Using case reports to determine when liver bleeding occurs during disease progression in HELLP syndrome

BACKGROUND: Hepatic hemorrhage occurs in less than 5% of patients with hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome but it is a profound cause of maternal/perinatal morbidity and mortality. OBJECTIVES: To determine when liver bleeding occurs during the development of HELLP syndrome. SEARCH STRATEGY: The English literature was searched for all reports of HELLP syndrome associated with liver bleeding. SELECTION CRITERIA: Eighty-seven case summaries of liver bleeding in the setting of HELLP syndrome were included. The standard definition of HELLP syndrome was used with expansion into the Mississippi classification system, supplemented by patients with partial HELLP syndrome. DATA COLLECTION AND ANALYSIS: Demographic and clinical data were collected and recorded in an Excel database. MAIN RESULTS: Liver bleeding was detected in 18 (20.7%) patients with class 1 HELLP syndrome, 24 (27.6%) with class 2 HELLP syndrome, and 12 (13.8%) with class 3 or partial HELLP syndrome. In 33 (37.9%) patients, the exact class of HELLP syndrome at the time liver bleeding was detected could not be determined from the published descriptions. CONCLUSIONS: Liver bleeding can occur early during HELLP syndrome development, not only in patients with advanced, class 1 illness.