*Reader (Department of Anaesthesiology & Critical Care),
+Reader (Department of Obstetrics & Gynaecology), AFMC,
Pune-40.Received : 29.11.2004Accepted :
18.05.2006CaseReportIntroductionThe acronym HELLP was coined in
1982 to describea syndrome consisting of Haemolysis Elevated
Liverenzyme levels and Low Platelet count [1]. The
syndromeconsidered a variant of preeclampsia, can occur on
itsownorinassociationwithpreeclampsia.Pregnancyinduced hypertension
(PIH), preeclampsia and HELLPare related and overlap in their
presentation.
MaternalandfoetalmorbidityandmortalityaresignificantinHELLPsyndrome[2].Variouslifethreateningcomplications
such as placental abruption, pulmonaryoedema, cerebral haemorrhage,
hepatorenal failure anddisseminated intravascular coagulation (DIC)
can occurinthesepatients.WepresenttwocasesofHELLPsyndrome with
vague presenting complaints. First
patientdevelopedHELLPinassociationwithseverepreeclampsia and in the
second patient HELLP led
tofoetaldeath.Wediscussthesurgicalandanaestheticimplications during
peri-operative period.Case Report-1A 21 year old primigravida at 35
weeks of gestation
wasadmittedwithlabourpain,headache,epigastricpainandblurringofvision.Onexaminationtherewasalteredconsciousness,
pulse 86 per minute, blood pressure 170/110mm Hg, breath rate 24
per minute, and brisk tendon jerks.Based on obstetrical examination
delivery by vaginal routewas planned. Baseline investigations
showed haemoglobin11.9gm%, platelets 1,60,000/mm3, blood urea
26mg%,
serumcreatinine0.9mg%,serumbilirubin0.9mg%,alanineaminotransferase(ALT)40unitsperlitre,aspartateaminotransferase(AST)28unitsperlitre.Totreathypertension
oral nifedipine 10mg and magnesium sulphateby Pritchards regime was
started. After 4 hrs of admission,repeat examination revealed pulse
rate of 84 per minute, bloodpressure of 160/100 mm Hg and urinary
output was 50 ml.Because of falling urinary output magnesium
sulphate waswithheld and oral nifedipine continued. After 2 hrs
patienthad an episode of generalised tonic clonic seizures, for
whichdiazepam 10 mg intravenously was administered. It was
thendecidedthatthepregnancybeterminatedbyemergencycaesareansection.Generalanaesthetictechniquewithacidaspirationprophylaxis
was selected. Pre-induction fentanyl 20 g andesmolol 10 mg
administered to decrease the pressure
responsetolaryngoscopyandendotrachealintubation.Afterpreoxygenationarapidsequenceinduction-intubationtechniquewasusedtofacilitateendotrachealintubation.Anaesthesiawasmaintainedwithgas,oxygen,isofluraneandatracurium.
Additionaldosesoffentanylandesmololwere given to keep haemodynamic
parameters within 20% ofpreoperative values. A live male baby was
delivered. Due toweak cry, newborn was given 300 g of naloxone.
Neostigmineand glycopyrrolate were given for reversal of muscle
relaxant.Followingextubationpatientwasdrowsyanddisorientedhence
observed in intensive care unit. Overthe next 12
hourspatienthadfourgeneralisedseizuresdespitecontinuingintramuscular
magnesium sulphate. Blood pressure rangedfrom 160 to 200 mm Hg
systolic and 110 to 130 mm Hg diastolicwith heart rate between 120
to 130 per minute. At this timeoliguria and tender hepatomegaly was
noticed. Because ofpersistent seizures and hypertension a
continuous infusionof magnesium sulphate 1 gm/hour and labetalol 20
mg/hourwasstartedandmonitoredbykneejerkresponse.Repeatinvestigations
after 24 hours revealed haemoglobin 6.8 gm%,platelets count
86,000/mm3, prothrombin time (PT) 07 secondsand partial
thromboplastin time (PTT) was 08 seconds
morethancontrolvalues.Thebloodureawas60mg%,serumcreatinine 1.9 mg
%, serum bilirubin 3.4 mg %, ALT 1040 unitsper litre, AST 646 units
per litre, lactate dehydrogenase (LDH)658 units per litre and
peripheral smear showed evidence ofhaemolysis. Antiphospholipid
antibodies were negative. Bothinfusions were continued for 36 hours
after last seizure. Atotal of 260 mg of labetalol was used. Blood
and fresh frozenplasma was transfused appropriately. Over the next
two dayspatient improved clinically, however laboratory
parameterstook10daystoreturntopreoperativevalues.On12thdaypatient
was discharged home uneventfully.Case Report-2A 26 year old lady
with twin pregnancy presented at 33weeks of gestation, with
intra-uterine death of one foetus atHELLP Syndrome : Report of Two
CasesWg Cdr RM Sharma*, Wg Cdr GS Sandhu+, VSMMJAFI 2006; 62 :
373-374Key Words: HELLP syndrome; PreeclampsiaMJAFI, Vol. 62, No.
4, 2006374
SharmaandSandhuthetimeofadmissionandwastakenupforemergencycaesareanundersubarachnoidblock.Onexaminationshewas
drowsy, pulse 120 per minute, blood pressure 100/56 mmHg, had pedal
and sacral oedema . Preoperative investigationsshowed haemoglobin
of 11.2gm %, platelet count 2,10,000/mm3, blood urea 24 mg %, serum
creatinine 0.8 mg %, serumbilirubin 3.0 mg%, ALT 184 units per
litre, AST 158 units perlitre. After adequate preloading, 12 mg of
bupivacaine
wasinjectedintrathecally.Boththebabiesdeliveredwerestillbornandtheintraoperativecoursewasuneventful.Inthepostoperative
period renal function deteriorated with bloodurea of 36 mg % and
serum creatinine 1.8mg %. There wasevidence of haemolysis on
peripheral blood smear and LDHwas raised to 1110 units perlitre.
Coagulation profile
wasderangedwithPT12secsandPTT23secsmorethanthecontrol values and
platelets count fell to 1,95,000/mm3. Onfirst postoperative day,
patient developed tachycardia (heartrate 130-140/min) and
hypertension (170/100 mm Hg) whichwas treated with oral atenolol.
With supportive care patientrecovered and was discharged after 2
weeks.DiscussionHELLPisamulti-systemdisease,resultingingeneralisedvasospasm,microthrombiformationandcoagulation
defects [3]. The syndrome seems to be thefinal manifestation of
insult that leads to micro
vascularendothelialdamageandintravascularplateletaggregation.Significantsymptomsandsignsinanypatientwithpreeclampsiaincludeheadache,blurredvision,
altered consciousness, clonus, increasing
serumcreatininelevel,consumptivecoagulopathywiththrombocytopenia,
and abnormal liver function tests [4].Both our patients had altered
consciousness, possibilyan early but subtle sign of developing
HELLP syndrome.The HELLP syndrome occurs in 4-18% of patientswith
preeclampsia. Upto 30% patients develop HELLPsyndrome after
parturition, typically appearing within 48hours. In fact, there may
be no evidence of
preeclampsiabeforeorduringlabourin20%ofcases.Theserumtransaminase
levels may be elevated and platelet countscan drop to as low as
6000/mm3. Platelet count is
thebestindicatorofHELLP.Progressiveisolatedthrombocytopenia may be
one of the first clues to
thediagnosis[5].Boththeabovementionedpatientsdeveloped renal
dysfunction, consumptive coagulopathyand thrombocytopenia.
Excessive fluid overload
duringanaestheticmanagementcanresultincerebralorpulmonary oedema. A
positive D-dimer test in the
settingofpreeclampsiahasrecentlybeenreportedtobepredictive of
patients who will develop HELLP syndrome[6].The laboratory
abnormalities typically worsen
afterdeliveryandpeakat24to48hourspostpartumandresolve by three to
four days [7]. Patients with
HELLPsyndromeshouldbetreatedprophylacticallywithmagnesiumsulphatetopreventseizures.InIntensiveCareUnit(ICU)settingmagnesiumsulphateandlabetalol
can be used as an intravenous infusion for
thetreatmentofseizuresandhypertension.Thisalsoreduces the risk of
maternal cerebral haemorrhage.
Themainstayoftherapyissupportivemanagementanddelivery is the
definitive treatment. These patients
maydevelopplacentalabruptionandrequireemergencycaesareansection.Althoughhypertensionisnotacontradiction
to regional anaesthesia [8] but patients withaltered consciousness
and platelet counts of less
than70,000/mm3shouldnotbegivenspinalorepiduralanaesthesia.Ahighdegreeofsuspicionshouldbemaintained
whenever patients with preeclampsia
presentwithnonspecificfeatures.Thefirstpatientdevelopedeclampsiadespiteprophylacticmagnesiumsulphatetherapy.Thecauseforfoetaldeathinsecondpatientcould
be severe coagulopathy and haemolysis. Womenwith a history of HELLP
syndrome are considered
tobeatincreasedriskforcomplicationsinfuturepregnancies.Conflicts of
InterestNone identifiedReferences1. Weinstein L. Syndrome of
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