HELLP syndrome: Laboratory parameters and clinical course in four patients treated with plasma exchange

Abstract

We report our apheresis department's experience with four patients with HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome. The average age of the patients was 23.25 years (range 19-27). Three were in their second pregnancy while one was a primigravida. All had symptoms of pre-eclampsia prior to delivery. All experienced the syndrome postpartum. Plasma exchange was instituted an average of 3.25 days postpartum (range 1.08-7.33 days). All underwent plasmapheresis with fresh frozen plasma replacement. The average number of plasma exchange treatments was four (range 1-8). The first laboratory parameter to reach its peak/nadir was the aspartate aminotransferase (AST), followed by the lactate dehydrogenase (LDH) enzyme level, followed by the hemoglobin (HGB) level, and, finally, the platelet count (PLT). The AST was the first parameter to peak and the first to normalize. In the three cases in which more than one plasmapheresis procedure was performed, plasmapheresis was required for an average of 98 hours (range 39-206 hours) after a normal AST level was obtained in order to achieve a self-sustaining platelet count of > or = 100 x 10(9)/L. No additional exchanges were required to maintain the PLT once a PLT of over 100 x 10(9)/L was attained. The laboratory values normalized in the following order: AST, HGB, PLT, and LDH. Three patients were discharged anemic. One was discharged with a normal LDH level. By our experience, awaiting normal LDH levels as an indicator for cessation of plasma exchange therapy would mean subjecting the patients to many unnecessary procedures.(ABSTRACT TRUNCATED AT 250 WORDS)

Early identification of women with HELLP syndrome who need plasma exchange after delivery

“…Reports suggest that PPEX in HELLP can be stopped earlier than is done in thrombotic thrombocytopenic purpura because in the former, the cause (pregnancy) is no longer present. Therefore, the endpoint is the platelet count [13]. According to our experience, when platelets start to rise and reach 100 × 10 9 /l and the condition of the patient is stable, PPEX can be discontinued.…”

“…Numerous reports, usually case reports, have described use of PPEX. Julius et al [13] recommended starting PPEX 72 hours after delivery if the condition has not improved and stopping it when platelets reach 100 × 10 9 /l and the patient's condition improves. Forster et al [4] advocated for an earlier start because HELLP carries features of hemolytic-uremic syndrome, and in many cases, a patient would benefit from earlier PPEX administration.…”

Thrombocytopenia in Adults: Review Article

“…Treatment is form of supportive measures (if the fetus reaches enough size, pregnancy is terminated, replace of liquid, if there is infections, it is treated or hypertension treatment etc.). Especially in class 1 patient groups postpartum plasmapheresis prevents to morbidity and mortality was seen [27].…”

Therapeutic Apheresis for Renal Disorders

“…Diagnostic tips include that liver enzyme elevations are very rare in TTP, and ADAMTS13 levels below 5% of normal are never seen in HELLP (123). HELLP syndrome causes renal impairment in 50% of cases, but TPE treatment is not necessary unless thrombocytopenia fails to improve by the fourth or fifth postpartum day, in which case, treatment with TPE (with FFP replacement) may be beneficial (124–126). Exacerbations of Upshaw–Schulman syndrome (congenital deficiency of ADAMTS13) can cause renal impairment and thrombocytopenia in pregnancy, and may mimic TTP (autoantibody‐type) or HELLP; TPE is not needed, but without correct treatment (FFP infusion), fetal outcomes may be impaired (127).…”