Are Clinical Symptoms More Predictive Than Laboratory Parameters for Adverse Maternal Outcome in HELLP Syndrome?

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Controversy continues about the diagnosis, management, and prognosis of HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome, in large part because of a lack of standardized diagnostic criteria. The investigators reviewed 61 pregnancies associated with HELLP syndrome that were diagnosed antenatally in the years 2003–2005. All participants had features of preeclampsia/eclampsia as well as evidence of hemolysis (a typical peripheral blood smear, a lactate dehydrogenase level of at least 600 IU/liter, or elevated indirect bilirubin), thrombocytopenia (a platelet count less than 150,000/mm3), and hepatic dysfunction (aspartate aminotransferase [AST] of at least 40 IU/liter and/or an alanine transaminase of 40 IU/liter or greater). The overall incidence of adverse maternal outcomes in this series was 73%. Three women, 5% of the total, died of intracranial bleeding or disseminated intravascular coagulation (DIC). About half the women had eclampsia, and nearly 60% of them had an eclamptic seizure before hospital admission. Compared to women without seizures, eclamptic women had significantly higher rates of headache, visual changes, epigastric pain, and nausea and vomiting. Women whose platelet counts were less than 50,000/mm3 were nearly 4-fold likelier to have eclampsia, but this was not a statistically significant association. Abruption occurred in 7 (11%), acute renal failure in 9 (15%), and DIC in 5 (8%), but neither laboratory nor clinical abnormalities distinguished between women with and those without these complications. The transfusion rate was significantly increased in women whose platelet counts were 50,000/mm3 or less. Adverse outcomes were similar in women whose peak AST was more or less than 150 U/liter. In this population of women diagnosed with HELLP syndrome before delivery, clinical symptoms predicted adverse maternal outcomes more accurately than did abnormal laboratory findings.