HELLP syndrome !

HELLP syndrome is a severe pregnancy complication with broken red cells, liver injury and low platelets, usually linked to preeclampsia.

Updated 2026-11-01

Structures involved

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Why it happens

What it is

A severe form of the preeclampsia spectrum defined by three laboratory findings: Haemolysis, Elevated Liver enzymes and Low Platelets. It usually appears in the third trimester or in the first days after delivery, and up to a fifth of cases have little or no hypertension or proteinuria at first.

Who gets it

Complicates a small fraction of all pregnancies (well under 1%) but a notable share of women with severe preeclampsia or eclampsia. Hypertensive disorders of pregnancy are among the leading direct causes of maternal death worldwide and in Latin America, where HELLP is a frequent reason for admission to obstetric intensive care.

Causes

Part of the preeclampsia spectrum: placental disease with widespread maternal endothelial injury
Can begin postpartum, usually within 48 hours of delivery

Risk factors

Preeclampsia, especially with severe features, and eclampsia
Previous HELLP syndrome or preeclampsia
Multiparity and older maternal age (unlike classic preeclampsia, not mainly first pregnancies)
Multiple pregnancy
Chronic hypertension, diabetes, kidney disease and antiphospholipid syndrome

Pathophysiology

A poorly perfused placenta releases anti-angiogenic factors that damage the maternal endothelium. Platelets are activated and consumed on the injured vessel walls, red cells are fragmented as they pass through fibrin-lined small vessels (microangiopathic haemolysis), and fibrin deposits with periportal necrosis in the liver raise transaminases. Swelling under the liver capsule causes right upper quadrant pain and can lead to subcapsular haematoma or rupture.

Classification

Complete HELLP (all three components) versus partial HELLP (one or two)
Tennessee criteria: platelets ≤100,000/µL, AST ≥70 U/L, LDH ≥600 U/L or evidence of haemolysis
Mississippi classes 1–3 by the lowest platelet count (class 1 is the most severe)

Symptoms and signs

Right upper quadrant or epigastric pain, often the first complaint
Nausea, vomiting and malaise that can look like a viral illness
Headache and visual disturbances
Raised blood pressure and proteinuria in most, but not all, women
Oedema, and occasionally jaundice or bleeding from gums or puncture sites

Diagnosis

Clinical: Suspected in any pregnant or recently delivered woman with right upper quadrant or epigastric pain, nausea or malaise, especially with preeclampsia; it is confirmed by laboratory tests, not by symptoms.
Tests: Complete blood count with platelets and blood smear (schistocytes); LDH, bilirubin and haptoglobin for haemolysis; AST and ALT; creatinine, uric acid and urine protein; coagulation tests and fibrinogen to detect DIC; glucose to help separate it from acute fatty liver of pregnancy. Tests are repeated frequently because values can change within hours.
Imaging: Liver ultrasound or CT when pain is severe, persistent or accompanied by shock, to look for subcapsular haematoma or rupture. Obstetric ultrasound and fetal monitoring assess fetal well-being.

Differential diagnosis

Acute fatty liver of pregnancy (more hypoglycaemia, coagulopathy and liver failure)
Thrombotic thrombocytopenic purpura and haemolytic uraemic syndrome
Immune thrombocytopenia and gestational thrombocytopenia
Viral hepatitis, cholecystitis and acute pancreatitis
Intrahepatic cholestasis of pregnancy and gastroenteritis

Goal of treatment

Stabilise the mother, prevent seizures, control severe hypertension, correct coagulation problems and plan delivery, which is the only definitive treatment.

Treatment

Acute: Admit to a facility with obstetric, intensive care, blood bank and neonatal services; assess airway, blood pressure, bleeding and fetal status.
Medical: Magnesium sulfate for seizure prophylaxis and intravenous or oral antihypertensives (such as labetalol, hydralazine or nifedipine) for severe-range blood pressure.
Medical: Antenatal corticosteroids for fetal lung maturity when the pregnancy is preterm and the mother is stable enough for a short delay.
Procedure: Delivery after stabilisation, usually promptly from 34 weeks or whenever the mother or fetus deteriorates; platelet and blood product transfusion as needed, particularly before caesarean section.
Surgical: Emergency laparotomy with a surgical team for a ruptured liver haematoma.
Follow-up: Nursing priorities: frequent blood pressure, reflexes, respiratory rate and urine output while on magnesium; watch for bleeding and new abdominal pain; serial labs; strict fluid balance; continuous fetal monitoring; continued close monitoring for at least 48 hours postpartum.

Complications

Disseminated intravascular coagulation and placental abruption
Acute kidney injury
Pulmonary oedema and acute respiratory distress syndrome
Subcapsular liver haematoma and liver rupture
Eclampsia and stroke
Preterm birth, fetal growth restriction, stillbirth and maternal death

Prognosis

Laboratory values usually worsen for a day or two after delivery and then recover within days; most women recover fully. Maternal mortality is low with timely delivery and intensive care but rises sharply with liver rupture or DIC. Perinatal outcome depends mainly on gestational age at delivery. The risk of preeclampsia or HELLP in future pregnancies is increased.

Prevention

Regular antenatal care with blood pressure checks and attention to new upper abdominal pain
Low-dose aspirin from early pregnancy for women at high risk of preeclampsia
Early referral and laboratory testing in women with preeclampsia

Test yourself

Think of the answer, then tap the question to see it.

What does the acronym HELLP stand for?

Haemolysis, Elevated Liver enzymes and Low Platelets.

What is the most common presenting symptom?

Right upper quadrant or epigastric pain, often with nausea and malaise.

What is the definitive treatment of HELLP syndrome?

Delivery after the mother has been stabilised.

Which finding on the blood smear supports haemolysis in HELLP?

Schistocytes (fragmented red cells), together with raised LDH and bilirubin and low haptoglobin.

Which life-threatening complication presents with sudden shoulder-tip pain and shock?

Rupture of a subcapsular liver haematoma.

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Educational information, not medical advice. For any symptom, see a health professional.

Sources: HELLP syndrome (MedlinePlus (U.S. National Library of Medicine), 2024); Maternal mortality (World Health Organization, 2025).

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Representative model, for educational purposes only.

Liver highlighted on the Durgical 3D model