Aggressive versus conservative management of HELLP syndrome--a status assessment

Abstract

The HELLP syndrome is a severe and life-threatening form of preeclampsia associated with typical laboratory findings. The major problems are the fluctuating course of the disease, the unpredictable occurrence of severe maternal complications and the high maternal and perinatal mortality. Time-limited reversal of the laboratory parameters has been observed in 20-40% of cases; however, the majority of patients shows a deterioration of the disease within 1-10 days. As no reliable clinical and laboratory indicators exist, as well as no precisely defined cut-off values in predicting the course and prognosis, the outcome of the HELLP syndrome is unpredictable. The high maternal morbidity and mortality are mainly due to the development of disseminated intravascular coagulation (DIC); the frequency of DIC has been shown to increase significantly with the time interval between diagnosis and delivery. The management of the HELLP syndrome has been controversial, with some authors recommending a conservative approach to induce fetal maturity in pregnancies below the 32nd (34th) week of gestation, whereas the majority recommend immediate delivery by Caesarean section in patients with an unfavourable cervix irrespective of the gestational age. It is generally agreed that early diagnosis by laboratory screening methods is mandatory and that patients with the HELLP syndrome should be transferred to a perinatal centre. A literature review since 1990 clearly demonstrates that aggressive management is associated with a significant reduction in maternal and perinatal mortality. We believe that conservative management is only justified in cases of fetal immaturity under the following conditions: no evidence of progression of the disease, no suspected or manifest DIC, fetal wellbeing and intensive monitoring of the patient in a specialised obstetric care unit cooperating closely with experienced neonatologists and anaesthesiologists.