Clinical Topics: HELLP Syndrome
What is HELLP Syndrome?
The acronym HELLP stands for Hemolysis Elevated Liver enzymes & Low Platelets. Hemolysis is the rupture of red blood cells and the distribution of their contents into the blood. This results in schistocytes, burr cells, and cells with variegated coloring in a stained red cell exam.
There is really no clear scientific reason for why this happens, though midwives attribute most cases of eclampsia/toxemia/HELLP to inadequate blood volume expansion in pregnancy due to inadequate caloric/protein intake.
Symptoms usually begin presenting themselves in the third trimester (though 10% of cases show up earlier and 20% show up after women give birth) and the allopathic way of treating HELLP is to induce birth if the pregnancy is 35 weeks or later, especially, or to give medications to lower blood pressure and possibly blood transfusions as well if the pregnancy is before 35 weeks gestation.
Symptoms:
Feeling tired, swelling, headache, nausea, upper right abdominal pain, blurry vision, nosebleeds, seizures, backache, anemia, high blood pressure (over 160/110). Symptoms can vary in severity greatly from individual to individual.
Possible complications:
Blood clots (yes, you’d think low platelets would mean less blood clotting, but there is an overcorrection mechanism that happens in the body that can cause a LOT of miniature blood clots throughout the body, which can cause problems in very tiny blood vessels), placental abruption, intrauterine growth restriction (IUGR), kidney and/or liver damage/failure, clotting problems (you can imagine this would be an issue during cesarean birth/surgery), seizures, stillbirth, or retinal detachment.
Risk factors:
Previous pregnancy with a HELLP diagnosis, being older than 25 years old, and being caucasion. Also being diagnosed with preeclampsia or eclampsia can happen concurrently with HELLP.
Diagnosis:
The earliest signs of potential impending issues are a stable or rising hemoglobin/hematocrit. This occurs because the blood volume is beginning to contract. (There should pretty much always be a drop in hemoglobin from the 12 week value as pregnancy progresses.) This combined with small for dates fetal growth are the absolute earliest signs of impending issues and should be very closely monitored and corrected as soon as possible with nutritional adjustments. This usually shows between 22 to 29 weeks and the mother may be still feeling fairly well at this point.
(Good news is that the above issues are SUPER EASILY rectified by adequate caloric/protein intake.)
Much later (possibly even 10+ weeks later) blood tests showing lactate dehydrogenase greater than 600 U/I, aspartate transaminase greater than 70 U/I, and platelets less than 100x10^9/l indicate true HELLP syndrome. These are the three main markers used to diagnose HELLP clinically.
Leukocytes, bilirubin, LDH, ALT, and AST can also be elevated. White blood cell count can be low. Protein may spill into the urine, and there can also be leukocytes and elevated uric acid showing in urine. Hematocrit levels fall dramatically as red blood cell destruction continues.
Action Plan:
At the first sign of issues, including marked slow down in rate of growth in the baby, or any symptoms of contracting blood volume, we need to sit down together and evaluate the mother’s lifestyle and diet in order to try to optimize it for her pregnancy and her baby. We can also go over my care for her and determine if there are any areas in which she is feeling a lack of support.
Depending on the mother’s lifestyle, some options would be to cut down on exercise (or alternatively add some gentle movement exercise like walking or yoga if there has been none), cut back on work, stay out of the heat, postpone big life events like moving homes or marriage or long trips, lower overall stress, adjust diet and supplements, and adding calming or spiritual connection based practices into her daily routine.
If the mother works a demanding job like nursing, doctoring, waitressing, or any other job on her feet all day or night, she will need to compensate for that by adding extra calories, protein, and healthy salt to her diet above and beyond what she would imagine during pregnancy. A good rule of thumb is to add 200 calories and 20 grams of protein per day for each additional stress that is in her daily life (ie working full time, nursing an older child, traveling often, working on her feet all day, working out to sweat every day, etc..).
150 to 250 grams of protein daily and 3000 to 4000 calories per day for a singleton pregnancy is not abnormal when trying to increase blood volume and support the liver to function adequately after blood volume has been contracted for some time.
This seems like SO MUCH to the average woman but TRUST, expanding your blood volume is worth it to avoid all of these potential complications.
If a woman is having a hard time regulating her blood pressure or with gaining adequate weight/blood volume during her pregnancy, she should try to eat at least a snack with high protein in it for every hour that she is awake, in addition to normal meals. This can be a handful of trail mix, nuts, cheese, a glass of milk, etc.. This will help ensure that she is getting adequate fuel for her body to make extra blood and perform all the extra metabolic functions of pregnancy.
Adding a high dose of vitamin C and lactobacilli intake (ideally from food: fermented dairy, ideally, for the lactobacilli source, not just from probiotic supplements) can help with platelet formation and red blood cell health, hematocrit and hemoglobin levels, lowering blood pressure, as well as general liver health and blood vessel integrity. Increasing calcium intake to 1200 mg and magnesium to 400-600 mg daily is also wise. Removing any herbs or supplements that could contribute to lower blood volume levels (like nettle, dandelion, alfalfa, celery - these are all mild diuretics which can cause low blood volume or dehydration if consumed in large doses) is also prudent.
Relaxation practices, guided meditations and visualizations, walking, gentle stretching, praying, taking time to connect with the baby, singing, gentle dancing, getting outside in nature, being creative in some way, and other pursuits of joy and relaxation can help a woman to slow down, come back into her body, and relax and ground to the point that health issues become less severe.
If there are psychological issues that may be preventing the mother from feeling good about gaining weight or being pregnant, we will inquire about those and attempt to shed some light and do some processing of those signposts as well.
If all of the above are tried and none of it has an effect on the mother’s health status or clinical factors like urinalysis, blood pressure, hemoglobin, size/growth of baby, and mother’s feeling of wellbeing within a few days (most women report feeling REMARKABLY better within a day or two of making these shifts), perhaps there is some issue within the body that we are not aware of or able to perceive (ie nutrient absorption issues) and transfer of care to a medical professional more suited to higher “risk” pregnancies would be prudent.
Allopathic care:
Western medicine providers would most likely administer corticosteroids and then if you are greater than or equal to 35 weeks, they would encourage delivery of your baby. If you are less than 34 weeks, they would see if the condition worsens after administering steroids and if so, deliver the baby regardless of your gestation. If your condition stabilizes, they would wait until 35 weeks (or later) and then deliver your baby at or after that point.
You could also receive anti-seizure medications (magnesium sulfate), medications to lower blood pressure (these will most likely further stress an already damaged/weakened liver and possibly negatively affect platelet function as well. A weakened liver would allow more medications to pass to the baby as well, which could cause platelet issues and low white blood cell counts in your baby), blood/platelet transfusions, medications to ripen your cervix, and medications to induce labor while at the medical care facility.
If you are not at a facility with a NICU, they will likely transfer you to one.
In conclusion:
HELLP is a pretty rare syndrome during pregnancy and it is extremely preventable by using diet/nutrition and the suggestions above. I hope this to-the-point post about HELLP was/is informative and please reach out to me if you have any further questions or if you feel I missed something!
Sources:
Anne Frye’s Diagnostic Tests
Anne Frye’s Holistic Midwifery Vol 1
Gail Hart’s Research Updates for Midwives
http://www.drbrewerpregnancydiet.com/id81.html
