A 44-Year-Old

Pregnant Patient Who Had and

Needed HELLP

C A S E R E V I E W

Author: Jeff Solheim, RN, CEN, Keizer, Ore

Section Editor: Anne Marie Lewis, RN, BSN, BA, MA, CEN

Jeff Solheim, Oregon State Council, is Consultant, Solheim Enterprises,Keizer, Ore.

For correspondence, write: Jeff Solheim, RN, CEN, 1039 ChardonnayLoop NE, Keizer OR, 97303; E-mail: jeff@solheimenterprises.com.

J Emerg Nurs 2006;32:412-4.

0099-1767/$32.00

Copyright n 2006 by the Emergency Nurses Association.

doi: 10.1016/j.jen.2006.05.004

412

44-year-old woman who is 7 months pregnant

Apresents to triage with complaints of nausea and

vomiting for the past 3 days along with general-

ized abdominal discomfort that she attributes to 5 days

of constipation. She complains that she feels ‘‘tired and

unwell.’’ She is gravida 12, para 11, with an uncomplicated

twelfth pregnancy. Approximately 2 months earlier she re-

located from Mexico but has not sought any prenatal care

since arriving in the United States. The patient denies any

significant medical history. The only medications that she

is taking are prenatal vitamins.

The patient’s vital signs at triage are as follows: blood

pressure, 130/74 mm Hg; heart rate, 110 beats/minute

with a regular rhythm; respiratory rate, 18 breaths/minute,

deep but unlabored; and temperature, 36.38C (97.38F).

The patient states that she can feel the baby move; fetal

heart tones (FHTs) are auscultated at 132 beats/minute

(normal range, 110-160 beats/minute).1 The patient’s skin

is pink and dry at triage, although she has scleral jaun-

dice. A brief head-to-toe assessment reveals no abnormal-

ities except poor skin turgor and bilateral +2 edema of

both lower extremities.

The patient presents at the height of f lu season. Her

nausea and vomiting are the same complaints as those of

many other patients seen at triage during the shift. Current

hospital policy indicates that pregnant patients presenting

to the emergency department with non–pregnancy-related

complaints should be evaluated initially by the ED phy-

sician, rather than being transported to the Labor and

Delivery unit. Because we do not suspect that her symp-

toms are related to her pregnancy, the triage nurse de-

cides to have her evaluated by the ED physician.

JOURNAL OF EMERGENCY NURSING 32:5 October 2006

TABLE 1

Highlights of the patient’s urinalysis and initial blood

work, obtained on arrival at the emergency department

Laboratory test Result Reference range

Hematocrit 42.8% 36%-47%

Platelets 107 thousand/mm3 (A)

150-450thousand/mm3

C A S E R E V I E W / S o l h e i m

Once in the department, the nurse initiates an intra-

venous line, administers a bolus of 1 L of 0.9% normal

saline solution and 25 mg of intravenous promethazine

hydrochloride (Phenergan; Wyeth, Madison, NJ) for nau-

sea, and obtains blood and urine samples for analysis

(Table 1). The physical examination reveals that the pa-

tient has right upper quadrant (RUQ) pain to palpation.

Blood ureanitrogen

32 mg/dL (z) 8-19 mg/dL

Creatinine 3.9 mg/dL (z) 0.7-1.1 mg/dL

Alkalinephosphatase

329 U/L (z) 39-117 U/L

SGOT 232 U/L (z) 0-31 U/L

SGPT 98 U/L (z) 0-45 U/L

LDH 346 U/L (z) 122-220 U/L

Ammonia 128 UMOL/L(z) 10-35 UMOL/L

Bilirubin 7.4 mg/dL (z) 0.2-1.2 mg/dL

INR 1.4 (z) 0.9-1.1

Octo

Although HELLP syndrome usuallybecomes evident [in the third trimesterof pregnancy], in 31% of cases itoccurs in the postpartum period,frequently within 48 hours of deliverybut sometimes as late as 7 daysafter delivery.

PTT 56 seconds (z) 26-36 seconds

D-dimer N4290 ng/mL (z) b150 ng/mL

Urinalysis

Bilirubin 3+ Negative

Hemoglobin/blood

1+ Negative

Protein 30 Negative

INR, International normalized ratio; LDH, lactate dehydrogenase; PTT, partialthromboplastin time; SGOT, serum glutamic oxaloacetic transaminase;SGPT, serum glutamic pyruvic transaminase.

Approximately 2 hours after the patient is escorted

to her bed in the emergency department, maternal vital

signs are remeasured and are as follows: blood pressure,

112/62 mm Hg; heart rate, 109 beats/minute with a regu-

lar rhythm; respiratory rate, 24 breaths/minute, deep but

unlabored; and FHTs have decreased to 90 beats/minute.

The ED nurse immediately administers oxygen to the patient.

A STAT obstetrical consult is obtained and a decision

is made to perform an emergency cesarean section because

of the fetal bradycardia. The obstetrician delivers an infant

boy weighing 1.6 kg (3.5 lb) with an estimated gestation of

32 weeks. The baby’s APGAR scores at 1 and 5 minutes

after birth are 7 and 9, respectively. Based on the laboratory

results, the mother is diagnosed with HELLP syndrome

and pre-eclampsia.

The patient is transferred to the ICU for hemody-

namic monitoring postoperatively, where she becomes

‘‘stridorous and coughs up bright red blood.’’ Immediately

suctioning is performed and she is intubated. No further

bleeding is noted, and her respiratory status improves with

positive pressure ventilation. A subsequent chest radio-

graph reveals a ‘‘white out’’ of the left lung of undeter-

mined etiology.

Discussion

The acronym HELLP was coined in 1982 to describe a syn-

drome consisting of Hemolysis, Elevated Liver enzymes,

ber 2006 32:5

and Low Platelets, which affects an estimated 0.2% to

0.6% of all pregnancies.2 It is important to note that

women who have HELLP syndrome may not demonstrate

all of the manifestations contained in the acronym. It is

not certain whether HELLP syndrome is an extension of

pre-eclampsia or is an independent process, but it affects

an estimated 10% of patients with severe pre-eclampsia

or eclampsia.3

Our patient’s symptoms began in her third trimester of

pregnancy. Although HELLP syndrome usually becomes

evident at this time, in 31% of cases it occurs in the post-

partum period, frequently within 48 hours of delivery

but sometimes as late as 7 days after delivery.2 The clinical

findings that our patient exhibited were typical of this

syndrome. Patients with HELLP syndrome usually seek

medical care for malaise that they have had for several

days (in 90% of cases), epigastric or RUQ pain (65% of

cases), nausea and vomiting (50% of cases), nonspecific

JOURNAL OF EMERGENCY NURSING 413

C A S E R E V I E W / S o l h e i m

viral-like symptoms, hematuria, and gastrointestinal bleed-

ing.3 The usual manifestations of pre-eclampsia, including

hypertension and proteinuria, may be absent or mild in

the patient with HELLP syndrome.

414

Indications of maternal deterioration,such as signs of intra-abdominalbleeding from hepatic rupture,indications of hypovolemic shock, oruncontrolled hypertension, and signsof fetal distress, such as fetalbradycardia, often will require deliveryby cesarean section.

Our patient’s abnormal results provided the informa-

tion that led to her diagnosis.. Hemolysis—increased bilirubin and lactate dehydro-

genase level. The hematocrit may be decreased or

normal. If it is abnormal, it is typically the last syn-

drome abnormality to appear.. Elevated liver enzymes—increased serum glutamic

oxaloacetic transaminase, serum glutamic pyruvic

transaminase, and lactate dehydrogenase.. Low platelet count—often less than 100 thousand/

mm3. Unless HELLP syndrome is complicated by

disseminated intravascular coagulation, bleeding times,

such as the international normalized ratio and partial

thromboplastin time, are not affected. Elevations in

our patient’s clotting studies (international normal-

ized ratio and partial thromboplastin time) and D-

dimer indicate that she may have been showing early

signs of disseminated intravascular coagulation.

The treatment for patients with HELLP syndrome is

aimed at reducing both maternal and fetal mortality. If the

mother is already in labor when the syndrome is diagnosed,

she usually is allowed to progress normally. If HELLP is

recognized prior to the onset of labor, the mother often

will be admitted to a tertiary care facility and maintained

on strict bed rest, while she and the fetus are monitored

closely.2 Indications of maternal deterioration, such as signs

of intra-abdominal bleeding from hepatic rupture, indica-

tions of hypovolemic shock, or uncontrolled hypertension,

J

and signs of fetal distress, such as fetal bradycardia, often

will require delivery by cesarean section.2

Hemorrhage is one of the maternal complications

of HELLP syndrome, such as the hemoptysis experienced

by our patient in her postpartum period. Patients with

HELLP syndrome also are at risk for bleeding into the

hepatic capsule secondary to liver necrosis. At times, the

expanding hepatic hematoma may rupture the capsule, re-

sulting in a catastrophic intra-abdominal bleed. Although

our patient never experienced an intra-abdominal bleed,

her elevated liver enzymes and bilirubin level, coupled with

her jaundice and RUQ pain, indicate that she had signifi-

cant liver involvement.

Emergency nursing considerations for pregnant pa-

tients include the following:. Maintain an increased index of suspicion for a

pregnancy-related complication, such as HELLP

syndrome, in any patient presenting at triage with

malaise or a viral-type illness in the third trimester

of pregnancy.. Examine laboratory results for alterations in liver

enzymes and platelet counts in pregnant patients

who are at risk for HELLP syndrome.. Palpate the RUQ cautiously in the patient with sus-

pected HELLP syndrome to prevent rupture of po-

tential hepatic hematomas.. Reassess FHTs periodically throughout the emer-

gency department course of treatment for any preg-

nant patient at risk for HELLP syndrome.

Our patient was fortunate that her diagnosis was made

quickly and we were able to perform a cesarean section be-

fore her baby’s well-being was compromised. She and her

baby eventually were discharged home and experienced no

permanent sequelae.

REFERENCES

1. Kerr MS. Obstetric trauma. In: Newberry L, Criddle LM, editors.Sheehy’s manual of emergency care St. Louis: Mosby; 2005. p. 776.

2. O’Hara Padden M. HELLP syndrome: recognition and perinatalmanagement [1999; online; retrieved 2004 Mar 10]. Availablefrom: URL: http://www.aacp.org/afp/990901ap

3. Egerman RS, Sabai BM. Recognizing and managing HELLPsyndrome and its imitators. Clin Obstet Gynecol 1999;42:381-2.

OURNAL OF EMERGENCY NURSING 32:5 October 2006