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International Journal of Biomedical And Advance Research

ISSN: 2229-3809 (Online)


Journal DOI:10.7439/ijbar
OD!N:IJ"#"N
Case Report
HELLP syndrome - A life threatening complication of severe pre- eclampsia
Vidyadhar B. Bangal* Milind B Chandurkar, Shalini Y. Sachdev, Rashmi K. Singh,
Rajiv M. Chandaliya
Department of Obstetrics and Gynecology, Rural Medical College of Pravara Institute of Medical Sciences, (Deemed
niversity! "oni, Ma#aras#tra, India
*Correspondence !nfo"
Dr. Vidyadhar B. Bangal
Proessor, De!". o #$s"e"rics and %ynecology,
Rural Medical College o Pravara &ns"i"u"e o Medical
Sciences 'Deemed (niversi"y), *oni, Maharash"ra, &ndia
+,mail, v$$-./0redimail.com
#. !ntrod$ction
1+**P syndrome is a grou! o sym!"oms "ha" occurs in !regnan" 2omen 2ho have !re,eclam!sia or eclam!sia
and 2ho also sho2 signs o liver damage and a$normali"ies in $lood clo""ing.
&" is charac"erised $y3 1, 1aemolysis, +*, +leva"ed liver en4ymes , *P, lo2 !la"ele" coun". &" occurs in 5.6 "o 5.78 o all
!regnancies and in .5,-58 o cases 2i"h severe !re,eclam!sia
.
. 958 o 2omen 2i"h 1+**P syndrome !resen" $eore
"erm. Pa"ien"s usually !resen" 2i"h sym!"oms o !rogressive nausea and vomi"ing, u!!er a$dominal !ain, headache and
visual !ro$lems. :he usual signs are jaundice ,u!!er a$dominal "enderness, es!ecially in "he righ" u!!er ;uadran",
he!a"omegaly and easy $ruising<!ur!ura. & 1+**P syndrome is no" "rea"ed early, u! "o -68 o 2omen may develo!
serious com!lica"ions. =i"hou" "rea"men" "here is a signiican" mor"ali"y. :he mor"ali"y ra"e among $a$ies $orn "o mo"hers
2i"h 1+**P syndrome varies and de!ends mainly on ges"a"ion and $ir"h 2eigh". :he common com!lica"ions o 1+**P
syndrome include ma"ernal liver haemorrhage or ru!"ure
-
, coagulo!a"hy, !os"!ar"um hemorrhage,!ermanen" liver damage
or necrosis
>
, 2hich may need "rans!lan"a"ion, in"raven"ricular haemorrhage 2i"h su$se;uen" hydroce!halus has $een
re!or"ed
?
. Re"inal de"achmen" and o"her eye !ro$lems have $een re!or"ed.
6
:ransien" dia$e"es insi!idus may ollo2 1+**P
syndrome.
@

%. Case Report
:2en"y "hree year un$ooked !rimigravida re!or"ed rom !riva"e nursing home 2i"h >9 2eeks o !regnancy 2i"h
severe !re eclam!sia and "hrom$ocy"o!enia or ur"her managemen". Pa"ien" 2as "aking an"ihy!er"ensive agen"s'*a$e"alol
IJBAR (2013) 04 (03) www.ssjournals.com
A&stract
1+**P Syndrome is a lie "hrea"ening com!lica"ion o severe !re eclam!sia ,2hich is charac"eri4ed $y evidence
o hemolysis, eleva"ed liver en4ymes and lo2 !la"ele" coun" during second hal o !regnancy.& un"rea"ed , i" carries high
risk o ma"ernal and !erina"al mor$idi"y and mor"ali"y due "o he!a"ic and renal com!lica"ions. A case o 1+**P
Syndrome 2i"h severe !re eclam!sia in a !rimigravida a" >7 2eeks o !regnancy is re!or"ed. She 2as a kno2n case o
severe !re eclam!sia and 2as "aking "rea"men" in a !riva"e nursing home.She 2as reered 2i"h a !ic"ure o 1+**P
Syndrome.Caesarean sec"ion under general anes"hesia or e"al dis"ress 2as carried ou" ollo2ing single donar !la"ele"
"ransusion. She had gross derrangemen" o he!a"ic and renal unc"ions and "hrom$ocy"o!enia ollo2ing caesarean
sec"ion. She 2as "rea"ed aggresively in in"ensive care uni" 2i"h "ransusion o 2hole $lood ,resh ro4en !lasma, mul"i!le
single donar !la"ele" "ransusions ,an"ihy!er"ensive agen"s and $road s!ec"rum an"i$io"ics.Pa"ien" re;uired
mul"idisci!linary "eam a!!roach or managemen".Pa"ien" 2as discharged a"er i"een days rom hos!i"al.
'ey(ords" 1+**P Syndrome , Severe !re eclam!sia ,:hrom$ocy"o!enia,Com!onen" "hera!y
Bangal V B et al

-08
.55 mg "2ice a day) since -5 days o admission. Pa"ien" had s2elling over $ody, ron"al headache, $lurring o vision and
e!igas"ric !ain. #n eBamina"ion, she 2as conscious and orien"ed. 1er $lood !ressure 2as .@5 <.5? mm 1g. She had high
BM& value o -9.Per a$dominal eBamina"ion revealed a ull "erm u"erus 2i"h large si4e $a$y in ce!halic !resen"a"ion 2i"h
a!!roBima"e $a$y 2eigh" o >.? kgs. &n"ernal eBamina"ion revealed a long uneaced cerviB 2i"h $orderline ce!halo !elvic
dis!ro!or"ion. She 2as ke!" in cri"ical care uni" and 2as "rea"ed 2i"h :a$. la$e"alol .55 mg "2ice a day. 1er la$ora"ory
inves"iga"ions revealed !la"ele" coun" o 6.,555<cumm, 1aemoglo$in , .?.- grams, Pro"hrom$in "ime ,./.-sec, &CR,..>-,
Par"ial "hrom$o!las"in "ime,6? sec. 1er S.*D1 levels 2ere .66@ &(<*. A"er .- hours o admission,her $lood !ressure
increased "o .@5<.-5 mm 1g. She 2as "rea"ed 2i"h in"ravenous *a$e"alol -5 mg and 6 grams o !ro!hylac"ic in"ramuscular
magnesium sul!ha"e. 1er undus eBamina"ion revealed serous re"inal de"achmen". &n vie2 o her lo2 !la"ele" coun" and
!ossi$le need o caesarean sec"ion, she 2as "ransused !re o!era"ively 2i"h one uni" o single donar !la"ele". Dollo2ing "his
"ransusion, !a"ien" 2en" in la$our and develo!ed severe e"al dis"ress. +mergency caesarean sec"ion 2as carried ou" under
general anes"hesia a"er counselling and eB!laining "he risk o o!era"ive in"erven"ion "o "he rela"ives. :here 2as no in"ra
o!era"ive com!lica"ion like !os" !ar"um haemorrhage. A male child 2i"h $ir"h 2eigh" o >.>kg 2as delivered 2i"h lo2
AP%AR score. Ba$y re;uired resusci"a"ion and in"ensive neona"al care. Pa"ien" 2as ke!" in in"ensive care uni" during !os"
o!era"ive !eriod. 1er !la"ele" coun",liver unc"ion and renal unc"ions sho2ed gross de"eriora"ion ollo2ing caesarean
sec"ion. 1er 1$ level dro!!ed "o @.7 grams,S Biliru$in raised "o ..mg <dl,S.S%#: ,?965&(<*, B.(rea "o .@/mg<dl,S.
Crea"inine "o -.>mg<dl.She 2as "ransused 2i"h 9 uni"s o resh ro4en !lasma,- uni"s o resh $lood and - uni"s o single
donar !la"ele"s during irs" !os" o!era"ive day.1er general condi"ion de"eriora"ed and she sho2ed early signs o dissemina"ed
in"ravascular coagulo!a"hy. )*ig # and %+ She develo!ed hema"uria, !e"echial hemorrhages and in"ra!eri"oneal $leeding.
1er !la"ele" coun" dro!!ed do2n "o -?,555<cumm. *iver en4ymes, $iliru$in levels,$lood urea, s.crea"inine values sho2ed
gross rise. 1er $lood !ressure remained in "he range o .65<.55mm 1g. She 2as managed aggressively $y resh $lood and
single donar "ransusions ,injec"ion vi"amin K .5 mgs. :he $lood urea, S. crea"inine,liver en4ymes, S $iliru$in values s"ar"ed
coming do2n on 6
"h
!os" o!era"ive day. 1er urine ou"!u" 2as normal "hroughou" "he !os" o!era"ive !eriod. Pa"ien" s"ar"ed
sho2ing clinical signs o im!rovemen" on @
"h
!os" o!era"ive day.1er !la"ele" coun" values ,liver unc"ion ,renal unc"ions
re"urned "o normal on .- !os" o!era"ive day. Re!ea" undus eBamina"ion sho2ed signs o resolving hy!er"ensive
re"ino!a"hy. She 2as discharged on an"ihy!er"ensive agen"s on .6
"h
!os" o!era"ive day.
Digure . Pe"echial haemorrhage on skin due "o
:hrom$ocy"o!enia
Digure - . &njec"ion si"e ecchymosis due "o coagulo!a"hy
,. -isc$ssion
:he 1+**P syndrome, a serious condi"ion in i"s com!le"e orm, is associa"ed 2i"h su$s"an"ial risk or "he mo"her
and her oe"us
/,.5
. Diagnosis o "he com!le"e orm o "he 1+**P syndrome re;uires "he !resence o all > major
com!onen"s, 2hile !ar"ial or incom!le"e 1+**P syndrome consis"s o only . or - elemen"s o "he "riad '1 or +* or
*P)
..,.-
. A 2ide range o com!lica"ions may arise and "he condi"ion re!resen"s diagnos"ic and "hera!eu"ic !ro$lemsE "iming
IJBAR (2013) 04 (03) www.ssjournals.com
Bangal V B et al 209
and me"hod o delivery are im!or"an". 1aemolysis, one o "he major charac"eris"ics o "he disorder, is due "o a
microangio!a"hic haemoly"ic anaemia 'MA1A). Red cell ragmen"a"ion caused $y high,veloci"y !assage "hrough damaged
endo"helium a!!ears "o re!resen" "he eB"en" o small vessel involvemen" 2i"h in"ima damage, endo"helial dysunc"ion and
i$rin de!osi"ion. Presence o ragmen"ed 'schi4ocy"es) or con"rac"ed red cells 2i"h s!icula 'Burr cells) in "he !eri!heral
$lood smear relec"s "he haemoly"ic !rocess and s"rongly sugges"s "he develo!men" o MA1A
.>
. Polychroma"ic red cells
are also seen in $lood smears, and increased re"iculocy"e coun"s relec" "he com!ensa"ory release o imma"ure red cells in"o
!eri!heral $lood. Des"ruc"ion o red $lood cells $y haemolysis causes increased serum lac"a"e dehydrogenase '*D1) levels
and decreased haemoglo$in concen"ra"ions
.?
. 1aemoglo$inaemia or haemoglo$inuria is macrosco!ically recogni4a$le in
a$ou" .58 o "he 2omen
.6
. *i$era"ed haemoglo$in is conver"ed "o unconjuga"ed $iliru$in in "he s!leen or may $e $ound in
"he !lasma $y ha!"oglo$in. :he haemoglo$in,ha!"oglo$in com!leB is cleared ;uickly $y "he liver, leading "o lo2 or
unde"ec"a$le ha!"oglo$in levels in "he $lood, even 2i"h modera"e haemolysis
.@
. *o2 ha!"oglo$in concen"ra"ion 'F . g<* G F
5.? g<*) can $e used "o diagnose haemolysis and is "he !reerred marker o haemolysis
./
. :hus, "he diagnosis o haemolysis
is su!!or"ed $y high *D1 concen"ra"ion and "he !resence o unconjuga"ed $iliru$in, $u" "he demons"ra"ion o lo2 or
unde"ec"a$le ha!"oglo$in concen"ra"ion is a more s!eciic indica"or.
+leva"ion o liver en4ymes may relec" "he haemoly"ic !rocess as 2ell as liver involvemen". 1aemolysis
con"ri$u"es su$s"an"ially "o "he eleva"ed levels o *D1, 2hereas enhanced as!ara"e amino"ranserase 'AS:) and alanine
amino"ranserase 'A*A:) levels are mos"ly due "o liver injury. Plasma glu"a"hione S,"ranserase,a. 'H,%S: or %S:,a.) may
!rovide a more sensi"ive indica"or or acu"e liver damage "han AS: and A*A:, and allo2 earlier recogni"ion
.9
.
:hrom$ocy"o!enia '!la"ele"s 'P*:s) F .65I.5
7
<*) in !regnancy may $e caused $y ges"a"ional "hrom$ocy"o!enia '%:)
'678), immune "hrom$ocy"o!enic !ur!ura '&:P) '..8), !reeclam!sia '.58), and "he 1+**P syndrome '.-8)
.7
P*:s F
.55I.5
7
<* are rela"ively rare in !reeclam!sia and ges"a"ional "hrom$ocy"o!enia, re;uen" in &:P and o$liga"ory in "he
1+**P syndrome 'according "o "he Si$ai deini"ion). Decreased P*: coun" in "he 1+**P syndrome is due "o "heir
increased consum!"ion. Pla"ele"s are ac"iva"ed, and adhere "o damaged vascular endo"helial cells, resul"ing in increased
!la"ele" "urnover 2i"h shor"er lies!an
-5
.
&n general, "here are "2o major o!"ions or "he managemen" o 2omen 2i"h severe !reeclam!sia and 1+**P
syndrome. :hese include3 .) &mmedia"e delivery 2hich is "he !rimary choice a" >? 2eeksJ ges"a"ion or la"er.-) Delivery
2i"hin ?9 hours a"er evalua"ion, s"a$ili4a"ion o "he ma"ernal clinical condi"ion and cor"icos"eroid 'CS)"rea"men". A" -/ "o
>? 2eeks o ges"a"ion, "his o!"ion a!!ears a!!ro!ria"e and ra"ional or "he majori"y o cases
-.,-?
.
:he !resen" case 2as a""ending an"ena"al clinic regularly a" a !riva"e nursing home. She develo!ed severe
hy!er"ension a"er >@ 2eeks o !regnancy. She 2as !u" on an"ihy!er"ensive agen"s or con"rol o hy!er"ension $y "he
"rea"ing o$s"e"rician. 1er condi"ion 2ors"ened a"er >/ 2eeks. :he !regnancy should have $een "ermina"ed $y a!!ro!ria"e
rou"e a" >/ 2eeks "o avoid "he su$se;uen" develo!men" o 1+**P Syndrome. Because "he 1+**P syndrome can $e
associa"ed 2i"h a $leeding "endency secondary "o a deiciency o !la"ele"s, i" may $e necessary "o adminis"er !la"ele"
"ransusions. :his may $e !ar"icularly im!or"an" $eore under"aking any surgery, such as a Caesarean sec"ion. :oo much o
conserva"ive a!!roach a"er >@ 2eeks in "his case has resul"ed in "he de"eriora"ion o "he condi"ion. Dor"una"ely ,"he $lood
and com!onen" "hera!y 2as availa$le in "he reerral ins"i"u"e and "he rela"ives 2ere a$le "o arrange or cos"ly medicines
including mul"i!le uni"s o single donar !la"ele"s.
.. Concl$sion
1+**P syndrome is a lie "hrea"ening com!lica"ion o severe !re eclam!sia.&" is associa"ed 2i"h serious risk o
coagula"ion ailure, renal ailure, he!a"ic ailure and ulminan" se!sis.&" can $e !reven"ed $y early recogni"ion o "he
condi"ion and immedia"e "ermina"ion o !regnancy. Managemen" re;uires mul"idisci!linary "eam a!!roach involving
anes"hesiologis", neona"ologis", in"ensivis", !hysician and good $lood $ank acili"y having availa$ili"y o com!onen"
"hera!y.
IJBAR (2013) 04 (03) www.ssjournals.com
Bangal V B et al 210
Ac/no(ledgement
:he au"hors eB!ress "heir dee! sense o gra"i"ude "o "he managemen", o "he Pravara Medical
:rus" and "he Princi!al, Rural Medical College, *oni, Maharash"ra, &ndia.
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IJBAR (2013) 04 (03) www.ssjournals.com

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