HELLP syndrome is a disorder associated with serious maternal morbidity and mortality. Distinguishing HELLP from other pregnancy related disorders is often challenging and may result in delay of treatment. Differential diagnoses include acute fatty liver of pregnancy, thrombotic thrombocytopenic purpura, antiphospholipid syndrome, and hemolytic uremic syndrome, and are reviewed in this chapter. While there is not any current treatment for HELLP, the mainstay of treatment involves maternal stabilization and timely delivery. Various treatment strategies have been attempted to help decrease the morbidity and mortality of HELLP, including the maternal use of corticosteroids. The authors review the studies and controversies surrounding the maternal use of corticosteroids, plasma exchange, and low molecular weight heparin for the treatment of HELLP, as well as the role of the complement system in HELLP. Further large, well-designed, randomized controlled trials are needed to address the role corticosteroids may play in the treatment of women with HELLP and to help improve maternal and fetal outcomes.

Problem Angiogenic imbalance during pregnancy is associated with immune activation, hypertension, increased T cell infiltration, and neurological insults. Method of Study On gestational day (GD) 12 timed-pregnant rats were infused with anti-angiogenic factors sFlt-1 and sEndoglin (4.7 and 7μg/kg) to create HELLP syndrome via mini-osmotic pumps for 8 days, with a subset of these rats having Orencia (2mg/kg) infused on GD13. On GD19, blood brain barrier (BBB) permeability was evaluated via Evan’s Blue infusion, blood was collected for T cell measurements, inflammatory cytokine secretion. Brain tissues were also collected to examine inflammatory cytokine infiltration. Results T cell attenuation with Orencia decreased circulating CD4+ and CD8+ T cells, circulating TNFα and IL-17, BBB permeability and significantly decreased biochemical evidence of HELLP compared to untreated HELLP rats. Conclusions These data support the hypothesis that T cells have a critical role in contributing to the pathophysiology that is seen in angiogenic imbalance during pregnancy.

Objective Higher-dose oxytocin is more effective than lower-dose regimens to prevent postpartum hemorrhage following cesarean delivery. We compared two higher-dose regimens (80U and 40U) to our routine regimen (10U) among women who delivered vaginally. Methods In a double-masked randomized trial, oxytocin (80U, 40U or 10U) in 500ml was given over 1 hour after placental delivery. The primary outcome was a composite: any treatment of uterine atony or hemorrhage. Prespecified secondary outcomes included outcomes in the primary composite and a decline of 6% or greater in hematocrit. A sample size of 600 per group (N=1800) was required to compare each of the 80U and 40U to the 10U group. At planned interim review (n=1201), enrollment in the 40U group was stopped for futility and enrollment continued in the other groups. Results Of 2,869 women, 1,798 were randomized: 658 to 80U, 481 to 40U and 659 to 10U. Most characteristics were similar across groups. The risk of the primary outcome in the 80U group (6%; RR 0.93, 95% CI: 0.62–1.40) or the 40U group (6%; 0.94, 0.61–1.47) was not different compared with the 10U group (7%). Treatment with additional oxytocin after the first hour was less frequent with 80U compared with 10U (RR 0.41; 0.19–0.88) as was a 6% or greater decline in hematocrit (0.83; 0.69–0.99); both outcomes declined with increasing oxytocin dose. Outcomes were similar between the 40U and 10U groups. Conclusion Compared with 10 units, 80 or 40 units of prophylactic oxytocin did not reduce overall postpartum hemorrhage treatment when given in 500ml over 1 hour for vaginal delivery. Eighty units decreased the need for additional oxytocin and the risk of a 6% or greater decline in hematocrit.