[babies_r_us]

WE have a patient that has severe pre-eclampsia and HELLP syndrome that we delivered at 32 weeks because she was so sick.....now her platelet count has dropped from 89 to 24!!! At what point do your physicians do a platelet transfusion in the absence of bleeding?? Maybe the platelet transfusion won;t be of any significance since there isn't any active bleeding...but I am scared to wait until there is bleeding and then have her in DIC!
We don't see too many HELLP syndrome patients (thank gosh) and so they scare the heck out of us! Any help would be appreciated. Also her liver enzymes are over 200 but her clotting factors are normal and HH are normal. I know if can take 3-4 days post partum for the labs to turn around, but it is making me gray and giving me ulcers!!! Thanks

[Kim44]

I don't work OB, I work oncology. We have standing orders for platelets if the count is 10 or less, that's when the chances of spontaneous bleeding increase. Same goes for our patients in DIC. Hope that helps.

[L&D_RN_OH]

We would have given platelets before delivery. I'm assuming it was a csection.

[unikuelady]

I have taken care of many HEELP patients postpartum. The Primary difference that you will see with HEELP is Hemolysis. This occurs mainly in the spleen. The patients H&H can drop very quickly without the "ususal" visual bleeding as in postpartum hemmhorage. Once you understand that concept, then it is easier to understand how to care for your patient. Every one of my HEELP patients needed to spend time in the ICU. Most will require blood transfusions, FFP, Cryopricipate and continious monitoring. Your assessment skills are the patients biggest asset. Get a good lab test result book. HEELP has to be seen in the "big picture". Also the one test that I found most helpful in anticipation of how my pt will do clinically is the FDP (Fibrinogen Degredation Products). If the FDP is >10 then DIC is confirmed. I once had a pt with a FDP >40 This patient was a C/S received to the postpartum unit from recovery @ 0700. She was alert/oriented/dtrs +2, UO 120cc/hr. On 2gm MGS04 with IVF. Her lab values were all abnormal. The MD stated that she was stable to be on postpartum. At 1100 the MD visited the patient who was sitting up in bed taking a clear liquid diet. Pt informed MD that she felt fine. 1130 had emesis, states she was feeling tired. UO 50cc/hr. DTRs 1+, small amount of lochia observed. 1200 c/o RU epigastric pain. again vomited. MD informed.
1300 lethargic, states feels funny, VS wnl, UO 40cc/hr, DTRs +1, small emesis with sips of water.
1330 very lethargic, DTRs absent. MGSO4 turned off, MD informed.
1340: blood drawn for MGSO4 level.
1400 UO 10cc/hr, BP dropping to 68/40, Pt responds to pain stimuli. ICU team called to bedside. MD paged.
1415 Taken to ICU. MGSO4 level 12, BP 48/24, O2 sats on RA 78%, No response to deep pain stimuli. Placed on Vent.
1500 Coded. Revived.
Yes this was an extreme case of HEELP. I just wanted you to see how fast a patient with this syndrome can deterioate. After spending 2 weeks in ICU, receiveing 14 units of blood, FFP etc. The patient made a full recovery. She was fortunate that her liver didn't rupture. I didn't write this to scare you....but to motivate you to learn as much as you can about this syndrome.
Yes.....This patient scared me and I care for High risk postpartum patients. (ps the lab tests PT & PTT can be normal with this syndrome) a frustrating disorder.
for caring.

[unikuelady]

writing when tired takes a toll on my spelling. HELLP not HEELP.

[babies_r_us]

That is exactly what I envisioned happening to her the day I cared for her. She has since been making a nice recovery....b/p normal for her, platelets up to 78, liver enzymes closer to normal.

Thanks goodness we only see one HELLP about every 3 years and they are all so sick and we are not a high risk unit....only do an average of 40 deliveries a month (sometimes as low as 29/month, sometimes as high as 60)

I would like our director to schedule a conference with the Dr.'s to discuss the case and be an educational session for us. I think our Dr.'s will take offense to some of our quesitoning however.

Thanks again for all of your insight. Sharon

[Speculating]

Originally posted by babies_r_us
That is exactly what I envisioned happening to her the day I cared for her. She has since been making a nice recovery....b/p normal for her, platelets up to 78, liver enzymes closer to normal.

Thanks goodness we only see one HELLP about every 3 years and they are all so sick and we are not a high risk unit....only do an average of 40 deliveries a month (sometimes as low as 29/month, sometimes as high as 60)

I would like our director to schedule a conference with the Dr.'s to discuss the case and be an educational session for us. I think our Dr.'s will take offense to some of our quesitoning however.

Thanks again for all of your insight. Sharon

It sounds more like a lab screw up especially with a normal H&H. Your clotting factor should be off just a little if the platelets are getting that low.