SECTION I

INTRODUCTION

The term HELLP syndrome is used to describe preeclampsia in association

with hemolysis, elevated liver enzyme levels, and low platelet count. This
syndrome is a life-threatening condition that can potentially complicate
pregnancy. It is found in about 10% of pregnancies complicated by severe
preeclampsia. The diagnosis is not always clear, and the syndrome may be
confused with other medical conditions. Any patient diagnosed with HELLP
syndrome should be considered to have severe preeclampsia.
The HELLP syndrome was once known as edema-proteinuria-hypertension
gestosis type B in the early 20 th century and was later renamed in 1982 by Louis
Weinstein. Although the idea is controversial, some propose that HELLP is a
severe form of pre-eclampsia, which, in turn, is defined as gestational
hypertension accompanied by proteinuria after the 20th week of gestation. Other
believe that HELLP syndrome is an entity of itus own. Although the cause of
HELLP syndrome is unknown, certain risk factors, including a maternal age of
older than 34 years, multiparity, and European descent.

SECTION II
CASE
I.

II.

Identity
Name
: Mrs. E
Age
: 29 years old
Address
:Mekarwangi
Ethnic
: Sunda
Religion
: Moslem
Education
: Junior High School
Job
: Housewife
Date of Admission
: August,17th 2016
Anamnesis
A. Chief Complaint
The patient came to hospital due to pain at pit of the stomach since 6
hours before admission to the hospital.
B. History of Present Illness
The patient came to hospital on August, 17 th 2016 due pain at pit of the
stomach since 6 hours before admission to the hospital. The patient
also complain pain during urinate and the color of her urine became
red 8 hours before admission. The patient also complain that she felt
dizziness and the fetus movement has been feel.
C. History of Past Illness
History of Hypertension
History of Diabetes Mellitus
History of Allergy
History of Hematologic Disease
History of Urinary tract/Kidney Disease
History of Trauma
History of Surgery
D. History of Family Illness
History of Hypertension
History of Diabetes Mellitus
History of Allergy
E. Menstrual Cycle
Age of Menarche : 14 years old

: denied
: denied
: denied
: denied
: denied
: denied
: denied
: denied
: denied
: denied

Menstrual Cycle: irregular, with duration 5-6 days, using 2 sanitary

napkins per day, dysmenorrhea (-)

Menopause : (-)
Contraception History : injection contraception.
F. Marital History
Married once, been together with her husband for 1 years.
G. Obstetry History
No
1
2

Gender
Male
This Pregnancy

Age
9 years
38-39

Labor History
Midwife

Years
2007
2016

weeks
III.

Physical Examination
A. General Status
General Condition
Level of Consciousness
Vital Signs
o Blood Pressure
o Heart Rate
o Respiraatory Rate
o Temperature
o Body Weight
o Body Height
B. General Examination
Mata
o Anemic conjunctiva
o Icteric sclera
o Pupil
o Light reflex
Thorax
o Cardiac
o Pulmo
o Mammae

: moderately ill condition

: compos mentis
: 140/90 mmHg
: 90 bpm
: 22 times per minute
: 36,3o C
: 59 kilograms
: 149 cm

: -/: -/: 3mm/3mm

: +/+
: regular S1&S2 heart sound,
murmur (-), gallop (-)
: Vesicular +/+, ronchi -/-, wheezing : areola hyperpigmentation +/+,

nipple retraction -/-, breast milk -/Abdomen

o Inspection
: convex

o Palpation

: pain at pitch of stomach, tenderness

(+)
o Percussion
o Auscultation
Extremities
o Edema
o Physiologic reflex
o Pathologic reflex

: tympanic at all quadrant

: bowel sound (+) 8 times per minute
: -/: +/+/+/+
:-

Obstetri examination

: November, 15th 2015

: October, 22th 2016
: 27 cm
:+
: 138 bpm

Last menstrual period

EDD
Fundal height
His
Fetal heart rate

Leopold Maneuver
Leopold I

: buttock

Leopold II

: back on the left of mother side

Leopold III

: Head

Leopold IV

: convergent, 5/5

Vaginal toucher

IV.

Inspection
Palpation
Inspeculo

:
: blood (+)
: portio thick and soft
: -V/V: fluxus (-), fluor (-)
- Portio: mass (-), fluxus (+),

lateration (-)
Internal
Vaginal
Examination
:

- Portio : thick and soft, bleed (+), cervical dilatation 1 cm

- V/V : vaginal abnormality (-), fluxus (-), fluor (-)
Diagnostic Testing Results

Hematology

August,

August,

August,

August,

Unit

Normal

17th 2016 17th 2016 18th 2016 18th

05.54
Hemoglobin
Leukocyte
Hematocrite
Trombocyte
Eritrocyte
MCV
MCH
MCHC

22.08

13.1
21,100

11.3
10,300

39
146,000

32
67,000

4.0
91
32
35

3.6
89
32
36

Value

08.27

2016

11.9
14,300

16.47
7.5
20,100

34
56,000

21
42,000

3.8
89
32
36

2.4
88
31
36

g/dL
/L

12-14
4,000-

%
/L

10,000
37-47
150,000-

juta/L
fL
pg
g/dL

450,000
3.8-5.2
80-100
26-34
32-36

Laboratory Test ( August, 17th 2016 )

Laboratory Test
Complete Urine
Color

Results

Unit

Normal range

Dark

Yellow

Clarity
Protein

yellow
Turbid
Pos
(++

Clear
Negatif

Erytrosit

+/500)
Pos
(++

Negatif

+/500)
Urine Microscopic
Eritrosit

35-40

<3

Clinical

August,

August,

Unit

Normal

Chemistry
Blood

17th 2016
88

18th 2016
97

mg/dL

Value
<140

Glucose
Liver Function
AST
418.8

250

U/I

<31

(SGOT)
ALT

115

U/I

<32

DUPLO
144

(SGPT)
DUPLO
Kidney Function
Urea
30.2
Creatinine
0.53
Electrolyte
Natrium
135
Kalium
4.4
Calcium
7.4
Cloride
108

48
0.77

mg/dL
mg/dL

15-36
0.52-1.04

130
4.7
8.4
100

mmol/L
mmol/L
mg/dL
mmol/l

137-150
3.5-5.5
8-10.4
94-108

Laboratory result (August, 17th 2016)

HEMOSTASIS
Bleeding time
Clotting time

Result
2.00
7.30

Unit
minute
minute

Normal value
1-3
5 - 15

Laboratory result (August, 18th 2016)

IMUNOSEROLOGI
MHepatitis Marker
HBsAg Kualitatif

V.

Result
Non reaktif

Normal Value
Non Reaktif

Resume
Mrs. E, 29 years old came to hospital due pain at pitch of the
stomach since 6 hours before admission to the hospital. The patient also
complain pain during urinate and the color of her urine became red 8 hours
before admission, dizziness and the fetus movement has been feel.
The examination found that the patient with moderate illness
appearance, vital sign when she came to the hospital show severe
preeclampsia. The physical examination has show there are pain and
tenderness at pitch of the stomach. Obstetrical examination has show
fundal height 27 cm and the fetal heart rate was 138 beats per minute. The
laboratory studies show anemic condition, thrombocytopenia and elevated
of liver enzymes.

VI.

Diagnosis
G2P1A0, 29 years old, gravid 38-39 weeks, with HELLP Syndrome.

VII.

Therapy
August,

17th 10.15

2016 06.45
RL+MgSO4

Metildopa

21.40

RL 500 cc + RL
MgSO4 20%

10 gr
Dopamet 3x2
Nifedipine

August,

MgSO4

20% 10 gr

2016 05.30
RL

Dopamet

O2
Dopamet

3x2
Nifedipine 3x1

18th

3x2
Nifedipine
2x1

3x1

VIII. Labor Progress History

August, 17th 2016 21.50

FHT: 143x/m
VT: v/v no abnormalities, portio thick
and thin 4cm, fetal membrane +,

August, 18th 2016

11.10
11.19
11.20

head presentation H1.

- completed, head at N III/IV, FHR
136 x/m, the mother lead to strain
- the baby was delivery ak A5 3/5
defect
- the placenta is birth spontaneous
complete, the perineum is intact, give
oxytocin, the bleeding is minimal, the
contraction is strong.

IX.

Follow Up

August, 17th 2016 08.15

S
Pain at pitch of the stomach
O
GA: moderate ill appearance

BP: 160/100
HR: 84
RR: 22
T: 36.2
LI: buttock, fundal height 27 cm
LII: back on the mother right side, FHR: 138 x/m
LIII: head
LIV: convergent
PD: v/v no abnormality, portio thick and thin, d 1 cm, fetal membrane +, head
presentation
HPHT: 15-11-15 TP: 28-08-2016
Lab: Ht 13,1 Leu: 21,10 Ht: 39 Trom: 146.000
UL: protein +3 CTG reaktif
Mrs. E 29 years old gravida aterm + severe pre-eclampsia
- Observation of general condition and vital sign
- Given informed consent to the family about mother and her

A
P

baby

August, 17th 2016 10.55

S
Pain in the stomach
O
GA: moderate ill appearance

LoC: Compos mentis

BP: 160/100
HR: 84x/m
RR: 21x/m
T: 34 C
FHR: 140 x/m
VT: v/v no abnormalities, portio thick and thin 3 cm, fetal membrane +,

head presentation H1
Leopold I: Fundal height: 27 cm
Leopold II: back at the left of mother side
Leopold III: head
Leopold IV: divergent
Mrs. E 29 years old G2P1A0 parturien aterm kala 1 latent phase + severe pre-

eclampsia.
GA: moderate ill appearance
BP: 160/100

HR: 84 x/m
RR: 21 x/m
T: 36C
FHR: 140 x/m
contraction: rare
dr. Ariefs advice: observation of FHR and contraction

August, 17th 2016 16.00

S
Dizziness decrease, pain in the stomach is rare
O
GA moderate ill appearance
Level of consciousness: compos mentis
BP: 140/90 mmHg
HR: 99 x/m
RR: 22 x/m
Leopold I: 27 cm, FHR: 143 x/m
Leopold II: back at the left of mother side
Leopold III: head
Leopold IV: divergent
VT: v/v no abnormalities, portio thick and thin 2-3 cm, fetal membrane +,
head presentation H1
Infused: RL 20 gtt + MgSO4 20% 10 gr
DC +
A

Mrs. E 29 years old G2P1A0 parturien aterm kala 1 active phase + severe pre-

eclampsia
Observation general appearance + vital sign
Observation fetal heart rate
Dr. Ariefs advice: observation contraction and labor progress

Informed consent to the family about condition of mother and her baby.
Take blood sample
Given dopamet

August, 18th 2016 08.30

S
Dizziness, pain in the stomach
O
GA: moderate ill appearance
Level of consciousness: compos mentis
BP; 160/100 mmHg
HR: 91 x/m
FHR: 132 x/m
VT: v/v no abnormalities, portio thick and thin almost complete
Fetal membrane +, head presentation + H1
A
P

O2 +, infuse +, DC +
Mrs. E 29 years old G2P1A0 parturien aterm kala 1 active phase + PEB
Observation general appearance and vital sign
Observation labor progress
Drip oxytocin 20 gtt
dr. Ismus advice: re-infeormed consent
transamin 3x1 amp
dexamethasone 3x1 amp
termination with drip oxytoscin 20 gtt

August, 18th 2016 12.00

S
The pain is decrease
O
BP: 140/90 mmHg
HR: 80 x/m
RR: 20 x/m
T: 36C
Bleeding is little, contraction is strong

A
P

Mrs. E 29 years old P2A0 post partus pervaginam

Observation vital sign and bleeding

August, 18th 2016 15.30

S
Pain in the stomach after labor
O
GA: moderate
Level of consciousness:
BP: 140/90
HR: 80x/m
RR: 22 x/m
T: 37,4
Fundal height: 1 finger above umbilical, uterus contraction: strong, bleeding:
P

minimal
Observation GA, vital sign, bleeding
Consult to Internist: dr. Faris, Sp.PD

August, 18th 2016 22.30

S
dizziness
O
GA: moderate ill appearance
LoC: compos mentis
BP: 150/100 mmHg
HR: 92 x/m
RR: 22 x/m
Infuse: 2 line RL, right hand: RL, left hand: RL+oxy 2 amp
TFU: 2 finger under umbilical
A

Bleeding: minimal
Mrs. E 29 years old P 2A0 partus matures per vaginam + HELLP syndrome +

anemia
Observation GA and vital sign
Observation bleeding: 50 cc

Given dopamet, dexamethasone

Transfusion PRC

August, 19th 2016 09.30

S
Pain in the stomach is decrease
O
GA: moderate ill appearance
LoC: compos mentis
BP: 130 x/m
Fundal height: 2 finger under umbilical
Uterus contraction: strong
A

Bleeding: +/N
Mrs. E 29 years old P2A0 partus matures per vaginam with HELLP Syndrome

+ anemia
Observation GA and vital sign
Blood transfusion
Give therapy appropriate schedule

SECTION III
CASE ANALYSIS

Problems:
1. How to diagnose HELLP Syndrome from this case?
2. How is the management for this patient?
3. What are complications of HELLP Syndrome?
1. How to diagnose HELLP Syndrome from this case?
The term HELLP syndrome is used to describe preeclampsia in association
with hemolysis, elevated liver enzyme levels, and low platelet count. It is found in
about 10% of pregnancies complicated by severe preeclampsia. The diagnosis is
not always clear, and the syndrome may be confused with other medical
conditions. Any patient diagnosed with HELLP syndrome should be considered to
have severe preeclampsia. In the past, the diagnostic criteria for HELLP syndrome
were variable and led to inconsistent diagnoses. The newer criteria used for the
diagnosis of HELLP syndrome are those reported by Sibai and include specific

laboratory abnormalities demonstrating hemolysis, elevated liver enzyme levels,

and low platelet count.
The clinical picture of patients with HELLP syndrome is highly variable.
However, in general, patients with HELLP are multiparous white females who
will be diagnosed at less than 35 weeks gestation. The typical symptomatology of
these patients consists of vague complaints, further skewing the diagnosis. A large
percentage of patients will have a history of general malaise for the few days
prior. Other complaints include epigastric or right upper quadrant pain (67%),
nausea or vomiting (30%), and nonspecific viral syndrome like complaints. Thus,
any pregnant woman with suspected preeclampsia who makes these complaints
should undergo a minimum workup of a complete blood count with platelet count
and liver enzyme levels.
Sibai has noted that hypertension may be absent (20%), mild (30%), or severe
(50%) in women diagnosed with HELLP syndrome. Therefore, the diagnosis of
HELLP syndrome cannot necessarily be ruled out in the normotensive patient who
has other signs and symptoms consistent with preeclampsia.

Theory
Symptoms:

In this case
Symptoms:

Headache

Nausea/vomiting/indisgesation

stomach

with pain after eating

(epigastric pain)

Abdominal or chest tenderness

and upper right upper side pain

Shoulder pain or pain when

Pain at pit of the

Dizziness

Physical examinations:
-

BP 160/100

breathing deeply

Laboratory examinations:

Bleeding

- Hematocrit

Changes in vision

- Eritosit

Malaise

- Thrombosit

Swelling

- AST

Physical examinations:

Hypertension

Tachycardia

Tachypnea

- ALT

Laboratory examinations:
Hemolysis
Abnormal peripheral smear
LDH >600 U/L
Bilirubin >1.2 mg/dL
Elevated liver enzymes
Serum AST >70 U/L
LDH >600 U/L
Low platelets
Platelet count <100,000/mm3

2. How is the management for this patient?

The initial evaluation of women diagnosed with HELLP syndrome should be
like that for severe preeclampsia. The patient should be cared for at a tertiary care
center. Management initially should include maternal and fetal assessment;

control of severe hypertension, if present; initiation of MgSO 4 infusion; correction

of coagulopathy, if present; and maternal stabilization. A potentially lifethreatening complication of HELLP syndrome is a subcapsular liver hematoma. If
the suspicion for a subcapsular liver hematoma is high, then it is appropriate to
proceed with obtaining a computed tomography scan.
Immediate delivery should be performed in patients >34 weeks gestation. In
patients less than 34 weeks and without proven fetal lung maturity,
glucocorticoids should be given for fetal benefits and delivery planned in 48 hours
provided no worsening of maternal or fetal status occurs. Multiple studies have
been done using steroids, volume expanders, plasmapheresis, and antithrombotic
agents in patients with HELLP to attempt to prolong gestation. These studies
show only marginal results. Some evidence exists as to the benefit of steroid
therapy for improvement in maternal condition. In a study by O'Brien and
colleagues, the antepartum use of glucocorticoids showed a dose-dependent
prolongation in latency, reduction in liver enzyme abnormalities, and
improvement in platelet count in patients with HELLP syndrome. Five
randomized trials comparing the use of high-dose dexamethasone with either no
treatment or with betamethasone in women with presumed HELLP syndrome. The
results of these studies demonstrate improved laboratory values and urine output
in patients receiving dexamethasone but provide limited evidence of reduced
maternal morbidity. However, because most of these trials were performed
postpartum, the true extent by which glucocorticoids can influence outcomes has
yet to be determined. The suggested recommended doses include 10 mg
intravenous dexamethasone every 6 hours for two doses, then followed with 6 mg

every 6 hours for an additional two doses; the other regimen is 20 mg of

intravenous dexamethasone every 6 hours for four doses.
Conservative management of HELLP syndrome has significant risk,
including abruptio placentae, pulmonary edema, adult respiratory distress
syndrome (ARDS), ruptured liver hematoma, acute renal failure, DIC, eclampsia,
intracerebral hemorrhage, and maternal death. It is the authors' opinion that
expectant management longer than 48 hours after glucocorticoid administration is
not warranted for the potential minimal fetal benefits when weighed against the
profound maternal risk.
If a patient with HELLP syndrome requires cesarean delivery, precautions
should be taken to minimize adverse outcomes. Platelet transfusion of
approximately 5 to 10 U should be done en route to the operating room for
patients with severe thrombocytopenia. Platelet consumption is rapid with a
platelet transfusion, and the effects are temporary. Intraoperative considerations
should include drain placement either subfascial, subcutaneous, or both due to
anticipated generalized oozing. The choice of skin incision should be made
entirely on the surgeon's best clinical judgment. In a study by Briggs and
colleagues, patients with HELLP syndrome undergoing cesarean section were
evaluated for wound complications. No statistical difference was found between
midline incision versus a Pfannenstiel incision, whether primary or delayed
closure.
Another potential life-threatening complication of HELLP syndrome is a
subcapsular liver hematoma. Clinical findings consistent with subcapsular
hematoma include physical examination with peritoneal irritation and

hepatomegaly and referred pain from the phrenic nerve. Pain to the pericardium,
peritoneum, pleura, shoulder, gallbladder, and esophagus are consistent with
referred pain from the phrenic nerve. Confirmation of the diagnosis can be made
by computed tomography, ultrasonography, or magnetic resonance imaging.
Conservative management in a hemodynamically stable patient with an
unruptured subcapsular hematoma is an appropriate plan, provided that close
hemodynamic monitoring, serial evaluations of coagulation profiles, and serial
evaluation of hematoma status by radiologic studies are performed. If the patient
decompensates hemodynamically, the diagnosis of ruptured subcapsular
hematoma should be considered.
Postpartum management of the patient with HELLP should include close
hemodynamic monitoring for at least 48 hours. Serial laboratory evaluations
should be done to monitor for worsening abnormalities. Most patients will show
reversal of laboratory parameters within 48 hours postpartum.

Management for this patient

- MgSO4 20% loading & maintenance dose

3.

Nifedipine 3x1

Dopamet 3x2

Transfusion PRC

Termination of pregnancy: drip oxytocin

What are complications of HELLP Syndrome?

In a multicenter study, Haddad and collague (2000) described 183 women

with HELLP syndrome of whom 40 percent had adverse outcome including two

maternal deaths. The incidence of subcapsular liver hematoma was 1.6 percent,
eclampsia 6 percent, placental abruption 10 percent, acute kidney injury 5 percent
and pulmonary edema 10 percent. Other serious complication included stroke,
coagulopathy, acute respiratory distress syndrome and sepsis.

Preference:
1.

Cunningham F, William J. William Obstetrics. 23th ed. New York: The

McGraw-Hill Companies; 2010.

2.

Gibbs, Ronald S.; Karlan, Beth Y.; Haney, Arthur F.; Nygaard, Ingrid E.
Danforths Obstetrics and Gynecology 10th Edition. California : Lippincott
Williams & Wilkins; 2008.

3.

Dutta DC, Konar H. DC Duttas textbook of Obstetrics 8th ed. New Delhi:
Jaypee Brothers Medical Publisher; 2015.

4.

Tim Penyusun PPK. Panduan Praktik Klinis Obstetri dan Ginekologi.

Bandung : DEP SMF Obstetri & Ginekologi Fakultas Kedokteran Universitas
Padjajaran RSUP Dr. Hasan Sadikin Bandung; 2015.