blood pressure medicines for severe hypertension, to reduce the risk of stroke.
• Platelet transfusions if platelets are very low, especially before a cesarean.
• Blood products for bleeding or clotting problems.
• Close monitoring for at least 48 hours after delivery, when lab values often worsen before they improve.

Complications

For the mother:

• placental abruption
• disseminated intravascular coagulation (DIC)
• liver hematoma or rupture, a surgical emergency
• kidney failure
• fluid in the lungs
• stroke and seizures

For the baby:

• preterm birth and its complications
• growth restriction
• low oxygen from abruption

Outlook and future pregnancies

Most women recover fully after delivery, with blood counts and liver tests returning to normal within days to a week. HELLP can be fatal if not recognized and treated quickly, which is why warning signs matter.

The risk of preeclampsia or HELLP recurring in a future pregnancy is increased. Women with a history of HELLP are advised to:

• see their provider early in the next pregnancy
• take low-dose aspirin from about 12 weeks if recommended
• have close blood pressure and blood test monitoring

Women who have had preeclampsia or HELLP also have a higher lifetime risk of high blood pressure and heart disease, so regular checks of blood pressure, cholesterol and blood sugar are important.

Frequently asked questions

What are the first symptoms of HELLP syndrome?

Early symptoms often include pain in the upper right or upper middle belly, nausea, vomiting, headache and feeling unwell, sometimes mistaken for flu or indigestion. Swelling and high blood pressure are common but not always present. Any of these after 20 weeks need prompt assessment.

What is the difference between HELLP and preeclampsia?

Preeclampsia is high blood pressure with signs of organ damage in pregnancy. HELLP is a severe variant, defined by red blood cell breakdown, raised liver enzymes and low platelets. Most women with HELLP have preeclampsia, but some have normal blood pressure.

Can HELLP syndrome happen after delivery?

Yes. A significant share of cases begin after birth, usually within 48 hours but sometimes up to a week later. Report upper belly pain, severe headache, vision changes, shortness of breath or nausea after delivery right away.

How is HELLP syndrome treated?

The main treatment is delivering the baby, after stabilizing the mother with magnesium sulfate to prevent seizures, blood pressure control and blood products if needed. Steroids may be given for the baby's lungs if delivery before 34 weeks can safely be delayed briefly.