HELLP Syndrome

What Is HELLP Syndrome?

HELLP is an acronym that describes the dangerous changes which occur inside the pregnant patient’s body:

H — Hemolysis: Red blood cells, which carry oxygen throughout the body, are broken apart.

EL — Elevated Liver enzymes: The liver is inflamed and injured.

LP — Low Platelets: Platelets, the tiny cells responsible for clotting, are rapidly used up and depleted.

At its core, HELLP is a disorder of the blood and blood vessels during pregnancy. The small vessels that normally carry blood through the body become damaged and inflamed. As blood pushes through those damaged vessels, red blood cells are sheared apart, the liver becomes injured, and platelets are consumed faster than the body can replace them.

Who Is at Risk for HELLP, When, and Why

HELLP can develop in any pregnancy, but certain patients face a higher risk. The most well-established risk factors include a current or prior diagnosis of preeclampsia, a prior pregnancy affected by HELLP, chronic high blood pressure, diabetes, certain autoimmune conditions, age over 35, and pregnancies with twins or other multiples.

HELLP most commonly develops in the third trimester, after about 28 weeks of pregnancy, but can appear earlier in pregnancy as well.  Critically, HELLP can develop after delivery in the postpartum period.  Postpartum HELLP most often occurs within the first 48 hours after birth, but it can develop up to a week later.

Postpartum HELLP Syndrome is one of the most dangerous patterns in obstetrics, and it is one of the most common scenarios in which health care providers overlook the diagnosis of HELLP. Families, and sometimes their obstetrical providers, assume that the obstetric danger ends once the baby is born. It does not. When a new parent calls their obstetrician or returns to the hospital with severe headache, upper abdominal pain, or unexplained illness in the days after delivery, the patient must be evaluated for HELLP.

The Most Common Symptoms of HELLP

The symptoms of HELLP tend to track what the syndrome is doing inside the body. Understanding that connection helps explain why each symptom matters:

Right upper quadrant or epigastric pain — severe pain under the ribs on the right side or in the upper middle of the abdomen — reflects the liver becoming swollen and injured.

Nausea and vomiting often accompany that liver injury and are frequently misread as a stomach bug, food poisoning, or ordinary late-pregnancy indigestion.

Severe or persistent headache may reflect rising blood pressure and changes in the brain’s blood vessels.

Visual changes — blurred vision, spots, flashing lights, or sensitivity to light — are warning signs that the condition is affecting the nervous system.

A profound sense of malaise — the feeling that something is deeply wrong — is common and should never be dismissed.

High blood pressure is present in most but not all cases.

Swelling of the face, hands, or legs may accompany the condition.

Easy bruising, nosebleeds, or bleeding from IV sites signal that platelets have dropped to dangerous levels.

Many of these symptoms overlap with the ordinary discomforts of late pregnancy.  A competent obstetric provider is trained to recognize that what seems like heartburn or a benign headache in a pregnant or postpartum woman may not be heartburn or a headache at all. Treating classic HELLP symptoms as routine complaints, without appropriate evaluation, is one of the most common mistakes leading to the missed diagnosis of HELLP.

How HELLP Progresses — and Why Delay In Diagnosis Is So Dangerous

HELLP tends to progress, sometimes slowly over days, and sometimes explosively over hours. In the early stage, symptoms are vague and laboratory values may just be starting to shift. This is the stage at which recognition is easiest and outcomes are best. As the condition advances, abdominal pain sharpens, liver enzymes climb, platelets fall, bruising and bleeding begin, blood pressure may rise, and the baby may begin to show signs of distress. In the most advanced stage, the pregnant patient is critically ill, the liver may be at risk of rupture.  At this stage, blood clotting has broken down, and the risks of hemorrhage, stroke, and placental abruption rise sharply.

From a medical-legal perspective, the fact HELLP is a progressive disease means that HELLP gives warning. Except in the rarest cases, there is a window — often hours, sometimes longer — during which a competent physician or other health care provider can intervene to treat HELLP and prevent catastrophic harm.

When Doctors Should Suspect HELLP — and When Failing to Suspect It Is Negligent

A competent obstetrician, emergency physician, hospitalist, or labor-and-delivery nurse is expected to consider and do testing to rule out HELLP when a pregnant or recently postpartum patient presents with:

• Upper abdominal pain
• Severe or persistent headache
• Visual disturbances
• Unexplained nausea and vomiting late in pregnancy or after delivery
• New or worsening high blood pressure
• New symptoms in a patient already known to have preeclampsia
• Any concerning complaint within the first week after delivery

The tests needed to rule out HELLP are inexpensive, widely available, and can be processed quickly in virtually any hospital. When a patient with those symptoms is sent home without a workup, or is told to wait for a routine appointment, or is given a diagnosis of “reflux” or “the flu” or “a tension headache” without laboratory evaluation, that is a moment at which the standard of care may have been breached. These are the moments our firm investigates most often. We focus on what was documented in the medical record, including what tests were ordered, what was not ordered, what was asked, and what was written down. The record of what did not happen is often as important as the record of what did.

How HELLP is Diagnosed

Diagnosing HELLP requires a physician or advanced practice provider to think to look for it and order ordinary laboratory tests. These tests include a complete blood count, liver function tests, a peripheral blood smear, kidney function tests, coagulation studies, and urinalysis — together with appropriate blood pressure and fetal monitoring. These are standard tests run in every hospital, every day.

The Harm Caused by Delay

When HELLP is missed or allowed to progress, the consequences can be devastating and permanent. Delayed diagnosis and treatment can cause disseminated intravascular coagulation (DIC) — a breakdown of the body’s clotting system in which the blood simultaneously clots and fails to clot, leading to uncontrolled bleeding and organ damage. HELLP can cause placental abruption, in which the placenta tears away from the uterine wall, threatening both massive maternal hemorrhage and fetal death. It can cause severe internal bleeding, including rupture of a liver hematoma, which carries a high fatality rate. It can cause stroke and intracerebral hemorrhage, leaving a pregnant patient dead or permanently disabled. It can cause acute kidney failure, acute liver failure, and maternal death. And it can cause grave harm to the baby — oxygen deprivation, brain injury, severe prematurity, stillbirth, and neonatal death.

The Overlap With Preeclampsia With Severe Features

HELLP Syndrome and preeclampsia with severe features are closely related and are often considered part of the same spectrum of hypertensive disorders of pregnancy. They share many symptoms — high blood pressure, severe headache, visual changes, and upper abdominal pain — and many women with HELLP also meet the criteria for preeclampsia.

Importantly, HELLP can develop without two of the common features of preeclampsia with severe features – dramatically elevated blood pressure and significant protein in the urine. When a clinician rules out preeclampsia based on a borderline blood pressure reading or a normal urine test, and stops there, HELLP can be missed entirely. A pregnant or postpartum patient with the classic symptoms of HELLP deserves a full evaluation for HELLP even when the patient does not neatly fit the picture of preeclampsia.

How HELLP Is Treated

The general approach to treatment involves stabilizing the pregnant patient.  This involves controlling blood pressure, administering magnesium sulfate to prevent seizures, correcting clotting problems, and transfusing blood products as needed.  Sometimes, corticosteroids are given to the pregnant patient to support the fetus’s lung development if delivery can be briefly delayed. Ultimately, delivery is the only definitive treatment for HELLP.

When serious harm occurs after recognition of HELLP, it is frequently because the response was too slow — too slow to transfer the patient to a facility equipped to deliver her, too slow to involve maternal-fetal medicine, too slow to proceed to cesarean delivery when it was clearly indicated, or too slow to treat the complications that had already begun. When care that results in a delay in treatment of a patient with HELLP falls below what is required of a competent medical team, it is a breach of the standard of care.

The Most Challenging Aspects of Diagnosis — And Why They Are Not Excuses

HELLP is genuinely difficult to catch. Its symptoms overlap with the ordinary discomforts of late pregnancy. It can mimic gallbladder disease, gastritis, viral illness, or migraine. Blood pressure may not always be dramatically elevated. Postpartum presentations are easy to dismiss because the pregnant patient has “already delivered” and is no longer under active medical treatment. And the condition can rapidly progress from mild to critical.

These challenges to the diagnosis and treatment of HELLP are real. But the standard of care takes those challenges into account. The law does not ask whether a diagnosis was easy; it asks whether a reasonably competent clinician, faced with the same patient and the same presentation, would have recognized the warning signs, ordered the appropriate tests, and acted on the results. The difficulty of HELLP is the reason for heightened vigilance, not an excuse for missing it.

Why Rarity Is No Excuse — The Role of the Differential Diagnosis

It is sometimes argued, after a tragic outcome, that HELLP is simply too rare to expect physicians to catch every time. That argument misunderstands both medicine and the law.

When a pregnant or postpartum patient presents with upper abdominal pain, severe headache, visual changes, or unexplained illness, her treating physicians are trained — and professionally required — to construct a differential diagnosis. A differential diagnosis is the systematic list of possible diagnosis that can explain a patient’s recent medical history, signs, and symptoms.  A competent physician must consider, test for, and rule out each potential diagnosis, starting with the most life-threatening. The process is not a formality. It is the central discipline of clinical medicine, and it is the standard against which a physician’s conduct is measured in a malpractice case.

The differential diagnosis exists precisely to catch both common and rare life-threatening conditions. Missing a rare but deadly diagnosis is exactly the kind of failure the process is designed to prevent. Upper abdominal pain in a pregnant patient has a short list of dangerous possibilities — HELLP Syndrome, preeclampsia with severe features, placental abruption, and acute fatty liver of pregnancy among them. A physician who dismisses that pain as reflux without considering and ruling out those diagnoses has failed to perform the analysis the standard of care requires.

The rarity of HELLP is not a defense. It is the reason the process of differential diagnosis exists.

Common Scenarios of Negligence in HELLP Cases

In our experience handling obstetric malpractice cases, failures involving HELLP Syndrome tend to fall into recognizable patterns. Not every bad outcome is a case of negligence, but when negligence is present, it often looks like one of the following:

• Dismissing the symptoms. A pregnant or postpartum patient reports upper abdominal pain, severe headache, visual changes, or persistent nausea and vomiting, and is told she has heartburn, a virus, or a tension headache without a workup.
• Failing to order readily available tests. A symptomatic patient is evaluated and sent home without a complete blood count, liver function tests, or coagulation studies — the very tests that would have revealed HELLP.
• Failing to recognize abnormal results. The tests are ordered, but the abnormal values are missed, minimized, not communicated to the treating physician, or not acted upon.
• Stopping at preeclampsia. The care team focuses on blood pressure and proteinuria, concludes preeclampsia is not present or not severe, and fails to recognize that HELLP can exist without those features.
• Sending a postpartum patient home. A recently delivered patient returns with classic HELLP symptoms and is reassured, advised to rest, or told to wait for her routine follow-up appointment instead of being evaluated.
• Communication breakdowns. A nurse documents concerning findings that never reach the physician, or a physician’s order is not carried out in a timely way, or a change in the patient’s condition is not escalated.
• Delayed delivery. HELLP is recognized, but the team is too slow to proceed to delivery, too slow to transfer to a higher-level facility, or too slow to treat bleeding and clotting complications that have already begun.
• Failing to monitor known high-risk patients. A patient with preeclampsia, a prior history of HELLP, or other risk factors is not monitored with the vigilance her risk level demands.

Each of these scenarios is preventable. Each of them shows up in the medical record when it happens. And each of them can be the foundation of a successful claim on behalf of a patient or family whose life was permanently changed by a failure that did not have to occur.

HELLP Syndrome is rare, but it is not foreign or too obscure for doctors to think about. The tools needed to diagnose are readily available to doctors and hospital staff. The symptoms that should raise suspicion are well known. The standard of care requires that obstetricians, emergency physicians, and labor-and-delivery teams consider HELLP, test for it, and act on it without delay. When that happens, patients and their babies usually survive. When it does not, the harm can be permanent.