Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

suspected/presumed HELLP

1st line – seizure prophylaxis

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INITIAL
|
suspected/presumed HELLP
1st line – 

seizure prophylaxis

When the diagnosis is suspected, a continuous infusion of magnesium sulfate should be started, even prior to completion of laboratory studies, owing to the significant risk of seizure.[86] Dose must be reduced in patients with low urine output (<25 mL/hour for 4 hours), and magnesium levels should be checked after 4 hours in these patients. If the magnesium level is over 9 mg/dL, the infusion must be stopped and the level rechecked after 2 hours. Infusion can be resumed at a reduced rate when the magnesium level is <8 mg/dL. Following delivery, magnesium sulfate administration should continue for 24 hours. In patients with renal compromise or acute kidney injury, a single bolus of magnesium sulfate can be given without a continuous infusion. Blood magnesium levels need to be monitored in these patients to determine when pretreatment is safe to undertake.

If a grand mal convulsion/eclampsia occurs or is likely in the presence of severe headache and hypertension, intravenous magnesium sulfate is indicated usually for a duration of not less than 24 hours. In addition, treatment of severe systolic and/or diastolic hypertension (>160 mmHg and/or >110 mmHg thresholds, respectively) is urgently needed and important to sustain. If magnesium sulfate use is contraindicated (myasthenia gravis), other medications/anticonvulsants should be considered while blood pressure control is scrupulously pursued. In addition, in the presence of renal compromise, dosing of magnesium sulfate must be reduced and guided by serial blood magnesium levels. There are no clinical trials to indicate which anticonvulsant agent is best in these circumstances and a specialist should be consulted.

Neonatal caution: the UK-based Medicines and Healthcare products Regulatory Agency recommends against using magnesium sulfate for more than 5-7 days in total during pregnancy, irrespective of indication. If prolonged or repeated use occurs during pregnancy, labour, and delivery, consider monitoring the neonate for abnormal calcium and magnesium levels and adverse skeletal effects.[87] The US Food and Drug Administration issued a similar recommendation in 2013.[88] Despite these concerns for extended fetal exposure to magnesium sulfate, evidence suggests that magnesium sulfate given before anticipated early pre-term birth provides neuroprotection for neonates.[93]​​

Primary options

magnesium sulfate: 4-6 g intravenously as a loading dose, followed by 1-2 g/hour infusion for at least 24 hours, maximum 40 g/day

Plus – intravenous dexamethasone

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INITIAL
|
suspected/presumed HELLP
Plus – 

intravenous dexamethasone

Treatment recommended for ALL patients in selected patient group

As soon as the diagnosis of class 1 or class 2 HELLP syndrome is made, intravenous dexamethasone is started and continued through delivery, after which the dose is decreased. The same regimen is initiated in patients with class 3/incomplete HELLP syndrome also affected by eclampsia, severe epigastric pain, severe systolic hypertension, and/or evidence of major maternal morbidity.[30][53][76]

Corticosteroids should be administered for 24 to 48 hours, ideally before delivery is undertaken, in pregnancies <34 weeks' gestation in order to enhance fetal lung maturation and diminish risk of intraventricular bleeding and necrotising enterocolitis.

Primary options

dexamethasone sodium phosphate: consult specialist for guidance on dose

Plus – antihypertensive therapy

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INITIAL
|
suspected/presumed HELLP
|
with blood pressure ≥160/105 mmHg
Plus – 

antihypertensive therapy

Treatment recommended for ALL patients in selected patient group

Blood pressure should be monitored every 15 minutes, and if it is at critical levels (≥160/105 mmHg, mean arterial pressure 120 mmHg), immediate reduction is required to a systolic pressure 140-150s mmHg.

Labetalol is commonly recommended for this indication.[8]​[10][94]​​[95] It can be administered as a continuous infusion, although bolus intravenous administration is more frequently used. If there is no response to the first bolus, incremental repeat doses should be given. Labetalol is contraindicated in patients with asthma or pre-existing cardiac disease, particularly decreased cardiac function. In these patients, nicardipine can be used.[86]

Hydralazine can be used especially if labetalol is ineffective or contraindicated. Although as effective as labetalol, hydralazine is associated with less favourable maternal and perinatal outcomes.[95]

Primary options

labetalol: 20 mg intravenously initially, followed by 40-80 mg every 10 minutes according to response, maximum 300 mg total dose

Secondary options

nicardipine: 5 mg/hour intravenously initially, increase by 2.5 mg/hour increments every 15 minutes according to response, maximum 10 mg/hour

Tertiary options

hydralazine: 5 mg intravenously every 20-30 minutes according to response

ACUTE

all patients (confirmed HELLP)

1st line – delivery + intravenous dexamethasone

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ACUTE
|
all patients (confirmed HELLP)
1st line – 

delivery + intravenous dexamethasone

Prompt delivery of the fetus and placenta is key to successful management, and virtually all patients will have spontaneous resolution with this management. If the patient is not already in labour, then the choices are induction of labour or caesarean delivery.

Caesarean delivery should be performed for the usual obstetrical indications and may be considered for gestational age <32 weeks in the absence of labour.

Attempts to delay delivery more than 48 to 72 hours to maximise fetal benefit are not recommended once the diagnosis is made, even in pre-viable gestations <23 weeks.

Intravenous dexamethasone is administered for maternal benefit before and after delivery is accomplished, especially in complicated or class 1 HELLP syndrome cases.[30][76]

Primary options

dexamethasone sodium phosphate: consult specialist for guidance on dose

Plus – continued seizure prophylaxis

Back
ACUTE
|
all patients (confirmed HELLP)
Plus – 

continued seizure prophylaxis

Treatment recommended for ALL patients in selected patient group

Magnesium sulfate is started as soon as the diagnosis is suspected and continued until 24 hours after delivery. Dose must be reduced in patients with low urine output (<25 mL/hour for 4 hours), and magnesium levels should be checked after 4 hours in these patients. If the magnesium level is over 9 mg/dL, the infusion must be stopped and the level rechecked after 2 hours. Infusion can be resumed at a reduced rate when the magnesium level is <8 mg/dL. In patients with renal compromise or acute kidney injury, a single bolus of magnesium sulfate can be given without a continuous infusion. Blood magnesium levels need to be monitored in these patients to determine when pretreatment is safe to undertake.

If a grand mal convulsion/eclampsia occurs or is likely in the presence of severe headache and hypertension, intravenous magnesium sulfate is indicated usually for a duration of not less than 24 hours. In addition, treatment of severe systolic and/or diastolic hypertension (>160 mmHg and/or >110 mmHg thresholds, respectively) is urgently needed and important to sustain. If magnesium sulfate use is contraindicated (myasthenia gravis), other medications/anticonvulsants should be considered while blood pressure control is scrupulously pursued. In addition, in the presence of renal compromise, dosing of magnesium sulfate must be reduced and guided by serial blood magnesium levels. There are no clinical trials to indicate which anticonvulsant agent is best in these circumstances and a specialist should be consulted.

Neonatal caution: the UK-based Medicines and Healthcare products Regulatory Agency recommends against using magnesium sulfate for more than 5-7 days in total during pregnancy, irrespective of indication. If prolonged or repeated use occurs during pregnancy, labour, and delivery, consider monitoring the neonate for abnormal calcium and magnesium levels and adverse skeletal effects.[87] The US Food and Drug Administration issued a similar recommendation in 2013.[88] Despite these concerns for extended fetal exposure to magnesium sulfate, evidence suggests that magnesium sulfate given before anticipated early pre-term birth provides neuroprotection for neonates.[93]​​

Primary options

magnesium sulfate: 4-6 g intravenously as a loading dose, followed by 1-2 g/hour infusion for at least 24 hours, maximum 40 g/day

Plus – continued antihypertensive therapy

Back
ACUTE
|
all patients (confirmed HELLP)
|
with blood pressure ≥160/105 mmHg
Plus – 

continued antihypertensive therapy

Treatment recommended for ALL patients in selected patient group

Blood pressure should be monitored every 15 minutes, and if it is at critical levels (≥160/105 mmHg, mean arterial pressure 120 mmHg), immediate reduction is required to a systolic pressure 140-150 mmHg.

Labetalol is commonly recommended for this indication.[10][94] It can be administered as a continuous infusion, although bolus intravenous administration is more frequently used. If there is no response to the first bolus, incremental repeat doses should be given. Labetalol is contraindicated in patients with asthma or pre-existing cardiac disease, particularly decreased cardiac function. In these patients, nicardipine can be used.[86]

Hydralazine can be used especially if labetalol is ineffective or contraindicated. Although as effective as labetalol, hydralazine is associated with less favourable maternal and perinatal outcomes.[95]

Primary options

labetalol: 20 mg intravenously initially, followed by 40-80 mg every 10 minutes according to response, maximum 300 mg total dose

Secondary options

nicardipine: 5 mg/hour intravenously initially, increase by 2.5 mg/hour increments every 15 minutes according to response, maximum 10 mg/hour

Tertiary options

hydralazine: 5 mg intravenously every 20-30 minutes according to response

Plus – platelet transfusion ± anti-D immunoglobulin

Back
ACUTE
|
all patients (confirmed HELLP)
|
with platelet count <25 × 10⁹/L (<25,000/microlitre) (or <30 × 10⁹/L [<30,000/microlitre] if bleeding, massive transfusions, or surgery)
Plus – 

platelet transfusion ± anti-D immunoglobulin

Treatment recommended for ALL patients in selected patient group

The effect of the platelet transfusion is only transient as consumption occurs rapidly. One unit of platelets is expected to increase the platelet count by 5000.[96] A standard platelet pack is usually 6 units, estimated to raise the platelet count by 30,000/mm³.

Anti-D immunoglobulins need to be co-administered to Rh-negative women if no type-specific platelets are available.

Primary options

anti-D immunoglobulin: consult specialist for guidance on dose

Plus – fresh frozen plasma or cryoprecipitate

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ACUTE
|
all patients (confirmed HELLP)
|
with fibrinogen <2.94 micromol/L (<100 mg/dL)
Plus – 

fresh frozen plasma or cryoprecipitate

Treatment recommended for ALL patients in selected patient group

To increase the serum level of fibrinogen by 25 mg, 1g of exogenous fibrinogen has to be administered. This amount is provided by 1 unit of fresh frozen plasma or 6 units of cryoprecipitate. Cryoprecipitate administration is preferable when fluid overload is a concern. Follow local specialist protocols.

Plus – blood transfusion

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ACUTE
|
all patients (confirmed HELLP)
|
with haematocrit <25%
Plus – 

blood transfusion

Treatment recommended for ALL patients in selected patient group

Patients with HELLP syndrome tolerate low haematocrit poorly, and blood transfusions may be required with haematocrit <25%. These may be required before delivery.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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