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This is a clinician-written, evidence-based summary aligned to the USMLE Step 2 CK Content Outline. It is intended for medical students preparing for USMLE Step 2 CK. Management reflects current ACC/AHA, USPSTF, and APA guidelines. Always cross-reference with UpToDate, institutional protocols, and clinical judgment.
The Bottom Line
- HELLP = Hemolysis, Elevated Liver enzymes, Low Platelets
- Often presents in third trimester or postpartum with RUQ/epigastric pain, nausea, vomiting, malaise, and hypertension
- Proteinuria or severe hypertension may be absent
- Management is stabilization, magnesium, severe BP control, corticosteroids if preterm, and delivery
- Major complications include DIC, hepatic hematoma/rupture, abruption, renal failure, pulmonary edema, and postpartum hemorrhage
Overview
HELLP syndrome is a severe manifestation within the preeclampsia spectrum, though hypertension and proteinuria may be less prominent. It can deteriorate rapidly into DIC, hepatic rupture, renal failure, or abruption.
Epidemiology
HELLP occurs in a small proportion of pregnancies and more often among those with severe preeclampsia. It most often occurs in the third trimester but can develop postpartum.
Clinical Features
Symptoms
Right upper quadrant or epigastric pain
Nausea, vomiting, malaise, or flu-like symptoms
Headache or visual symptoms
Bleeding, bruising, or oozing
Postpartum worsening can occur
Signs
Hypertension after 20 weeks, sometimes mild
RUQ tenderness from hepatic swelling or hematoma
Jaundice is uncommon but possible
Petechiae, mucosal bleeding, or IV-site bleeding suggests DIC
Fetal growth restriction or nonreassuring status
Investigations
First-line
CBC with plateletsPlatelets <100,000/microliter support diagnosis
Liver enzymesAST/ALT elevated, often at least twice upper limit
Hemolysis labsSchistocytes, elevated LDH, elevated indirect bilirubin, low haptoglobin
Second-line
Renal function and urine proteinCreatinine may rise; proteinuria may or may not be present
Coagulation studiesPT, aPTT, fibrinogen, D-dimer if bleeding/DIC concern
Fetal assessmentNST/BPP and growth assessment as gestational age permits
Specialist
Hepatic imagingIf severe RUQ/shoulder pain, hypotension, or hepatic hematoma/rupture concern
MFM/anesthesia consultationSevere thrombocytopenia, preterm delivery, or complex instability
1
Immediate stabilization
- Hospitalize and involve OB/GYN, anesthesia, blood bank, neonatology as needed
- Magnesium sulfate for seizure prophylaxis
- Treat severe BP with labetalol, hydralazine, or nifedipine
- Type/crossmatch and prepare blood products
2
Delivery timing
- Definitive treatment is delivery
- At >=34 weeks or maternal/fetal instability: deliver after stabilization
- Before 34 weeks and stable: brief delay for corticosteroids may be considered
- Route depends on obstetric factors and fetal/maternal status
3
Blood products and steroids
- Antenatal corticosteroids if preterm delivery anticipated
- Platelets for bleeding or safe procedural threshold
- Correct DIC with appropriate blood products
4
Postpartum monitoring
- Labs may worsen for 24-48 hours after delivery
- Continue magnesium when indicated
- Monitor BP, urine output, platelets, enzymes, hemolysis, and bleeding
Complications
- DIC: Consumptive coagulopathy with bleeding and low fibrinogen
- Hepatic hematoma/rupture: Severe RUQ or shoulder pain with shock
- Placental abruption: Painful bleeding and fetal distress
- Acute kidney injury: Microangiopathy and severe disease
- Postpartum hemorrhage: Thrombocytopenia and DIC increase bleeding
USMLE Step 2 CK Exam Tips
- 1RUQ pain + low platelets + high AST/ALT in pregnancy = HELLP
- 2HELLP can occur without dramatic hypertension or proteinuria
- 3Do not confuse with acute fatty liver: AFLP has hypoglycemia/encephalopathy/prominent liver failure
- 4Definitive treatment is delivery after stabilization
- 5Magnesium is used because HELLP is severe preeclampsia spectrum
- 6Severe RUQ pain + hypotension = hepatic rupture until proven otherwise
- 7Platelets may worsen for 24-48 hours postpartum
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