REVIEW ARTICLE

Anesthetic considerations in HELLP syndrome

M. del-Rio-Vellosillo1 and J. J. Garcia-Medina2,3
1

Department of Anesthesia, University Hospital Virgen de la Arrixaca, El Palmar, Murcia, Spain

Department of Ophthalmology, University Hospital Reina Sofia, Murcia, Spain
3
Department of Ophthalmology and Optometry, University School of Medicine, University of Murcia, Murcia, Spain
2

Correspondence
M. del-Rio-Vellosillo, Department of
Anaesthesia, University Hospital Virgen de la
Arrixaca, Ctra. Madrid-Cartagena, s/n, 30120 El
Palmar, Murcia, Spain
E-mail: monicadelriov@hotmail.com
Conflicts of interest
None for either author.
Funding
None.
Submitted 25 May 2015; accepted 3
September 2015; submission 18 February
2015.
Citation
del-Rio-Vellosillo M, Garcia-Medina JJ.
Anesthetic considerations in HELLP syndrome.
Acta Anaesthesiologica Scandinavica 2015
doi: 10.1111/aas.12639

Background: HELLP syndrome (hemolysis, elevated liver

enzymes, low platelets) is an obstetric complication with heterogonous presentation and multisystemic involvement. It is characterized by microangiopathic hemolytic anemia, elevated liver
enzymes by intravascular breakdown of fibrin in hepatic sinusoids
and reduction of platelet circulation by its increased consumption.
Methods: In terms of these patients anesthetic management, it
is essential to consider some details: (1) effective, safe perioperative management by a multidisciplinary approach, and quick,
good communication among clinical specialists to achieve correct
patient management; (2) neuroaxial block, particularly spinal
anesthesia, is the first choice to do the cesarean if there is only
moderate, but not progressive thrombocytopenia; (3) if a general
anesthesia is required, it is necessary to control the response to
stress produced by intubation, especially in patients with either
severe high blood pressure or neurological signs, or to prevent
major cerebral complications; (4) invasive techniques, e.g., as tracheostomy, arterial, and deep-vein canalization, should be considered; (5) if contraindication for neuroaxial anesthesia exists, rapid
sequence intubation with general anesthesia should be regarded
as an emergency in patients with full stomach; (6) increased risk
of difficult airways should be taken into account.
Results: Optimal patient management can be chosen after considering the risks and benefits of each anesthetic technique, and
based on good knowledge of these patients pathophysiological
conditions.
Conclusion: Later, close patient monitoring is recommended for
potential development of hemorrhagic complications, disseminated intravascular coagulation (DIC), or eclampsia.

Editorial comment: what this article tells us

Hemolysis, elevated liver enzymes, and low platelets HELLP syndrome continues to be a threat
to the well-being of some obstetric patients. This article provides an updated review of perioperative approaches for safest care for obstetric patients with HELLP syndrome who need urgent operative delivery.
Pregnancy-induced hypertension is a broadspectrum entity which occurs in approximately
5% of pregnancies whose physiopathology

abnormalities are found in vasoconstrictor and

vasodilator agent production as a response to
diffuse endothelial injury, where placental

Acta Anaesthesiologica Scandinavica (2015)

2015 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd

M. DEL-RIO-VELLOSILLO AND J. J. GARCIA-MEDINA

vasculitis plays a major role. The clinical translation is high blood pressure, kidney failure by
fibrin renal deposits, and multiorgan failure by
fibrin extrarenal deposits and consumption
coagulopathy.1
HELLP syndrome (SH), described in 1982 by
Weinstein,2 is a severe manifestation of pregnancy-induced hypertension, defined by some
authors as a variation of pre-eclampsia.
Nonetheless, SH may appear alone or in association with it.3,4
Despite the improvements made in recent
years in managing this syndrome, many details
of SH remain unknown in terms of its etiology,
diagnosis, management, and treatment.
Incidence
Its incidence is between 212% of all pregnancies, and in 1020% of cases of pre-eclampsia.5
It occurs during 70% of antepartum periods and
during 30% of postpartum periods, and emerges
mostly in the first 48 h.6,7

liver damage and a hemolytic process.5 A drop

in platelets is due to increased platelet consumption by adhesion to endothelium damage
with a short half-life.11
Women with partial SH have few symptoms
and develop less complications than those with
complete SH.6 However, partial or incomplete
SH patients may develop complete SH.12
Typical clinical symptoms include abdominal
pain in the right upper quadrant or epigastralgia, nausea, and vomiting; therefore, the diagnosis of the illness can be delayed for a long
time.1315 Up to 3060% of women complain of
headaches and up to 20% suffer visual disturbances.9 However, women with SH can also
present non-specific symptoms and signs.9
Another common feature of SH is a severe, evolutionary coagulopathy before, during, and after
childbirth or cesarean section, which requires a
close, continuous clinical evaluation.1 This syndrome is also characterized by becoming exacerbated at night and recovering during the day.16
Diagnosis

Classification
Several classification systems are used to categorize SH. The first is based on the number of present abnormalities (hemolysis, elevated liver
enzymes, and low platelets), in such a way that
patients are classified as partial SH (they present
one or two abnormalities) or complete SH (three
abnormalities are present).4,6
Alternatively, SH may be classified based on
the number of platelets: class I, < 50 9 109/l;
class II, 50100 9 109/l; and class III, 100
150 9 109/l.8 Morbidity and mortality are high
in class I.8
Clinical manifestations
This syndrome is characterized by hemolysis,
elevated liver enzymes, and thrombocytopenia
(lactate dehydrogenase (LDH) 600 IU/l, AST
70 IU/l, platelets 100 9 109/l).9
Hemolysis is caused by microangiopathic
hemolytic anemia produced by vascular damage
and fibrin deposits. This destruction of red
blood cells causes fragmented red blood cells
and schistocytes on a blood film and increased
LDH.10 Elevated liver enzymes may reflect both

The diagnostic criteria to define this syndrome

vary vastly.9
The first thing one should do is to assess the
patients clinical situation, gestational age,
blood pressure control, and the fetus.
A suspected diagnosis is based on clinical
grounds, but is confirmed by laboratory data.
Complimentary laboratory tests should include
a complete blood cell count, in particular a
platelet count, coagulation parameters, AST,
LDH, and haptoglobin and urine examination.
Thrombocytopenia is primary and an early
cause of bleeding disorders in SH. Fibrinogen
degradation products are non-specific unless
they are > 40 mg/l, but 15% of patients with
DIC present concentrations of < 40 mg/l.
Fibrinogen degradation products also have a
half-life of 572 h and do not always reflect the
current coagulation state.17,18
Thromboelastography can be useful for knowing the etiology of bleeding in these patients
with SH, but it has not been demonstrated as
being useful for predicting risk of bleeding.17,18
A differential diagnosis in SH patients should
include a wide variety of processes. Nevertheless, the most important diagnosis to distinguish
Acta Anaesthesiologica Scandinavica (2015)

2015 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd

HELLP SYNDROME AND ANESTHESIA

it are those with thrombocytopenia (gestational

thrombocytopenia, autoimmune thrombocytopenic purpura), or those associated with
microangiopathic hemolytic anemia (pre-eclampsia, hemolytic uremic syndrome, thrombotic
thrombocytopenic purpura, acute fatty liver disease of pregnancy).
Treatment
Based on this literature review, one can see that
the management of these patients is quite
diverse, with the final treatment being delivery
of the fetus and the placenta.19
Following the SH classification, delivering
women with complete SH are at more risk of
complications than those with partial SH, so
they should be scheduled for delivery within
48 h. However, women with partial SH could
be candidates for conservative treatment.20
Nonetheless, most cases are usually indicated
for cesarean section because of deteriorating
maternal conditions.13,21
Other guidelines to follow are weeks of pregnancies, for which there are generally three main
options1,22: (1) immediate delivery at 34 weeks
or later; (2) delivery in 48 h after evaluating or
stabilizing the maternal clinical conditions and
treating with corticoids. The most advisable
option appears to be between 27 and 34 weeks;
(3) a wait-and-see attitude in pregnancy earlier
than 27 weeks, and treatment with corticoids.
During treatment, it is important to monitor
the patient by assessing vital signs and balanced
fluid.23
Some of the drugs used in this syndrome are:
corticoids, antihypertensive drugs (e.g., labetalol) and magnesium sulfate.9,23 Another therapy
discussed in SH is plasmapheresis.
Obstetric anesthetists should be cautious with
administrating fluids, and should also consider
transfusing blood products whenever needed.

lets, extremely high liver enzymes, or diminished urine output.

When high doses of corticoids are used in
mothers, treatment duration is variable (there
are studies that have used them from 24 h to
2 weeks) in terms of following up protocols in
their hospital or observing improvements in laboratory parameters.19 An increased platelet
count has been found in observational studies
with this treatment.25 Based on available evidence, it is not clear whether administration of
corticoids increases the number of platelets so
that locoregional anesthesia can be performed.26
Even so, a systematic review has concluded
that there was not enough evidence to accept or
reject the use of corticoids, such as adjuvants, to
treat these patients.25 There is no scientific support for the use of either corticoids in postpartums as no changes have been observed in
maternal morbidity and mortality, or blood
products in such patients.27
When administering corticoids in the fetus,
the Task Force on Hypertension in Pregnancy
recommends, be it with low-quality evidence,
administering corticoids for fetal benefits to
mothers before gestation week 34 if the mother
and the fetus are stable.28
Antihypertensive drugs
Given the risk of cerebral hemorrhaging and
abruptio placentae due to high blood pressure,
most guidelines recommend lowering systolic
blood pressure to 140150 mmHg and diastolic
blood pressure to 90100 mmHg using labetalol
as the drug of choice and monitoring the patient
for the first 24 h.5,7,29
Other safe drugs to control high blood pressure in pregnancy are hydralazine, methyldopa,
nifedipine or isradipine, some b-adrenoceptor
blockers (metoprolol, pindolol, propranolol),
and low-dose diazoxide.30

Corticoids

Anticonvulsants drugs

Although the use of corticoids in these patients

is still controversial, two guidelines for corticoids can be used in SH management19,24,25: (1)
For fetal lung maturation (standard regime treatment), and (2) for maternity benefits (high doses
of corticoids) for extremely low levels of plate-

Magnesium sulfate (MgSO4) is the drug of

choice for prophylaxis, treatment, and recurrences of seizures (eclampsia).31,32 SH patients
must be treated prophylactically with magnesium sulfate to prevent seizures, regardless of
them having hypertension or not.33

Acta Anaesthesiologica Scandinavica (2015)

2015 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd

M. DEL-RIO-VELLOSILLO AND J. J. GARCIA-MEDINA

The guideline recommended by the Collaborative Eclampsia Trial is 45 g of MgSO4 administered in 5 min, and subsequently 1 g/h for 24 h.
If a recurring seizure appears, 2 g of MgSO4
should be administered.34
MgSO4 monitoring is taken by clinical parameters of urine output, breathing rate, oxygen saturation, and patellar reflexes. The normal
plasma concentration lies between 1.58 and
2.55 mg/dl. The recommended therapeutic concentrations lie between 4 and 7 mg/dl.35
Toxicity is often presented as kidney failure.
Treatment of its toxicity must be given with
10% calcium gluconate, 1 g administered in
10 min.36
Blood products transfusion
In cases with continuing hemolysis and persistent postpartum thrombocytopenia, blood and
platelet transfusion, as well as treatment with
albumin, are standard treatments.23,37
When the platelet count falls below 50 9 109/l,
it can be considered a DIC with a worse prognosis. For this reason, it is advisable to keep platelet
levels above 50 9 109/l to avoid the risk of bleeding.38 If DIC occurs, it can be treated with fresh
frozen plasma to replace clotting proteins.33
Plasmapheresis
Plasmapheresis is one of the support therapies
that offers more favorable results in patients
who are refractory to conventional treatment.39
41
The exact mechanism is unknown but, in
general, plasmapheresis removes plasma factors
and replaces new elements by encouraging
plasma from patients. However, more research
work needs to be done into this technique for it
to be recommended.42
Some SH patients, whose bilirubin or creatinine has progressively increased for more than
72 h after delivery, could benefit from plasmapheresis with fresh frozen plasma.39,43
Fluid therapy
In line with this, a restrictive therapy in these
patients could exacerbate intravascular vasoconstrictors and lead to kidney failure.44,45 Nevertheless, a non-restrictive fluid therapy is not

recommended because a positive fluid balance

entails a possible risk of producing a pulmonary
edema.
Evidence suggests that the use of intravenous
fluids to increase plasma volume or to treat oliguria in women with normal renal function and
stable creatinine levels is not advisable, nor is
treating oliguria with furosemide and low doses
of dopamine recommended in women with normal renal function.46,47
Complications
Maternal and fetal morbidity in SH is higher
than normal, which poses a challenge: cooperation for the pediatric, anesthetic, and obstetric
team to optimize maternal-fetal care and to
reduce morbidity and mortality for both the
mother and fetus.
Maternal complications
Since 1982, SH has been associated with a range
of mortalities of between 124%,48 where average mortality is 5%.48
The laboratory values that indicate over 75%
of maternal morbidity and mortality are: LDH
concentration > 1400 U/l, AST > 150 U/l, ALT
> 100 U/l, and uric acid concentration > 7.8 mg/
100 ml (> 460 lmol/l).44 Nonetheless clinical
symptoms, such as headaches, visual disturbance, epigastric pain, and nauseas or vomiting,
have been suggested to be better predictors of
adverse maternal outcomes than laboratory
parameters.49
The high maternal morbidity and mortality
associated with this syndrome is due to multiple organs being affected: liver, kidney, brain,
and vascular system.50 Therefore, it often
implies having to terminate pregnancy early.51
The maternal complications that can occur
with this syndrome are: eclampsia, placental
abruptio, DIC, acute renal failure, severe ascites,
cerebral edema, pulmonary edema, hematoma
infection, subcapsular liver hematoma, liver
rupture, hepatic infarction, recurrent thrombosis,
retinal detachment, cerebral infarction, cerebral
hemorrhaging, and maternal death.5 Indeed, 15
38% of SH patients have complications associated with kidney failure, pulmonary edema, and
DIC.5154
Acta Anaesthesiologica Scandinavica (2015)

2015 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd

HELLP SYNDROME AND ANESTHESIA

The risk of renal failure and pulmonary edema

increases in patients with postpartum SH when
compared to patients with prepartum SH.5
A recent study by Habli et al., considered
long-term maternal morbidities in women with
SH, where new-onset essential hypertension
(33%), depression (32%) and anxiety (26%)
appeared more frequently. Other less frequent
morbidities in these women were respiratory disease (4.8%), renal disease requiring hemodialysis (2.4%) and retinal disease (1.6%).55
Isler et al. detected that cerebral hemorrhaging
or stroke was the primary cause of maternal
death in 26% of cases and a main contributor in
45% of women.48
The incidence of liver rupture in SH is
between 12% of cases and is the cause of
maternal mortality, estimated to be between 18
86% of cases.56 It is due to liver ischemia by
reduced liver flow with the appearance of
infarct, subcapsular hematoma and intraparenchimal hemorrhaging, which leads to liver
rupture.5759 Liver bleeding can occur early during HELLP syndrome development in patients
with advanced class I.60 In these patients, close
hemodynamic monitoring and assessment of
clotting parameters are necessary, along with
serial imaging test evaluations and manipulation of the liver should be avoided. The clinical
picture includes pain in the upper right quadrant, or epigastric or shoulder pain with anemia
and hypotension. Liver rupture is confirmed by
a computed tomography (CT) scan, ultrasonography, or magnetic resonance imaging (MRI).5 If
hemodynamic decompensation occurs, surgery
may be necessary. Cases of liver transplantation
with acute liver failure or uncontrolled bleeding
have been documented,61 and other cases with
conservative treatment in hemodynamically
stable patients have been reported.62
Fetal complications
Perinatal mortality in SH, with an incidence of
7.434.0%, depends on gestational age at delivery.9,63 Fetal complications with this syndrome
include: placental abruption, cerebral hemorrhaging, perinatal death, preterm delivery,
neonatal thrombocytopenia, respiratory distress
syndrome, and intrauterine growth restriction.5,33

Anesthetic recommendations
Premature delivery in these patients is normal
and deliveries are often complicated by
intrauterine growth retardation or placental
abruption. Therefore, cesarean section is quite a
common practice in such cases.
Given the high incidence in delayed or missed
diagnoses among these patients, the anesthesiologist should have a high index of suspicion and
should recognize that a delivering woman with
abdominal pain, nausea and vomiting could
have SH.
The key to safe management of such patients
is to treat hypertension and eclampsia, considering the presence of liver or kidney dysfunction,
and reduce the tendency of bleeding. The determination of appropriate anesthetic management
is based on the conditions of both the delivering
woman and the fetus, and also on urgent surgery.64,65 So anesthetic treatment in these
patients is complex, and the risks and benefits
of each anesthetic technique must be contemplated, based on sound knowledge of these
patients pathophysiological conditions.
First a preoperative examination should be
performed, which should include an electrocardiogram (ECG) and a complete blood count
with a platelet count, liver function tests, serum
creatinine concentrations, urea and uric acid,
fibrin degradation products, and prothrombin
and partial thromboplastin times.14 Blood components, including cross-matched red cells, platelet concentrates, and plasma, should be
available.21
Moreover, a blood transfusion should be evaluated depending on hemoglobin levels.66 In
patients with thrombocytopenia, platelet transfusion should be considered at the time of surgery, and not before, because platelets can be
rapidly consumed.67 Urinary catheterization is
also advisable to control dieresis hourly.
An intravascular volume assessment, proper
blood pressure control, and invasive hemodynamic monitoring should be performed.
Intravascular volume depletion in SH is usually
related with hypertension severity.21 It is important to remember that excessive crystalloid
administration in patients with widespread
vasospasm, drop in colloid oncotic pressure and

Acta Anaesthesiologica Scandinavica (2015)

2015 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd

M. DEL-RIO-VELLOSILLO AND J. J. GARCIA-MEDINA

increased capillary membrane permeability may

easily produce an pulmonary edema.
Central venous pressure monitoring is not
usually necessary in these patients, unless it is
complicated by oliguria, pulmonary edema, or
some form of heart disease. Although the results
of the control studies are not available, the use
of a catheter in a pulmonary artery has been recommended in patients with: (1) refractory
hypertension; (2) oliguria with resistance to
fluid therapy; (3) signs or symptoms of pulmonary edema.33,68,69
Blood sugar monitoring is recommended
because of some case reports of severe hypoglycemia in SH with assumed liver dysfunction.20,29,70
To manage uterine contractions in pregnant
women with hypertension, oxytocin is considered the treatment of choice. Cases of hypertensive crisis have been attributed to ergometrine,
so it should not be used in these patients.7173
Misoprostol is associated with rising blood
pressure, but to a lesser extent than ergometrine.36
In most patients, blood pressure, platelet
count, and levels of liver enzymes normalize
within 4896 h postpartum, so a follow-up of
these patients in an intensive care unit is considered necessary.21,74 Moreover, these patients
may develop complications during the postpartum period, such as postpartum bleeding, DIC,
or eclampsia. Abnormal bleeding is often seen
and there is a higher incidence of perioperative
bleeding complications, such as blood loss,
wound hematoma, and postpartum blood transfusions.13,21
Avoiding non-steroidal anti-inflammatory
agents for postoperative pain is recommended
because hypertensive crises have been described
in these patients. Hence, we should use alternative drugs such as paracetamol and opioids.75
Types of anesthesia
The anesthetic management of these SH patients
poses a challenge to anesthesiologists because
both general and regional anesthetic techniques
are potentially associated with complications in
SH.
Administration of regional anesthesia not only
prevents the complications of general anesthe-

sia, such as difficult intubations, a vasopressor

response to tracheal intubation but also
improves uteroplacental blood flow and neonatal results.76 It has been proven that the sympathetic blockade that produces neuroaxial
anesthesia improves intervillous blood flow in
hypertensive delivering women by lowering
uteroplacental resistance.77
Administration of neuraxial anesthesia minimizes the potential risk of fetal exposure to
depressant anesthetic drugs, reduces the risk of
maternal pulmonary aspiration, promotes rapid
wandering and lowers the incidence of maternal
thromboembolism.76 Nevertheless, it is advisable to closely monitor the neurological status of
these patients.78
Thus, deciding about the anesthetic technique
to be adopted must be done on an individual
basis in each case, based on maternal and fetal
factors as coagulation and maternal cardiovascular stability are decisive (Fig. 1).52 Even so, we
must explain to patients the risks and benefits
of the anesthetic technique to be used in each
case.
Regional anesthesia
Regional anesthesia offers benefits to women
and fetuses in SH, but it also involves coagulopathy-related risks.
Epidural venous plexus engorgement in delivering woman and a smaller number of platelets
predispose them to a higher risk of hematoma
after regional anesthesia.75.
The very few published reports there are on
an epidural hematoma in obstetric patients with
epidural anesthesia have always been associated
with other etiological factors, such as spinal
tumors or arteriovenous malformations.79 The
incidence of epidural hematoma in obstetric
epidural anesthesia is estimated to be about
1:50,0000 cases of anesthesia.80 More than 100
spontaneous epidural hematoma without spinal
puncture have also been published.81
Hemodynamic stability should be ensured
prior to performing locoregional anesthesia, as
should checking the absence of altered blood
coagulation and assessing the number of platelets.
Coagulation in these patients is usually due to
a drop in the number of platelets and is less
Acta Anaesthesiologica Scandinavica (2015)

2015 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd

HELLP SYNDROME AND ANESTHESIA

PREOPERATIVE

- High-caliber intravenous access

- Complete blood count
- Blood sugar monitoring
- ECG
- Urinary catheterization
- Cross-matched red cells and possible blood and platelet transfusion should be evaluated
- Intravascular volume assessment, and proper blood pressure and invasive hemodynamic monitoring
should be performed

CLINICAL SITUATION AND TYPE OF ANESTHESIA

-Raised increased intracranial pressure (ICP)

-Clinical evidence of bleeding
-Coagulopathy
-Drop in platelet count < 80,000/mm3
-Hemodynamic instability
-Maternal or fetal compromise

Yes

GENERAL ANESTHESIA (GA)

REGIONAL ANESTHESIA(RA)

ADVANTAGES

ADVANTAGES

-Rapid onset of anesthesia

-Control of airway
-Potential for less hypotension than RA

-Reduces serum catecholamine level

-Improves uteroplacental blood flow
-Precludes the risk of aspiration, failed
intubation or laryngoscopic intubation
-Minimizes the risk of neonatal exposure to
depressant anesthetic drugs
- Promotes early ambulation
- Lowers the incidence of maternal
thromboembolism
- Better analgesia and minimizes the
consumption of systemic opioids

DISADVANTAGES

Fig. 1. Optimal anesthetic management of

delivery in patients with HELLP syndrome.

No

- Difficult endotracheal intubation and risk of

aspiration
-Magnesium sulfate: empowered effect of
neuromuscular blocking agents
- Slow metabolic degradation of choline-ester
drugs can occur
- Increases systemic and pulmonary vascular
resistance
- Hypoproteinemia, low plasma volume,
increased interstitial fluid and altered liver
function could alter requirements and effects
of drugs.

frequently attributed to DIC.76 This alteration

prevents having to give regional anesthesia for
cesarean sections in most cases.
From the anesthesiologists point of view, no
consensus on the minimum number of platelets
that confers safety to neuroaxial anesthesia in
these patients has been reached. In the absence
of risks factors (anticoagulants, antiplatelet
agents, acquired or congenital abnormalities of
coagulation or platelet function, a fast drop in
platelets), a platelet count higher than 80,000/
mm3 indicates that it is safe to undertake spinal

DISADVANTAGES
- A higher risk of epidural hematoma

and epidural anesthesia. It is likely that lower

counts confer safety, but existing publications
have not yet provided enough evidence to recommend it.82
There are other published studies where neuroaxial anesthesia has been administered safely
in these patients with platelet counts below
10,0000/mm3, but a timely coagulation evaluation is recommended.8385 Studies that have also
investigated coagulation in these patients using
thromboelastography have not described coagulopathies with platelet counts over 10,0000/mm3.

Acta Anaesthesiologica Scandinavica (2015)

2015 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd

M. DEL-RIO-VELLOSILLO AND J. J. GARCIA-MEDINA

However, SH-related coagulopathy should not

be assessed only before making the decision
about the anesthetic technique to be adopted
because, as it is evolutionary, it could become
more severe with time after spinal punctures
have been done.1
In addition to thrombocytopenia in SH, this
syndrome causes hepatic alterations, which may
worse in the following hours and add quick
time alterations to platelet problems.51,52 That
is, after performing spinal puncture in these
patients who previously presented acceptable
coagulation tests, closely monitor them because
unfavorable postoperative coagulopathy development could imply a significant bleeding risk
in previously traumatized epidural vessels.
Disturbances in hepatic flow during anesthesia
and cesarean section may exacerbate liver function which, together with fibrinolysis of uterine
and placental manipulation, may act synergistically to make the coagulopathy worse.1
Even though a spinal hematoma is a potential
risk in these patients,78 neuroaxial anesthesia is
recommended to perform cesarean sections in
patients with moderate, but non-progressive,
thrombocytopenia,74 but is contraindicated in
cases with a severe coagulopathy or preoperative
bleeding.1
Some published studies have observed an
incidence of insignificant spinal hematoma in
patients with SH who have undergone regional
anesthesia.
Vigil-De-Gracia et al. studied 36 SH cases
with levels of platelets below 10,0000/mm3 in
whom locoregional anesthesia was used. Their
study did not mention any epidural hematoma;
in fact the platelet count in 12 patients was
below 50,000/mm3. No patient had either DIC
or disturbances in prothrombine time (PT)/partial thromboplastin time (PPT).86
Ankichetty et al. carried out a retrospective
review of spinal hematoma incidence in delivering women with SH. It clearly demonstrates that
administration of neuroaxial anesthesia can be
safely performed with a platelet count that
equals or is higher than 90,000/mm3.76
The study by Sibai et al. documented 16
patients with SH who had epidural analgesia;
there was only one case of bleeding in the
epidural space, and the number of platelets in
this patient was 93,000/mm3.13

SH diagnosis is a relative, but not an absolute,

contraindication of using epidural analgesia. If
there is no evidence for abnormal bleeding in
the patients medical history or assessment, and
the platelet count and hemostasis are normal,
epidural analgesia can be performed.21
Prior to undertaking epidural analgesia in
these patients, the evolving nature of the coagulopathy must be taken into account, which not
only affects the initial indication of the technique but also the appropriate time to remove
the epidural catheter and the need to monitor
coagulation and the appearance of neurological
signs, as they are indicative of epidural hematoma. For patients at risk of bleeding, and if
coagulation tests raise doubts, intradural anesthesia conducted with a pencil-tip small caliber
needle still offers more advantages than general
anesthesia, provided that maternal hemodynamic stability is ensured, although there is
very little evidence that it is a frequent problem.1,87 In this way, we also reduce potential
traumas as no epidural catheter is introduced
into the epidural space.88
As the platelet count often continues to fall
during the postpartum period and bleeding complications are common in SH patients, it is advisable to remove the epidural catheter as soon as
possible after delivery.21,44 Sprung et al.89 established the following recommendations to remove
the epidural catheter in cases with CID: (1) if
there are no signs of intraspinal bleeding, the
catheter must be removed as soon as possible
given the risk of intravascular catheter migration
and bleeding could begin; (2) if bleeding is
observed around the insertion point, it could also
occur in the intraspinal or the epidural space, so
the catheter must be left without moving it; (3)
in any case, neurological assessments must be
frequently made until the coagulopathy is
solved; (4) in those cases showing neurological
alarm signs, consult a neurologist immediately
and explore the patient by CT. However, an MRI
offers the safest diagnosis, and decompressive
laminectomy may be proposed.
The use of local anesthetics with adrenaline
for bolus in epidural anesthesia seems a safe
procedure in such patients, and it is widely
used to minimize the risks of systemic absorption of local anesthetics. There is one published
case of a hypertensive crisis with adrenaline
Acta Anaesthesiologica Scandinavica (2015)

2015 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd

HELLP SYNDROME AND ANESTHESIA

absorption which involved the introduction of

30 ml 2% lidocaine with 1:200,000 adrenaline.90
So frequent observation after its administration
is indicated in these patients.90
General anesthesia
General anesthesia, in comparison with regional
anesthesia, for SH patients involves a higher
materno-fetal anesthetic risk.20,91 A higher risk
of respiratory depression may occur given the
increased incidence of premature fetuses, deleterious effects of sympathetic stimulations of the
laryngoscopy, drug interactions, and access to
difficult airways, these being the main causes of
maternal anesthetic mortality.92
Indications of general anesthesia in these
patients are: if there is an immediate threat for
the mother and the fetus, as occurs with eclampsia; pulmonary edema; and if the level of consciousness has altered. Another indication is
when regional anesthesia is contraindicated
(e.g., coagulopathy).
Difficulty in airways is one of the main concerns for such patients in general anesthesia and
there are several reasons for this: pregnancy may
induce an edema in airways and severe bleeding; limited movement of the cervical spine; and
breast enlargement because of obesity in pregnancy, which can hinder laryngoscopies and
intubation.69,70 These factors may raise Mallampati category 3 to category 4.93 In fact, a fault in
endotracheal intubation after inducing general
anesthesia is eightfold higher in a delivering
woman that in the general population, and is
one of the causes that leads to maternal morbidity and mortality.94
There are risks related to pulmonary ventilation or gastric aspiration as these patients are
considered to have a full stomach, even though
they have been fasting, because their stomach
takes longer to empty.73 So in such situations,
one should perform general anesthesia with
rapid sequence induction and intubation.76
Prior to anesthetic induction, it is useful to
place the patient in the supine position with a
left uterine displacement, and denitrogenation,
to help ensure optimal maternal oxygenation.
General anesthesia in these patients is at high
cardiovascular risk and may cause a cardiovascular response disproportionately with intuba-

tion by producing cerebral hemorrhaging and

an edema, or cardiovascular decompensation by
causing a pulmonary edema and, therefore,
increases materno-fetal morbidity and mortality.86,95,96 In addition, a disproportionate pressor
response to intubation may increase the concentration of circulating plasmatic catecholamines
in the mother, which could be harmful for
uteroplacental blood flow.9799
The drugs used to mitigate the hemodynamic
response to intubation, as well as the surgical
procedure, include esmolol, fentanyl, remifentanil, alfentanil, and lidocaine. In such situations, it is important to consider those drugs
that have minimal effects on the fetus. One of
the drugs used in obstetrical anesthesia is
remifentanil because of its rapid metabolization
and short duration. This opioid is not metabolized by the kidney or liver, so there is no risk
of accumulation. It also involves a low risk of
respiratory depression and sedation in the neonate given its short duration, although some
cases of mild rigidity and respiratory depression
in neonates have been published. Hence more
studies are required to confirm its security in
obstetrical anesthesia.100102
SH patients often have hypoproteinemia, low
plasma volume, increased interstitial fluid, and
altered liver function. Thus, the requirements
and effects of drugs administration may be
altered.103
As a result of kidney and liver involvement in
these patients, it is advisable to choose those
drugs with less liver and kidney metabolism.
Propofol is a good choice for anesthetic induction
because it has no active metabolites, a short halflife and rapid recovery. Suxamethonium is useful
for ensuring rapid sequence intubation, but its
half-life may be prolonged because of falling
serum cholinesterase concentrations as a result of
liver dysfunction and pregnancy. A neuromuscular blockade may be performed with atracurium
or cisatracurium, which is independent of liver
and kidney metabolism. Nonetheless, neuromuscular monitoring, along with neuromuscular
blocking agents, is advisable in these patients.
The choice of volatile agents depends on each
anesthesiologist as those hepatotoxic drugs must
be avoided. Isoflurane seems a good choice given
its low biotransformation and vasodilator
action.66,104 Drugs such as ketamine should be

Acta Anaesthesiologica Scandinavica (2015)

2015 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd

REVIEW ARTICLE

Anesthetic considerations in HELLP syndrome

M. del-Rio-Vellosillo1 and J. J. Garcia-Medina2,3
1

Department of Anesthesia, University Hospital Virgen de la Arrixaca, El Palmar, Murcia, Spain

Department of Ophthalmology, University Hospital Reina Sofia, Murcia, Spain
3
Department of Ophthalmology and Optometry, University School of Medicine, University of Murcia, Murcia, Spain
2

Correspondence
M. del-Rio-Vellosillo, Department of
Anaesthesia, University Hospital Virgen de la
Arrixaca, Ctra. Madrid-Cartagena, s/n, 30120 El
Palmar, Murcia, Spain
E-mail: monicadelriov@hotmail.com
Conflicts of interest
None for either author.
Funding
None.
Submitted 25 May 2015; accepted 3
September 2015; submission 18 February
2015.
Citation
del-Rio-Vellosillo M, Garcia-Medina JJ.
Anesthetic considerations in HELLP syndrome.
Acta Anaesthesiologica Scandinavica 2015
doi: 10.1111/aas.12639

Background: HELLP syndrome (hemolysis, elevated liver

enzymes, low platelets) is an obstetric complication with heterogonous presentation and multisystemic involvement. It is characterized by microangiopathic hemolytic anemia, elevated liver
enzymes by intravascular breakdown of fibrin in hepatic sinusoids
and reduction of platelet circulation by its increased consumption.
Methods: In terms of these patients anesthetic management, it
is essential to consider some details: (1) effective, safe perioperative management by a multidisciplinary approach, and quick,
good communication among clinical specialists to achieve correct
patient management; (2) neuroaxial block, particularly spinal
anesthesia, is the first choice to do the cesarean if there is only
moderate, but not progressive thrombocytopenia; (3) if a general
anesthesia is required, it is necessary to control the response to
stress produced by intubation, especially in patients with either
severe high blood pressure or neurological signs, or to prevent
major cerebral complications; (4) invasive techniques, e.g., as tracheostomy, arterial, and deep-vein canalization, should be considered; (5) if contraindication for neuroaxial anesthesia exists, rapid
sequence intubation with general anesthesia should be regarded
as an emergency in patients with full stomach; (6) increased risk
of difficult airways should be taken into account.
Results: Optimal patient management can be chosen after considering the risks and benefits of each anesthetic technique, and
based on good knowledge of these patients pathophysiological
conditions.
Conclusion: Later, close patient monitoring is recommended for
potential development of hemorrhagic complications, disseminated intravascular coagulation (DIC), or eclampsia.

Editorial comment: what this article tells us

Hemolysis, elevated liver enzymes, and low platelets HELLP syndrome continues to be a threat
to the well-being of some obstetric patients. This article provides an updated review of perioperative approaches for safest care for obstetric patients with HELLP syndrome who need urgent operative delivery.
Pregnancy-induced hypertension is a broadspectrum entity which occurs in approximately
5% of pregnancies whose physiopathology

abnormalities are found in vasoconstrictor and

vasodilator agent production as a response to
diffuse endothelial injury, where placental

Acta Anaesthesiologica Scandinavica (2015)

2015 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd

HELLP SYNDROME AND ANESTHESIA

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

with preeclampsia or HELLP syndrome: a survey.

J Perinat Med 2015; 43: 616.
Sibai BM, Ramadan MK, Usta I, Salama M, Mercer
BM, Friedman SA. Maternal morbidity and
mortality in 442 pregnancy with hemolysis,
elevated liver enzymes, and low platelets (HELLP
syndrome). Am J Obstet Gynecol 1993; 169: 10006.
Crosby ET. Obstetrical anaesthesia for patients
with the syndrome of haemolysis, elevated liver
enzymes and low platelets. Can J Anaesth 1991;
38: 22733.
Sibai BM, Mercer BM, Schiff E, Friedman SA.
Aggressive versus expectant management of severe
preeclampsia at 28 to 32 weeks gestation: a
randomized controlled trial. Am J Obstet Gynecol
1994; 171: 81822.
Ertan AK, Wagner S, Hendrik HJ, Tanriverdi HA,
Schmidt W. Clinical and biophysical aspects of
HELLP-syndrome. J Perinat Med 2002; 30: 4839.
Basaran A, Basaran M, Sen C. Choice of
glucocorticoid in HELLP syndrome
dexamethasone versus betamethasone:revisiting
the dilemma. J Matern Fetal Neonatal Med 2012;
25: 2597600.
Woudstra DM, Chandra S, Hofmeyr GJ, Dowswell
T. Corticosteroids for HELLP (hemolysis, elevated
liver enzymes, low platelets) syndrome in
pregnancy. Cochrane Database Syst Rev 2010 (9):
CD008148.
OBrien JM, Shumate SA, Satchwell SL, Milligan
DA, Barton JR. Maternal benefit of corticosteroid
therapy in patients with HELLP (hemolysis,
elevated liver enzymes, and low platelet count)
syndrome: impact on the rate of regional
anesthesia. Am J Obstet Gynecol 2002; 186: 4759.
Katz L, de Amorim MM, Figueiroa JN, Pinto e
Silva JL. Postpartum dexamethasone for women
with hemolysis, elevated liver enzymes, and low
platelets (HELLP) syndrome: a double-blind,
placebo-controlled, randomized clinical trial. Am J
Obstet Gynecol 2008; 198: 283. e1-8.
Hypertension in pregnancy. Report of the
American College of Obstetricians and
Gynecologists Task Force on Hypertension in
Pregnancy. Obstet Gynecol 2013; 122: 112231.
Martin JN Jr, Thigpen BD, Moore RC, Rose CH,
Cushman J, May W. Stroke and severe
preeclampsia and eclampsia: a paradigm shift
focusing on systolic blood pressure. Obstet
Gynecol 2005; 105: 24654.
Hennessy A, Thornton CE, Makris A, Ogle RF,
Henderson-Smart DJ, Gillin AG, Child A. A
randomized comparison of hydralazine and mini-

31.

32.

33.

34.

35.

36.
37.

38.

39.

40.

41.

42.

43.

bolus diazoxide for hypertensive emergencies in

pregnancy: the PIVOT trial. Aust N Z J Obstet
Gynaecol 2007; 47: 27985.
Duley L, G
ulmezoglu AM, Chou D. Magnesium
sulphate versus lytic cocktail for eclampsia.
Cochrane Database Syst Rev 2010; 9: CD002960.
Duley L, Henderson-Smart DJ, Walker GJA, Chou
D. Magnesium sulphate versus diazepam for
eclampsia. Cochrane Database Syst Rev 2010; 12:
CD000127.
Garg R, Nath MP, Bhalla AP, Kumar A.
Disseminated intravascular coagulation
complicating HELLP syndrome: perioperative
management. BMJ Case Rep 2009; 2009: pii:
bcr10.2008.1027.
The Collaborative Eclampsia Trial Group. Which
anticonvulsant for women with eclampsia?
Evidence from the Collaborative Eclampsia Trial.
Lancet 1995; 345: 145563.
Chan SM, Lu CC, Ho ST, Liaw WJ, Cherng CH,
Chen WH, Lin TC. Eclampsia following cesarean
section with HELLP syndrome and multiple organ
failure. Acta Anaesthesiol Taiwan 2008; 46: 468.
Dennis AT. Management of pre-eclampsia: issues
for anaesthetists. Anaesthesia 2012; 67: 100920.
Baxter JK, Weinstein L. HELLP syndrome: the
state of the art. Obstet Gynecol Surv 2004; 59:
83845.
The Royal College of Obstetricians and
Gynaecologists. Blood transfusion in obstetrics.
Guideline Number 47. 2007:110. Available at:
http://www.rcog.org.uk/files/rcog-corp/uploadedfiles/GT47 BloodTransfusions1207amended.pdf
(accessed 30 December 2011).
Eser B, Guven M, Unal A, Coskun R, Altuntas F,
Sungur M, Serin IS, Sari I, Cetin M. The role of
plasma exchange in HELLP syndrome. Clin Appl
Thromb Hemost 2005; 11: 2117.
Bayraktaro
glu Z, Demirci F, Balat O, Kutlar I,
Okan V, U
gur G. Plasma exchange therapy in
HELLP syndrome: a single-center experience. Turk
J Gastroenterol 2006; 17: 99102.
Martin JN Jr, Files JC, Blake PG, Perry KG Jr,
Morrison JC, Norman PH. Postpartum plasma
exchange for atypical preeclampsia-eclampsia as
HELLP (hemolysis, elevated liver enzymes, and
low platelets) syndrome. Am J Obstet Gynecol
1995; 172: 110727.
Rowe T. Diagnosis, evaluation, and management
of the hypertensive disorders of pregnancy. J
Obstet Gynaecol Can 2008; 30(Suppl): 148.
Martin JN Jr, Files JC, Blake PG, Norman PH,
Martin RW, Hess LW, Morrison JC, Wiser WL.

Acta Anaesthesiologica Scandinavica (2015)

2015 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd

11

M. DEL-RIO-VELLOSILLO AND J. J. GARCIA-MEDINA

44.

45.

46.

47.

48.

49.

50.

51.

52.

53.

54.

55.

Plasma exchange for preeclampsia. I. Postpartum

use for persistently severe preeclampsia eclampsia
with HELLP syndrome. Am J Obstet Gynecol
1990; 162: 12637.
Magann EF, Martin JN Jr. Twelve steps to optimal
management of HELLP syndrome. Clin Obstet
Gynecol 1999; 42: 53250.
Duley L, Williams J, Henderson-Smart DJ.
Plasma volume expansion for treatment of
pre-eclampsia. Cochrane Database Syst Rev 1999;
4: CD001805.
Ho KM, Sheridan DJ. Meta-analysis of frusemide
to prevent or treat acute renal failure. BMJ 2006;
333: 420.
Steyn DW, Steyn P. Low-dose dopamine for
women with severe pre-eclampsia. Cochrane
Database Syst Rev 2007; 1: CD003515.
Isler CM, Rinehart BK, Terrone DA, Martin RW,
Magann EF, Martin JN Jr. Maternal mortality
associated with HELLP (hemolysis, elevated liver
enzymes, and low platelets) syndrome. Am J
Obstet Gynecol 1999; 181: 9248.
Cavkaytar S, Ugurlu EN, Karaer A, Tapisiz OL,
Danisman N. Are clinical symptoms more
predictive than laboratory parameters for adverse
maternal outcome in HELLP syndrome? Acta
Obstet Gynecol Scand 2007; 86: 64851.
Barton JR, Sibai BM. Gastrointestinal
complications of preeclampsia. Semin Perinatol
2009; 33: 17988.
Argueta M, Neri C, Lira J, Ibaguengoitia F,
V
azquez ME. HELLP syndrome: year experience at
the National Institute of Perinatology. Gynecol
Obstet Mex 1995; 63: 21721.
Laguna EM, Edo L, Sorribes V, Benlloch R,
Barrachina V, Moral MV. HELLP syndrome and its
complications during preeclampsia-eclampsia. Rev
Esp Anestesiol Reanim 1995; 42: 14850.
Osmanagaoglu MA, Osmanagaoglu S, Ulusoy H,
Bozkaya H. Maternal outcome in HELLP
syndrome requiring intensive care management
in a Turkish hospital. Sao Paulo Med J 2006;
124: 859.
Witlin AG, Baha DO, Sibai M. Diagnosis and
management of women with hemolysis, elevated
liver enzymes, and low platelet count (HELLP)
syndrome. Hosp Physician 1999; 49: 405.
Habli M, Eftekhari N, Wiebracht E, Bombrys A,
Khabbaz M, How H, Sibai B. Long-term maternal
and subsequent pregnancy outcomes 5 years after
hemolysis, elevated liver enzymes, and low
platelets (HELLP) syndrome. Am J Obstet Gynecol
2009; 201: 385.e1-5.

56. Mihu D, Costin N, Mihu CM, Seicean A, Ciortea

R. HELLP syndrome a multisystemic disorder. J
Gastrointestin Liver Dis 2007; 16: 41924.
57. Kawabata I, Nakai A, Takeshita T. Prediction of
HELLP syndrome with assessment of maternal
dual hepatic blood supply by using Doppler
ultrasound. Arch Gynecol Obstet 2006; 274: 3039.
58. Levine RJ, Maynard SE, Qian C, Lim KH, England
LJ, Yu KF, Schisterman EF, Thadhani R, Sachs BP,
Epstein FH, Sibai BM, Sukhatme VP,
Karumanchi SA. Circulating angiogenic factors
and the risk of preeclampsia. N Engl J Med 2004;
350: 67283.
59. Araujo AC, Leao MD, Nobrega MH, Bezerra PF,
Pereira FV, Dantas EM, Azevedo GD, Jeronimo
SM. Characteristics and treatment of hepatic
rupture caused by HELLP syndrome. Am J Obstet
Gynecol 2006; 195: 12933.
60. Darby M, Martin JN Jr, Mitchell SQ, Owens MY,
Wallace K. Using case reports to determine when
liver bleeding occurs during disease progression in
HELLP syndrome. Int J Gynaecol Obstet 2013;
123: 79.
61. Wicke C, Pereira PL, Neeser E, Flesch I,
Rodegerdts EA, Becker HD. Subcapsular liver
hematoma in HELLP syndrome: Evaluation of
diagnostic and therapeutic optionsa unicenter
study. Am J Obstet Gynecol 2004; 190: 10612.
62. Carlson KL, Bader CL. Ruptured subcapsular liver
hematoma in pregnancy: a case report of
nonsurgical management. Am J Obstet Gynecol
2004; 190: 55860.
63. Aslan H, Gul A, Cebeci A. Neonatal outcome in
pregnancies after preterm delivery for HELLP
syndrome. Gynecol Obstet Invest 2004; 58: 969.
64. Wulf H. Anesthesia and intensive therapy of
pregnant women with the HELLP syndrome.
Anaesthesist 1990; 39: 11721.
65. Miyamoto N, Kawamata M, Okanuma M, Kawana
S, Namiki A. Obstetrical anesthesia for parturient
patients with HELLP syndrome. Masui 2002; 51:
96872.
66. Patterson KW, OToole DP. HELLP syndrome: a
case report with guidelines for diagnosis and
management. Br J Anaesth 1991; 66: 5135.
67. Barton JR, Sibai BM. Acute life-threatening
emergencies in preeclampsia eclampsia. Clin
Obstet Gynecol 1992; 35: 40213.
68. Fox DB, Troiano NI-I, Graves CR. Use of the
pulmonary artery catheter in severe preeclampsia:
a review. Obstet Gynecol Surv 1996; 51: 68495.
69. Practice guidelines for pulmonary artery
catheterization. A report by the American Society
Acta Anaesthesiologica Scandinavica (2015)

12

2015 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd

HELLP SYNDROME AND ANESTHESIA

70.

71.

72.

73.

74.

75.

76.

77.

78.

of Anesthesiologists Task force on pulmonary

artery catheterization. Anesthesiology 1993; 78:
38094.
Egley CC, Gutliph J, Bowes WA Jr. Severe
hypoglycemia associated with HELLP syndrome.
Am J Obstet Gynecol 1985; 152: 5767.
National Collaborating Centre for Womens and
Childrens Health. Hypertension in pregnancy. The
management of hypertensive disorders during
pregnancy. National Institute for Health and
Clinical Excellence Guideline 107. August 2010
revised reprint January 2011 ed. London: RCOG,
2011. http://www.nice.org. uk/nicemedia/live/
13098/50475/50475.pdf (accessed 30 December
2011).
Lewis G, ed. The Confidential Enquiry into
Maternal and Child Health (CEMACH). Saving
Mothers Lives: Reviewing Maternal Deaths to
Make Motherhood Safer 20032005. The Seventh
report on Confidential Enquiries into Maternal
Deaths in the United Kingdom. London:
CEMACH, 2007.
Cantwell R, CluttonBrock T, Cooper G, Dawson
A, Drife J, Garrod D, Harper A, Hulbert D, Lucas
S, McClure J, Millward-Sadler H, Neilson J,
Nelson-Piercy C, Norman J, OHerlihy C, Oates M,
Shakespeare J, de Swiet M, Williamson C, Beale
V, Knight M, Lennox C, Miller A, Parmar D,
Rogers J, Springett A. Saving mothers lives:
reviewing maternal deaths to make motherhood
safer: 20062008. The eighth report of the
confidential enquiries into maternal deaths in the
United Kingdom. Br J Obstet Gynaecol 2011; 118:
1203.
Crosby ET, Preston R. Obstetrical anaesthesia for a
parturient with preeclampsia, HELLP syndrome
and acute cortical blindness. Can J Anaesth 1998;
45: 4529.
Makris A, Thornton C, Hennessy A. Postpartum
hypertension and nonsteroidal analgesia. Am J
Obstet Gynecol 2004; 190: 5778.
Ankichetty SP, Chin KJ, Chan VW, Sahajanandan
R, Tan H, Grewal A, Perlas A. Regional anesthesia
in patients with pregnancy induced hypertension.
J Anaesthesiol Clin Pharmacol 2013; 29: 43544.
Jouppila R, Hollm

en A. The effect of segmental
epidural analgesia on maternal and foetal acidbase balance, lactate, serum potassium and
creatine phosphokinase during labour. Acta
Anaesthesiol Scand 1976; 20: 25968.
Koyama S, Tomimatsu T, Kanagawa T, Sawada K,
Tsutsui T, Kimura T, Chang YS, Wasada K, Imai
S, Murata Y. Spinal subarachnoid hematoma

79.

80.

81.

82.

83.

84.

85.

86.

87.

88.

89.

90.

91.

following spinal anesthesia in a patient with

HELLP syndrome. Int J Obstet Anesth 2010; 19:
8791.
Lao TT, Halpern SH, MacDonald D, Huh C. Spinal
subdural haematoma in a parturient after
attempted epidural anaesthesia. Can J Anaesth
1993; 40: 3405.
Scott DB, Hibbard BM. Serious non-fatal
complications associated with extradural block
in obstetric practice. Br J Anaesth 1990; 64:
53741.
Tetzlaff JE. Spinal, epidural and caudal blocks. In:
Morgan GE Jr, Mikhail MS, eds. Clinical
anesthesiology, 2nd edn. Stamford: Lange Medical
Book. Prentice Hall Intemational, 1996: 2l144.
van Veen JJ, Nokes TJ, Makris M. The risk of
spinal haematoma following neuraxial anaesthesia
or lumbar puncture in thrombocytopenic
individuals. Br J Haematol 2010; 148: 1525.
Sharma SK, Philip J, Whitten CW, Padakandla
UB, Landers DF. Assessment of changes in
coagulation in parturients with preeclampsia using
thromboelastography. Anesthesiology 1999; 90:
38590.
Beilin Y, Zahn J, Comerford M. Safe epidural
analgesia in thirty parturients with platelet counts
between 69,000 and 98,000 mm(-3). Anesth Analg
1997; 85: 3858.
Frenk V, Camann W, Shankar KB. Regional
anesthesia in parturients with low platelet counts.
Can J Anaesth 2005; 52: 114.
Vigil-De Gracia P, Silva S, Montufar C, Carrol I,
De Los Rios S. Anesthesia in pregnant women
with HELLP syndrome. Int J Gynaecol Obstet
2001; 74: 237.
Hood DD, Boese PA. Epidural and spinal
anesthesia for elective cesarean section in severely
pre-edamptic parturients. Reg Anesth 1992; 17S:
35.
Writer D. Hypertensive disorders. In: Chestnut DH
ed. Obstetric anesthesia. Principles and practice.
St. Louis: Mosby, 1994: 846878.
Sprung J, Cheng EY, Patel S. When to remove an
epidural catheter in a parturient with disseminated
intravascular coagulation. Reg Anesth 1992; 17:
3514.
Hadzic A, Vloka J, Patel N, Birnbach D.
Hypertensive crisis after a successful placement
of an epidural anesthetic in a hypertensive
parturient. Case report. Reg Anesth 1995; 20:
1568.
Hawkins JL, Koonin LM, Palmer SK, Gibbs CP.
Anesthesia-related deaths during obstetrics

Acta Anaesthesiologica Scandinavica (2015)

2015 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd

13

M. DEL-RIO-VELLOSILLO AND J. J. GARCIA-MEDINA

92.

93.

94.
95.

96.

97.

98.

99.

delivery in the United States, 1979-1990.

Anesthesiology 1997; 86: 27784.
Chestnut DH. Anesthesia for the high risk
obstetrical patient, vol. 234. Annual Refresher
Course Lectures. Atlanta: American Society of
Anesthesiologists, 1995: 17.
Boutonnet M, Faitot V, Katz A, Salomon L, Keita
H. Mallampati class changes during pregnancy,
labour, and after delivery: can these be predicted?
Br J Anaesth 2010; 104: 6770.
Lyons G. Failed intubation. Anaesthesia 1985; 40:
759762.4.
Lawes EG, Downing JW, Duncan PW, Bland B,
Lavies N, Gane GA. Fentanyl-droperidol
supplementation of rapid sequence induction in
the presence of severe pregnancy-induced and
pregnancy-aggravated hypertension. Br J Anaesth
1987; 59: 138191.
Loughran PG, Moore J, Dundee JW. Maternal
stress response associated with caesarean delivery
under general and epidural anaesthesia. Br J
Obstet Gynaecol 1986; 93: 9439.
Gin T, OMeara ME, Kan AF, Leung RK, Tan P,
Yau G. Plasma catecholamines and neonatal
condition after induction of anaesthesia with
propofol or thiopentone at caesarean section. Br J
Anaesth 1993; 70: 3116.
Shnider SM, Wright RG, Levinson G, Roizen MF,
Wallis KL, Rolbin SH, Craft JB. Uterine blood
flow and plasma norepinephrine changes during
maternal stress in the pregnant ewe.
Anesthesiology 1979; 50: 5247.
Jouppila P, Kuikka J, Jouppila R, Hollm

en A.
Effect of induction of general anesthesia for

100.

101.

102.

103.

104.

105.

106.

cesarean section on intervillous blood flow. Acta

Obstet Gynecol Scand 1979; 58: 24953.
Richa F, Yazigi A, Nasser E, Dagher C, Antakly MC.
General anesthesia with remifentanil for Cesarean
section in a patient with HELLP syndrome. Acta
Anaesthesiol Scand 2005; 49: 41820.
Van de Velde M, Teunkens A, Kuypers M,
Dewinter T, Vandermeersch E. General
anaesthesia with target controlled infusion of
propofol for planned caesarean section: maternal
and neonatal effects of a remifentanil-based
technique. Int J Obstet Anesth 2004; 13: 1538.
Carvalho B, Mirikitani EJ, Lyell D, Evans A,
Druzin M, Riley ET. Neonatal chest wall rigidity
following the use of remifentanil for cesarean
delivery in a patient with autoimmune hepatitis
and thrombocytopenia. Int J Obstet Anesth 2004;
13: 536.
del-Rio-Vellosillo M, Martin-Gil-Parra R, GarciaMedina JJ. Anesthetic considerations for Cesarean
section in a parturient with Charcot-Marie-Tooth
disease and HELLP syndrome. J Clin Anesth
2014; 26: 2512.
Palit S, Palit G, Vercauteren M, Jacquemyn Y.
Regional anaesthesia for primary caesarean section
in patients with preterm HELLP syndrome: a
review of 102 cases. Clin Exp Obstet Gynecol
2009; 36: 2304.
Ghoneim MM, Long JP. The interaction between
magnesium and other neuromuscular blocking
agents. Anesthesiology 1970; 32: 237.
Weitzner RM, Malinow AM. The eclamptic
patient-Anesthestic management. Anaesthesiol
Clin 1998; 16: 32330.

Acta Anaesthesiologica Scandinavica (2015)

14

2015 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd