9 Oct 2026 · Case #034
HELLP syndrome
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Diagnosis
HELLP syndrome
First-line treatment
Delivery, with magnesium sulfate and blood pressure control
How the diagnosis is reached
Upper abdominal pain in the third trimester is the presentation that gets mistaken for indigestion, and the antenatal record is what reframes it: blood pressure rising across successive visits with new proteinuria is pre-eclampsia, and the headache and visual flashes mark it as severe. HELLP is its haematological expression, and all three components are on the sheet. Haemolysis shows as schistocytes with a raised LDH and bilirubin and an unrecordable haptoglobin, the liver enzymes are several times normal, and the platelets are low. The second panel exists to kill the mimics, because each is treated differently. Normal prothrombin time, APTT and fibrinogen exclude disseminated intravascular coagulation, in which the clotting screen is deranged. A negative Coombs excludes autoimmune haemolysis. ADAMTS13 activity well above 10% excludes thrombotic thrombocytopenic purpura, which otherwise looks nearly identical and would need plasma exchange rather than delivery. Normal glucose and ammonia argue against acute fatty liver of pregnancy, where hypoglycaemia and coagulopathy dominate. The right upper quadrant pain comes from stretching of the liver capsule, and its worsening matters: subcapsular haematoma and hepatic rupture are the feared complications. Nothing reverses HELLP except delivery, and at 35 weeks, with platelets down to 58, transaminases still climbing and reduced variability on the trace, there is no argument left for waiting. Magnesium sulfate runs for seizure prophylaxis, and the pressure is brought below 160/110 with labetalol or nifedipine to prevent maternal stroke. Platelets are transfused only if the count falls very low or surgery is planned. The 48 hours after delivery still need watching, because the counts and liver enzymes characteristically worsen before they turn.
Key clinical clues
- Third-trimester upper abdominal pain dismissed as indigestion
- Blood pressure rising across antenatal visits with new proteinuria, headache and visual flashes
- Schistocytes with raised LDH and bilirubin and an unrecordable haptoglobin
- Transaminases several times normal while the clotting screen stays normal, excluding DIC
- ADAMTS13 well above 10% with a negative Coombs, separating this from TTP
The case in full
Presenting complaint
Patient history
A 31-year-old woman who is 35 weeks into her first pregnancy has had two days of upper abdominal pain, nausea and malaise. She put it down to indigestion and has been taking antacids without benefit.
Antenatal background
Patient history
Her blood pressure has crept up at each of the last three antenatal visits, and a trace of protein was noted a week ago. Yesterday she developed a headache and saw brief flashes of light. Her hands and face look puffy.
Examination and observations
Vital signs
She is uncomfortable and tender in the right upper quadrant. Reflexes are brisk with three beats of clonus. The fetal heart rate is normal.
| Parameter | Value | Reference |
|---|---|---|
| Blood pressure | 168/112 mmHgRef <140/90 | <140/90 |
| Heart rate | 92 bpmRef 60–100 | 60–100 |
| Temperature | 36.9 °CRef 36.1–37.5 | 36.1–37.5 |
| Urine dipstick protein | 3+Ref Negative | Negative |
| Urine protein:creatinine ratio | 88 mg/mmolRef <30 | <30 |
Blood tests and film
Laboratory results
Bloods and a blood film are sent.
| Parameter | Value | Reference |
|---|---|---|
| Haemoglobin | 96 g/LRef 115–165 | 115–165 |
| Platelets | 74 ×10⁹/LRef 150–400 | 150–400 |
| Blood film | Schistocytes presentRef None | None |
| LDH | 890 U/LRef <250 | <250 |
| Bilirubin | 34 µmol/LRef <21 | <21 |
| Haptoglobin | <0.1 g/LRef 0.3–2.0 | 0.3–2.0 |
| AST | 210 U/LRef <40 | <40 |
| ALT | 185 U/LRef <40 | <40 |
Tests to separate the mimics
Laboratory results
A second panel is sent to distinguish this from the conditions it resembles.
| Parameter | Value | Reference |
|---|---|---|
| Prothrombin time | 11.5 sRef 11–14 | 11–14 |
| APTT | 30 sRef 25–35 | 25–35 |
| Fibrinogen | 3.4 g/LRef 2.0–4.0 | 2.0–4.0 |
| Direct antiglobulin (Coombs) | NegativeRef Negative | Negative |
| ADAMTS13 activity | 58 %Ref >50 | >50 |
| Glucose | 5.1 mmol/LRef 3.9–7.8 | 3.9–7.8 |
| Ammonia | 28 µmol/LRef <50 | <50 |
| Creatinine | 96 µmol/LRef 45–90 | 45–90 |
Progress over twelve hours
Clinical course
Her platelets fall to 58 and the transaminases climb further. The abdominal pain intensifies and cardiotocography shows reduced variability.