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HELLP Syndrome

Extracted from Survival Guide to Midwifery, 2nd Edition (2012) Diane M. Fraser and Margaret A. Cooper, Oxford; Churchill Livingstone: 2012. Courtesy Elsevier

The syndrome of haemolysis (H), elevated liver enzymes (EL) and low platelet count (LP) is considered a variant of pre-eclampsia/eclampsia. Pregnancies affected by this syndrome are associated with significant maternal and perinatal morbidity and mortality. HELLP syndrome typically presents between 32 and 34 weeks' gestation but 30% of cases occur postpartum.

Signs

  • Sharp rise in blood pressure
  • Diminished urinary output
  • Increase in proteinuria
  • Headache, usually severe, persistent and frontal in location
  • Drowsiness or confusion
  • Visual disturbances e.g. blurring of vision or flashing lights
  • Epigastric pain
  • Nausea and vomiting

Women with HELLP syndrome should be admitted to a consultant unit with intensive or high dependency facilities. In pregnancies of less than 32 weeks' gestation, expectant management may be undertaken with appropriate safeguards and consent. In term pregnancies, or where there is a deteriorating maternal or fetal condition, immediate delivery is recommended.

Further reading/ Resources

Newson L. (2013) HELLP syndrome. (Professional reference). Available at: http://patient.info/doctor/hellp-syndrome

Medscape. Khan H. (2015) HELLP syndrome. Available at: http://emedicine.medscape.com/article/1394126-overview

Pre-eclampsia Foundation (2015). HELLP syndrome. Available at: http://www.preeclampsia.org/health-information/hellp-syndrome

Hepatitis

The hepatitis viruses A, B, C, D and E cause acute hepatitis. Hepatitis B and, particularly, C, can cause chronic infection that can lead to cirrhosis, liver failure, and liver cancer. All types of viral hepatitis are notifiable diseases in UK. Services will have a policy for vaccinations against hepatitis A and B. Acute infection may present with:

  • Nausea and vomiting
  • Myalgia
  • Fatigue/malaise
  • Right upper quadrant pain
  • Change in sense of smell or taste
  • Coryza
  • Photophobia
  • Headache.

Diarrhoea (with pale stools) and dark urine may also be present. However, often no signs unless jaundice develops, when hepatomegaly, splenomegaly and lymphadenopathy may occur.

Hepatitis A Previously a common childhood infection in the UK but now unusual. May occur in outbreaks in institutions, and is common in travellers. Infection confers immunity. Spread normally by the faecal-oral route (ingestion of food or drink contaminated by infected stool) but occasionally through blood. Usually self-limiting (rarely fulminant); there is no carrier state, and chronic liver disease does not occur. HepA vaccine can protect people at high risk, e.g., those who have been in contact with an infected person, travellers to countries where the infection is common, and injecting drug users.

Hepatitis B Early symptoms flu-like; infection can lead to liver disease and liver cancer. Hepatitis B is 10-100 times more infectious than HIV. Transmitted by contact with infected blood or body fluids, e.g. by:

  • Sharing or use of contaminated equipment during injecting drug use
  • Vertical transmission (mother to baby) from an infectious mother to her unborn child
  • Sexual transmission
  • Receipt of infectious blood (via transfusion) or infectious blood products (e.g. Clotting factors)
  • Needlestick or other sharps injuries (in particular those sustained by healthcare workers)
  • Tattooing and body piercing.

HepB vaccination:

  • Should be given to all individuals at risk, including health professionals.
  • Is usually provided free (on the NHS) to people in a high-risk group.
  • Is not free if requested for travel abroad.

Hepatitis C Often asymptomatic initially; 15-20% clear their infection within 2-6 months. Of those with chronic infection, some remain well but many develop mild to moderate liver damage (with or without symptoms); of these, 20% progress to cirrhosis over 20-30 years. Excessive alcohol consumption increases risk of severe liver complications. Hepatitis C is blood borne and most often acquired through injecting drug use; also by sharing razors or toothbrushes or during body piercing (eg, tattooing, acupuncture) with non-sterile needles. Was also spread by blood transfusions before September 1992, when screening for hepatitis C was brought in. There is no vaccine. Increasingly effective drug treatment (not suitable for everyone, lasts 6 or 12 months) can clear the virus in c. 50%. Around 100,000 people in England are thought to have undiagnosed hepatitis C; DH runs awareness campaigns to promote diagnosis and treatment.

Hepatitis D An important cause of acute and severe chronic liver damage in some parts of the world (Mediterranean, parts of Eastern Europe, Middle East, Africa, and South America). Occurs only in people infected with hepatitis B.

Hepatitis E Uncommon in the UK, but common in Asia, Africa and Central America, particularly where sanitation is poor. Disease is usually mild but rarely can be fatal, particularly in pregnant women. Transmission and clinical features similar to hepatitis A.

Further reading

Hepatitis A Professional reference Patient.co.uk http://www.patient.co.uk/doctor/hepatitis-a-pro

Hepatitis B Professional reference Patient.co.uk http://www.patient.co.uk/doctor/hepatitis-b-pro

Chronic hepatitis Professional reference Patient.co.uk http://www.patient.co.uk/doctor/chronic-hepatitis

NICE Clinical Knowledge Summaries. Hepatitis C http://cks.nice.org.uk/hepatitis-c

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