Signs of
PIH/HELLP
90% of patients with HELLP
have generalized symptoms. 65% complain of epigastric pain, 30 %
with nausea and vomiting, and 31 % with headache. Any woman who complains
of these problems in the third trimester should be evaluated for HELLP.
If there is any significant platelet drop as well, HELLP should be suspected.
In a recent survey only 2 of 14 patients who entered the hospital with
HELLP were correctly diagnosed. (1)
The
signs and symptoms of PIH (pregnancy induced hypertension) and pre-eclampsia
are classified as mild, moderate or severe. They include: hypertension,
proteinuria (the presence of excessive protein in the urine) and edema.
Mild pre-eclampsia objectively presents
with mild hypertension of about 140/90 or a increase of 30mm Hg systolic
and 15mm Hg diastolic over baseline blood pressure. Edema of mild PIH is
differentiated from normal dependent edema of pregnancy by weight gain
of greater than 2lb per week. Urine protein is in the range of 1+ or 2+.
Edema
frequently accompanies normal gestation, so that its presence alone is
not a useful in diagnosing pre-eclampsia, while its absence does not eliminate
the diagnosis. 30% of all pregnancies show signs of edema. For example
sudden and rapid weight gain often proceeds overt manifestation of the
disease. On the other hand severe disease can occur even in the absence
of edema (the "dry" pre-eclamptic). Edema of the hands and face is more
likely to be associated with sodium retention and is therefore a more reliable
indicator of pre-eclampsia than is dependent edema. Edema is diagnosed
as clinically evident swelling, but fluid retention may also be manifest
as a rapid increase of weight without evident swelling.
Elevations
in blood pressure after mid-pregnancy in previously normotensive women
are often the initial clue of impending pre-eclampsia. Since blood
pressure is measured at every antepartum visit it comes as no surprise
that hypertension has been the focus of most studies regarding pathophysiology
and therapy in pre-eclampsia.
The
diagnosis of pre-eclampsia is uncertain in the absence of proteinuria.
However is that proteinuria may be a late manifestation, and it may be
prudent to treat women as pre-eclamptics even before proteinuria develops.
Severe
PIH is differentiated by the appearance of subjective complaints of, headaches,
visual disturbances, and epigastric or right upper quadrant abdominal pain.
BP is in excess of 160/110 or rise over a period of time to greater than
60mm Hg systolic and 300mm Hg diastolic over baseline. Proteinuria is 3+
to 4+ . Edema is often pitting, and weight gain is in excess of 10lb per
week. Oliguria (reduced excretion of urine) of less then 400ml in
24 hours is also diagnostic.
The
liver is not involved primarily in pre-eclampsia but becomes the target
organ in severe cases. Vasospasms (spasms in the blood vessels, resulting
in a decrease in their diameter) lead to a reduction in blood flow to the
uterus and other organs which in turn is responsible for the hypertension
found in PIH. They are also responsible for the visual disturbances and
low urine output. These same Vasospasms are also responsible for the anemia
that occurs in HELLP along with the hematacrit level falling. This reduced
blood flow is also a complication of delivery.
In
some reported cases of HELLP, pre-eclampsia was absent or mild. Patients
presented with HELLP Syndrome (Hemolysis, Elevated Liver enzymes, Low Platelet
counts) often have right upper quadrant and epigastric pain, and a peripheral
blood smear consistent with a microangiopathic hemolytic anemia. There
may be decreases in platelet counts.
With
HELLP changes in the liver occur. It become swollen and engorged causing
the epigastric or right upper quadrant pain and tenderness. Liver rupture,
hemorrhaging have also been reported. Along with Liver failure and jaundice.
Hypoglycemia is a particularly grave laboratory finding; however, the cause
of the hypoglycemia is yet obscure, even though it is obviously related
to liver failure. The low platelet count associated with HELLP syndrome
appears to be due to increased peripheral vascular destruction. Liver cell
damage results in the elevated enzymes.
HELLP signs
1. Weakness & fatigue
2. Nausea & vomiting
3. *Right upper quadrant and/or
epigastric pain
4. Headache
5. Changes in vision
6. Increased tendency to bleed
from minor trauma
7. Jaundice
8. Diarrhea
9. *Shoulder or neck pain
*Patients with HELLP syndrome who
complain of severe right upper quadrant pain, neck pain or shoulder pain
should be considered for hepatic imaging regardless of the severity of
the laboratory abnormalities, to assess for subcapsular hematoma or rupture.
(2)
There
are various classes of HELLP. They are:
Class 1 is considered most severe
form with patients with platelets under 50,000
Class 2 patients have a platelet
level between 50,00 & 100,000
Class 3 patients have a platelet
level between 100,000 & 150,000
Still
looking for more HELLP information? Effects
of HELLP on Mother & Child will take you to the next page.
Also if you have a HELLP story to share please stop by the HELLP
Syndrome Birth Stories Page and leave or read a story. Here you
will also find up to date HELLP/Pre-E net articles and books. You
will also find WebRing information at the above listed url.
(1)Schroder W, Heyl W. HELLP-syndrome.
Difficulties in diagnosis and therapy of a severe form of preeclampsia.
Clin Exp Obstet Gynecol 1993;20:88-94.
(2)Barton JR, Sibai BM. Hepatic
imaging in HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet
count).
Am J Obstet Gynecol 1996; 174:1820-7.
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