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HELLP syndrome

Key sources
The following summarized guidelines for the evaluation and management of HELLP syndrome are prepared by our editorial team based on guidelines from the European Association for the Study of the Liver (EASL 2023; 2017), the American Association for the Study of Liver Diseases (AASLD 2021), the American College of Gastroenterology (ACG 2016), the Italian Association for the Study of the Liver (AISF 2016), and the Society of Obstetricians and Gynaecologists of Canada (SOGC 2014).
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Guidelines

1.Screening and diagnosis

Indications for monitoring: as per EASL 2023 guidelines, view HELLP syndrome as a manifestation of severe preeclampsia.
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2.Diagnostic investigations

Liver tests: as per EASL 2023 guidelines, obtain serum liver tests as abnormalities are frequently associated with an adverse maternal outcome in HELLP syndrome. Do not use liver test results in isolation to guide care.
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  • Abdominal ultrasound

3.Medical management

Corticosteroids
As per EASL 2023 guidelines:
Do not administer corticosteroids to improve maternal outcomes in patients with HELLP syndrome.
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Administer high-dose dexamethasone or betamethasone to improve fetal lung maturity if a pregnancy complicated by HELLP syndrome is to be delivered before 35 weeks gestation.
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  • Antihypertensive therapy

  • Magnesium sulfate

4.Therapeutic procedures

Platelet transfusion
As per EASL 2023 guidelines:
Be aware of the higher prevalence of hepatic hemorrhage or hematoma in patients with HELLP syndrome and markedly reduced platelet count (≤ 20×10⁹/L).
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Consider administering platelet transfusion in pregnant patients with a platelet count < 100×10⁹/L to reduce the risk of abnormal coagulation and adverse maternal outcomes associated with preeclampsia.
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  • Delivery

  • Plasmapheresis

5.Surgical interventions

Liver transplantation: as per EASL 2023 guidelines, refer patients with HELLP syndrome to a transplant center early if there are signs of hepatic failure likely to require transplantation.
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6.Specific circumstances

Patients with acute fatty liver of pregnancy: perform prompt delivery of the fetus as the treatment of choice in patients with HELLP syndrome and acute fatty liver of pregnancy, especially in case of elevated lactate levels and hepatic encephalopathy. Offer screening for putative fatty acid defects.
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7.Follow-up and surveillance

Breastfeeding: recognize that breastfeeding is not contraindicated in patients with HELLP syndrome on antihypertensive therapy, including nifedipine, labetalol, atenolol, methyldopa, captopril, and enalapril.
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