Controversies with the diagnosis and management of HELLP syndrome

Significant hepatic involvement by preeclampsia leading to hepatocyte necrosis and thrombocytopenia should alarm the clinician regardless of whether criteria for HELLP syndrome have been fully achieved. Liver parenchyma is relatively unforgiving of the endovascular insult presented by severe preeclampsia. This vasculopathy can result in adverse maternal outcomes such as DIC, subcapsular hematoma, hepatic infarction, and death. The greatest challenges in caring for women with this disease are appreciating the diagnosis, instituting timely interventions, and avoiding associated complications. The addition of high-dose glucocorticoids to the armamentarium of therapy for HELLP syndrome may improve outcomes for both the mother and fetus, but definitive proof by randomized trials is lacking. Delivery is the ultimate cure, and optimizing the status of a seriously ill patient before delivery improves outcome.