Anesthetic Implications of HELLP Syndrome

HELLP syndrome is a life-threatening pregnancy complication that is a variant of preeclampsia.1 It usually occurs during the later stages of pregnancy, but may also occur after childbirth.1 HELLP syndrome is named after its characteristics, which include hemolysis (the breaking down of red blood cells), elevated liver enzymes and low platelet count.1 Pregnant women with HELLP syndrome need to give birth as soon as possible and may even mean their babies are born prematurely.2 Early birth can involve induced labor or Cesarean section, which require anesthetic management.2 Given the instability associated with HELLP, anesthesiology professionals must be particularly vigilant when administering medications to afflicted patients.3 Anesthesia providers should be familiar with the biology, signs and symptoms of HELLP syndrome, as well as common anesthetic techniques for HELLP patients.

Patients with HELLP syndrome have a variety of potentially fatal conditions and suffer from highly unpleasant symptoms. HELLP syndrome can be difficult to diagnose, and its symptoms are often mistaken for gastritis, flu, acute hepatitis, gallbladder disease or other conditions.1 This may be due to its rarity, as it occurs in only one to two of every 1,000 pregnancies.2 However, HELLP is very serious—its mortality rate has been reported as high as 30 percent.1 Pregnant patients who have preeclampsia or eclampsia are at risk for developing HELLP, as about 10 to 20 percent of these patients will later have HELLP.2 Other risk factors include being in poor physical shape before pregnancy, lacking prenatal care, and having previous high-risk pregnancies or a family history of HELLP syndrome, preeclampsia or hypertension.1 Signs and symptoms of HELLP syndrome include blurry vision, chest or abdominal pain, headache, fatigue, general malaise, nausea or vomiting that gets worse, quick weight gain and swelling, nosebleed or even seizures.2 Clinicians should look out for high blood pressure or blood in the urine as other potential signs of HELLP syndrome.1 HELLP syndrome is almost always treated with the delivery of the baby, though it can also be alleviated with blood transfusions and steroids.1 HELLP syndrome is extremely dangerous to a patient and her pregnancy, and patients who show signs or symptoms should contact their medical providers immediately.

Anesthesia providers must be aware of the signs of HELLP and adjust their practices accordingly. The anemia, liver damage and clotting issues of HELLP may all affect anesthesia’s effects and anesthesia-related complications.3 In their review, del-Rio-Vellosillo and Garcia-Medina emphasize the most important details for anesthetic management of HELLP syndrome. A multidisciplinary approach with good communications among specialists, neuroaxial block for patients who have moderate thrombocytopenia (low blood platelet count, which causes poor clotting), stress control and speed during intubation for general anesthesia, consideration of invasive techniques, such as tracheostomy and deep-vein canalization, and awareness of increased risk for difficult airways.3 Though spinal anesthesia may be safely administered in parturient patients with HELLP syndrome,4 general anesthesia is more often the modality of choice.4,5 This is particularly true for patients with severe thrombocytopenia and/or eclampsia, which is marked by high blood pressure and seizures.5 Like del-Rio-Vellosillo and Garcia-Medina, Zuccolotto et al.’s case study found success in rapid tracheal intubation due to a difficult airway and the use of drugs for hemodynamic stability.6 As found in a study by Wang et al., these strategies—plus blood transfusion, diuresis and anticoagulation—helped a patient with HELLP who had comorbid renal dysfunction and coagulopathy.7 After surgery, an anesthesia provider must also monitor the patient closely for possible hemorrhage, disseminated intravascular coagulation (DIC; i.e., blood clot accumulation and decreased platelet count) or eclampsia.3 The delicate state of a patient with HELLP requires an anesthesia provider to use alternative techniques and provide high-quality monitoring.

HELLP syndrome is a pregnancy-related disease marked by hemolysis (the breaking down of red blood cells), elevated liver enzymes and low platelet count. Anesthesia providers are crucial to the care of a patient with HELLP syndrome who is undergoing induced labor or Cesarean section. HELLP syndrome includes unpleasant symptoms that range from headache to seizures, and it can be difficult to diagnose. It is anesthesiology professionals’ duty to assess patients for signs of HELLP and to use a multidisciplinary anesthetic approach, with emphasis on hemodynamic stability and possible difficult intubation. After a procedure, the anesthesia provider must monitor the patient for possible hemorrhage, coagulopathy and eclampsia. Future research should investigate the advantages and disadvantages of using local or general anesthesia for patients with HELLP syndrome.

1.         Preeclampsia Foundation. HELLP Syndrome. Health Information January 3, 2019;

2.         March of Dimes. HELLP Syndrome. Pregnancy Complications February 2019;

3.         del-Rio-Vellosillo M, Garcia-Medina JJ. Anesthetic considerations in HELLP syndrome. Acta Anaesthesiologica Scandinavica. 2016;60(2):144–157.

4.         Hupuczi P, Rigo B, Szabo G. Anaesthetic management of HELLP syndrome (haemolysis, elevated liver enzymes, low platelets): A-700. European Journal of Anaesthesiology (EJA). June 2006;23:181.

5.         Başaran B, Çelebioğlu B, Başaran A, Altınel S, Kutlucan L, Martin JN, Jr. Anesthetic practices for patients with preeclampsia or HELLP syndrome: A survey. Journal of the Turkish German Gynecological Association. 2016;17(3):128–133.

6.         Zuccolotto EB, Pagnussatt Neto E, Nogueira GC, Nociti JR. Anesthesia in pregnant women with HELLP syndrome: case report. Brazilian Journal of Anesthesiology (English Edition). 2016;66(6):657–660.

7.         Wang J, Wang N, Han W, Han Z. Anesthetic management of a parturient with hemolysis, elevated liver enzyme levels, and low platelet syndrome complicated by renal insufficiency and coagulopathy. Anesthesia: Essays and Researches. 2017;11(4):1126–1128.

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