This handout is for hellp syndrome with severe htn + eclampsia overlap (peripartum htn crisis). Your care team identified this based on: bp ≥160/110 in pregnancy/postpartum + hellp triad on labs (plt <100k, ast/alt >70, ldh >600) — acog 2020.
Other reasons your team may use this plan: mississippi/tennessee hellp triad: hemolysis (ldh >600 + schistocytes + ↑indirect bili) + transaminitis (ast/alt >70) + thrombocytopenia (plt <100k) — sibai pmid 15467566; new ruq or epigastric pain in pregnancy/postpartum + htn — concern for hellp / hepatic capsular distension / subcapsular hematoma; seizure on background of pre-eclampsia + hellp labs → eclampsia-hellp overlap (highest maternal mortality phenotype).
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| labetalol | 20 mg IV → 40 mg → 80 mg q10 min (max 300 mg cumulative) | IV | bolus | ACOG 2020 first-line; safe in pregnancy + HELLP; CHIPS PMID 25629739 supports tight BP control |
| hydralazine | 5-10 mg IV q15-20 min (max 30 mg cumulative) | IV | q15-20 min | ACOG 2020 alternative; safe in pregnancy + HELLP |
| nifedipine | 10-20 mg PO immediate-release, repeat in 30 min if no response (max 50 mg/h) | PO | q30 min × 2 then q4-6h | ACOG 2020 first-line oral option; monitor for hypotension with concurrent MgSO4 |
| magnesium sulfate | 4-6 g IV load over 20 min then 1-2 g/h infusion | IV | continuous | MAGPIE PMID 12053139 + Lucas PMID 7494569 — primary anti-seizure prophylaxis + treatment per ACOG 2020; goal Mg 4.8-8.4 mg/dL; reflex + RR + UOP q1h |
| lorazepam | 2-4 mg IV | IV | PRN seizure breakthrough on MgSO4 | Adjunct AED for refractory seizures on MgSO4; consider levetiracetam if recurrent |
| dexamethasone | 10 mg IV q12h × 2-4 doses (debated benefit) | IV | q12h | Antenatal corticosteroid for fetal lung maturity if <34 wk (Class I); maternal dexamethasone for HELLP plt recovery debated — Cochrane meta (Woudstra 2010) shows small plt rise but no maternal mortality benefit; Mississippi protocol uses; consider when delaying delivery 24-48h benefits fetus |
| metoprolol | 25 mg PO BID titrate (postpartum only — not first-line antepartum) | PO | BID | Postpartum oral BB; AVOID atenolol antepartum (FGR association); metoprolol acceptable postpartum + during lactation (compatible) |
| platelet transfusion (1 unit pheresis = 6-pack) | Goal plt >50K for vaginal delivery, >80K for C-section; transfuse if plt <20K (any bleeding) OR <50K + active bleeding/surgery | IV | pre-procedure or active bleed | ACOG 2020; Sibai PMID 15467566 — platelet support drives delivery safety in Mississippi class 1 |
| FFP + cryoprecipitate (DIC support) | FFP 10-15 mL/kg if INR >1.5 + bleeding; cryo 10 units if fibrinogen <100 | IV | as bleeding/INR/fibrinogen dictates | DIC overlap occurs in ~20% severe HELLP; replacement protocol per OB hemorrhage standards |
| AVOID ACE inhibitors / ARBs antepartum | AVOID | N/A | N/A | Fetotoxic — oligohydramnios, renal dysgenesis, lung hypoplasia, IUGR; FDA Pregnancy Category D; ACOG Class III antepartum. Postpartum: enalapril/captopril lactation-compatible if needed. |
| AVOID nitroprusside in pregnancy | AVOID | N/A | N/A | Cyanide crosses placenta → fetal toxicity; ACOG 2020 AVOID |
| AVOID atenolol in pregnancy | AVOID | N/A | N/A | FGR association in 1st-trimester exposure; use labetalol or metoprolol postpartum if BB needed |
| URGENT DELIVERY (definitive treatment) | Per OB judgment — C-section vs induction based on HELLP class + cervical readiness + fetal status | OR_or_LD | as needed | ACOG 2020 — delivery is curative; Mississippi class 1 → urgent regardless of GA; class 2/3 with stable mom <34 wk → individualized 24-48h steroids then deliver |
Plan: HELLP overlap — pregnancy-safe BP control + MgSO4 + platelet/FFP/cryo transfusion + URGENT DELIVERY
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
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)
Guideline: ACOG Practice Bulletin 222 (2020/2022) Severe Pre-eclampsia + HELLP + 2025 ACC/AHA HTN (Whelton) + ESC/ESH 2024 HTN (Mancia PMID 38613493) + Sibai HELLP review (PMID 15467566)