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cardio.hypertensive-emergency.eclampsia-hellp-overlap.v1

HELLP syndrome with severe HTN + eclampsia overlap (peripartum HTN crisis)

cardiologyacuteadultpregnancyacuteinpatienttransitionoutpatient
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Phase E variant of cardio.hypertensive-emergency.core.v1 — narrowed to HELLP syndrome with severe HTN + eclampsia overlap (peripartum HTN crisis, highest mortality phenotype). Inherits HTN-emergency framework + sister eclampsia variant regimen; specializes for HELLP triad (plt <100K + AST/ALT >70 + LDH >600 + schistocytes) + Mississippi class staging + transfusion support (plt/FFP/cryo) + URGENT DELIVERY. Watches for subcapsular liver hematoma (mortality ~60% if rupture), DIC overlap (~20%), AKI, postpartum cardiomyopathy unmasked by fluid shifts. Manifest pointer reuses cardio.hypertensive-emergency.core.v1 manifest. Design-brief pointer reuses parent (HELLP-specific differences documented inline). Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-15 by shard-06-cardio-acute as part of HTN emergency Phase E variant batch wave 16.

Entry points (4)

  • vital_abnormality
    BP ≥160/110 in pregnancy/postpartum + HELLP triad on labs (plt <100K, AST/ALT >70, LDH >600) — ACOG 2020
    sbp_ge_160_or_dbp_ge_110_with_hellp_labs
  • lab_abnormality
    Mississippi/Tennessee HELLP triad: hemolysis (LDH >600 + schistocytes + ↑indirect bili) + transaminitis (AST/ALT >70) + thrombocytopenia (plt <100K) — Sibai PMID 15467566
    hellp_lab_triad
  • symptom
    New RUQ or epigastric pain in pregnancy/postpartum + HTN — concern for HELLP / hepatic capsular distension / subcapsular hematoma
    ruq_or_epigastric_pain_in_pregnancy
  • symptom
    Seizure on background of pre-eclampsia + HELLP labs → eclampsia-HELLP overlap (highest maternal mortality phenotype)
    eclampsia_seizure_with_hellp

Required inputs (13)

  • agerequired
    demographic • used at CONTEXT
    Maternal age extremes (<20 or >35) increase HELLP severity + complication risk
  • pregnancy_gestational_agerequired
    history • used at CONTEXT
    Gestational age + HELLP class drives delivery urgency (Mississippi class 1 → expedited delivery regardless of GA; class 2/3 with stable mom → consider steroids 24-48h if <34 wk)
  • sbprequired
    vital • used at TREATMENT
    Goal SBP <160 within 30-60 min (ACOG 2020); preserve placental perfusion (avoid <130/80)
  • dbprequired
    vital • used at TREATMENT
    Goal DBP <110 within 30-60 min (ACOG 2020)
  • plateletsrequired
    lab • used at INITIAL_WORKUP
    HELLP severity classification (Mississippi class 1: <50K; class 2: 50-100K; class 3: 100-150K). <50K + bleeding/surgery → platelet transfusion before delivery
  • ast_altrequired
    lab • used at INITIAL_WORKUP
    AST/ALT >70 confirms HELLP transaminitis component; >2× ULN = severe feature; rising trend signals worsening disease
  • ldhrequired
    lab • used at INITIAL_WORKUP
    LDH >600 confirms hemolysis component of HELLP (Mississippi); >1400 indicates severe hemolysis with high adverse outcome risk
  • peripheral_smearrequired
    lab • used at INITIAL_WORKUP
    Schistocytes on smear confirm microangiopathic hemolytic anemia (MAHA) — distinguishes HELLP from acute fatty liver of pregnancy (AFLP) + TTP/HUS overlap
  • creatininerequired
    lab • used at INITIAL_WORKUP
    AKI (Cr ≥1.1 or doubling) — HELLP-AKI common; drives nephrology consult + transfusion timing + HD decision
  • fibrinogenrequired
    lab • used at INITIAL_WORKUP
    Fibrinogen <300 + platelet drop → DIC overlap (occurs in ~20% severe HELLP); cryo + FFP for delivery preparation
  • magnesium_levelrequired
    lab • used at MONITORING
    Goal 4.8-8.4 mg/dL during MgSO4 infusion; reflex + RR + UOP check q1h
  • fetal_heart_rate_monitoringrequired
    imaging • used at MONITORING
    Continuous fetal monitoring — non-reassuring tracing in HELLP often heralds placental insufficiency / abruption
  • liver_us_or_ct
    imaging • used at BRANCHING_WORKUP
    Imaging if RUQ pain + HELLP — rule out subcapsular hematoma (life-threatening; mortality ~60% if rupture); US first then CT/MRI per stability

12-phase flow (10)

  1. 1FRAME
    HELLP overlap = pregnancy/postpartum + severe HTN + Hemolysis (LDH >600 + schistocytes) + Elevated Liver enzymes (AST/ALT >70) + Low Platelets (<100K) ± eclampsia. Mississippi class 1 (plt <50K) is highest mortality phenotype. Pregnancy-safe drug profile (labetalol/hydralazine/nifedipine + MgSO4) per ACOG 2020. URGENT DELIVERY is definitive treatment. Watch for subcapsular liver hematoma + DIC + AKI + abruption.
    inputs: sbp, dbp, platelets, ast_alt, ldh
    advance: HELLP overlap phenotype confirmed + Mississippi class assigned
  2. 2ENTRY
    Recognize HELLP triad on labs + severe HTN + pregnancy/postpartum; activate OB + anesthesia + neonatology + hematology + intensivist; type & cross 4 units + platelets
    inputs: age, sbp, dbp, pregnancy_gestational_age
    advance: multidisciplinary team activated + transfusion products mobilized
  3. 3CONTEXT
    Gestational age, prior HELLP/pre-eclampsia, antiphospholipid syndrome (PMID 16505467 sister-engine), CKD, multiple gestation, IVF, family history, obesity, AFLP differential
    inputs: age, pregnancy_gestational_age
    advance: context complete + AFLP/TTP/HUS differential considered
  4. 4RED_FLAGS
    Subcapsular liver hematoma (sudden RUQ pain + shock + hemoperitoneum), eclampsia seizure on background HELLP, DIC progression, postpartum cardiomyopathy unmasked by fluid shifts, placental abruption, refractory HTN
    inputs: platelets, fibrinogen
    actions: htn_emergency
    advance: red flags screened + delivery urgency tier set
  5. 5INITIAL_WORKUP
    CBC + smear + LDH + indirect bili (hemolysis), AST/ALT (transaminitis), plt + fibrinogen + INR/PTT + D-dimer (DIC), BMP (AKI), urine protein, type & cross + platelet crossmatch, fetal monitoring, US for fetal/placental + maternal liver assessment
    inputs: platelets, creatinine, ast_alt, ldh, peripheral_smear, fibrinogen
    actions: panel.cardiac, panel.renal
    advance: workup documented + Mississippi/Tennessee class assigned
  6. 6BRANCHING_WORKUP
    Mississippi class 1 (plt <50K + AST/ALT >70 + LDH >600) → urgent delivery regardless of GA; class 2/3 with stable mom + GA <34 wk → individualized 24-48h steroids + delivery; RUQ pain + hypotension → STAT US/CT for subcapsular hematoma; AFLP differential (hypoglycemia + ammonia + INR — Swansea criteria)
    inputs: pregnancy_gestational_age, platelets, liver_us_or_ct
    advance: delivery plan + transfusion plan + imaging plan finalized
  7. 7TREATMENT
    IV labetalol 20 → 40 → 80 mg q10 min (max 300 mg) FIRST-LINE per ACOG 2020 OR IV hydralazine 5-10 mg q15-20 min OR nifedipine 10-20 mg PO. Goal SBP <160 + DBP <110 within 30-60 min; AVOID below 130/80 (placental perfusion). MgSO4 4-6 g IV load + 1-2 g/h infusion (MAGPIE PMID 12053139; Lucas PMID 7494569). Platelet transfusion if <50K + bleeding OR <20K OR pre-surgery (target plt >50K for vaginal, >80K for C-section). FFP + cryo if DIC + fibrinogen <100. Corticosteroids debated — small benefit for plt recovery per Lancet meta but no maternal mortality reduction (Woudstra Cochrane 2010). URGENT DELIVERY is definitive.
    inputs: sbp, dbp, platelets, fibrinogen
    advance: BP at target + MgSO4 loaded + delivery underway + transfusion ready
  8. 8DISPOSITION
    OR for emergent C-section if Mississippi class 1 / non-reassuring fetal status / abruption / hepatic hematoma; L&D if induction feasible + class 2/3 + favorable cervix; ICU postpartum for HELLP class 1 / DIC / AKI / postpartum cardiomyopathy
    advance: unit assigned + delivery in motion
  9. 9MONITORING
    q5-15 min BP; continuous fetal monitoring antepartum; q1h reflex+RR+UOP during MgSO4; q4-6h CBC + LFTs + Cr + LDH + fibrinogen until trending toward recovery; daily liver imaging if hematoma noted; postpartum echo if PPCM concern (BP shifts may unmask)
    inputs: sbp, magnesium_level, platelets, fetal_heart_rate_monitoring
    actions: panel.renal
    advance: BP at target + HELLP labs trending down + delivery completed
  10. 10FOLLOWUP
    Postpartum: HELLP labs typically peak 24-48h postpartum then recover by day 5-7; continue MgSO4 24h post-delivery; HTN often persists 1-2 wk postpartum (40% have chronic HTN at 1 yr); switch to PO labetalol/nifedipine; AVOID ACEi/ARB until lactation considerations addressed (enalapril/captopril lactation-compatible); 1-2 wk + 6-wk postpartum BP check; 3-mo cardiology + nephrology assessment; lifetime CV risk discussion (Bellamy BMJ 2007)
    advance: postpartum oral regimen + 1-2 wk follow-up booked + lifetime CV risk educated