Patient handout

HELLP Syndrome (Hemolysis / Elevated Liver enzymes / Low Platelets)

PRODUCTION

1. Your condition

This handout is for hellp syndrome (hemolysis / elevated liver enzymes / low platelets). Your care team identified this based on: hellp lab triad: ldh > 600 + ast/alt ≥ 70 + plt < 100 k (sibai 1993 tennessee; sibai 2004 mississippi; acog 222 2020).

Other reasons your team may use this plan: platelets < 100 × 10⁹/l in pregnancy / postpartum (acog 222 severe-feature criterion); hemolysis: ldh > 600 + schistocytes on smear + haptoglobin < 25 mg/dl ± elevated indirect bilirubin (isshp 2024); ast and/or alt ≥ 70 iu/l (≥ 2× uln) antepartum, intrapartum, or postpartum (acog 222 severe-feature criterion).

2. Your medications

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
magnesium sulfate	Load 4–6 g IV over 15–30 min, then 1–2 g/h continuous × 24 h post-delivery (or 24 h post-last-seizure for eclampsia)	IV	continuous	Magpie 2002 (PMID 12057549) — magnesium reduces eclampsia by 58 %; NNT ≈ 100 in severe-features cohort; HELLP-severe-features qualify per ACOG 222

Plan: HELLP severity-driven — magnesium prophylaxis + BP control + antenatal corticosteroids if remote-from-term + delivery per Mississippi class + GA + complications (ACOG 222 + ISSHP 2024)

3. When to call your provider

Contact your care team if any of the following happen:

New severe HTN ≥ 160/110 within 6 wk postpartum → ED for IV antihypertensive + magnesium prophylaxis (ACOG 767 + AHA 2021)
New severe-feature symptoms (HA / vision / RUQ pain) within 6 wk → ED (ACOG 222 postpartum window)
New seizure within 6 wk postpartum → ED for magnesium (late postpartum eclampsia; Magpie 2002 PMID 12057549)
New / persistent thrombocytopenia + hemolysis + AKI postpartum (failure to resolve at 72 h) → hematology / nephrology / MFM for AFLP / TTP / aHUS / SLE flare workup (ISSHP 2024)
EPDS ≥ 13 or active suicidal ideation → urgent perinatal mental health referral (ACOG 757)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

HELLP Mississippi class I — platelet count < 50 × 10⁹/L per Sibai 2004 (PMID 15121574); life-threatening; immediate delivery indication regardless of GA except in glucocorticoid window with strict tertiary-centre monitoring + maternal-fetal stability + no complications(life-threatening)
HELLP + new tonic-clonic seizure (or coma) without alternative neurologic explanation (ACOG 222; Magpie Trial Lancet 2002 PMID 12057549)(life-threatening)
HELLP + placental abruption (painful uterine bleeding ± fetal distress) OR overt DIC (fibrinogen < 200, INR > 1.5, schistocytes, D-dimer markedly elevated) per ACOG 222 + RCOG GTG 52 2016(life-threatening)
HELLP + subcapsular hepatic hematoma or hepatic rupture — RUQ / epigastric pain + falling Hgb + hemodynamic instability (Wicke 2004 PMID 14749644)(life-threatening)
HELLP failure-to-resolve at 48–72 h postpartum (persistent thrombocytopenia + hemolysis + transaminitis OR new AKI worsening) → broaden differential to AFLP / TTP / aHUS / SLE flare / viral hepatitis (ACOG 222 + ISSHP 2024)
HELLP at 24+0 to 33+6 wk gestation + maternal-fetal stable + Mississippi class II/III (NOT class I) + tertiary centre + no complications → 48 h antenatal corticosteroid window (betamethasone 12 mg IM × 2 doses 24 h apart) then deliver OR sooner if deterioration (ACOG 222 + ACOG 713 + Roberts Cochrane 2017 PMID 28321847)
Coombs-negative MAHA + neuro symptoms + renal dysfunction + thrombocytopenia + ADAMTS13 result pending OR < 10 % → rule in TTP rather than HELLP (Scully J Thromb Haemost 2017 PMID 27868334); pregnancy-associated aHUS if persistent postpartum without ADAMTS13 deficiency (Fakhouri 2010 PMID 20203157)
HELLP Mississippi class progression within 24 h: class III → class II (plt 100–150 → 50–100) OR class II → class I (plt 50–100 → < 50), OR rapidly rising AST/ALT > 2× baseline, OR new schistocytes on smear (ISSHP 2024)
Sustained severe HTN ≥ 160/110 refractory to maximum IV bolus antihypertensives (labetalol cumulative 220 mg + hydralazine 30 mg) in HELLP patient → ICU + titratable drip (ACOG 767 + ACOG 222)(life-threatening)
HELLP + AKI (Cr ≥ 1.1 mg/dL OR doubling from baseline OR oliguria < 0.5 mL/kg/h × 6 h OR rising BUN) per ACOG 222 severe-feature criterion + KDIGO 2026 AKI staging

5. Follow-up

BP + lab check 3–7 d postpartum + 1–2 wk + 4–6 wk per ACOG 222; lifetime CV risk follow-up (PE/HELLP doubles future CV risk per AHA 2021); next-pregnancy aspirin 81–150 mg PO daily from 12 wk per USPSTF 2021 (PMID 34581729) given recurrence 19–27 %; preconception counseling re recurrence risk; postpartum BP self-monitoring daily × 1 wk → weekly × 6 wk; psychosocial screen (PPH/HELLP increase PPD/PTSD risk); endocrine-renal review at 6 wk (lipid, fasting glucose / HbA1c, UACR, Cr, BMI per AHA 2021 + ACOG 2025)

6. Sources

Guideline: ACOG Practice Bulletin 222 (2020, reaffirmed 2024) + ACOG 2025 update on severe-features pre-eclampsia management + ACOG 713 antenatal corticosteroids (2017) + ACOG 767 (severe HTN in pregnancy) + NICE NG201 (2023) + ISSHP 2024 (Mol et al; supersedes ISSHP 2021) + Sibai 1993 Tennessee classification + Sibai 2004 Mississippi classification review + Magpie Lancet 2002 + Roberts Cochrane antenatal steroids 2017 + Liggins 1972 betamethasone original + USPSTF aspirin 2021 + ASPRE NEJM 2017 + CHIPS NEJM 2015 + CHAP NEJM 2022 + Ch'ng Swansea AFLP 2002 + Scully ADAMTS13 / TTP consensus 2017 + Fakhouri pregnancy-associated aHUS 2010 + Wicke subcapsular hepatic hematoma in HELLP 2004 + Bauer ASRA neuraxial thrombocytopenia meta-analysis 2020