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Pre-eclampsia, HELLP Syndrome and DIC
McDonough, K, D.O., M.S., Merolli, A, M.D.
Kent Hospital, Warwick, RI
Introduction: Disseminated Intravascular Coagulation (DIC) is a systemic process that
results from an uncontrolled and excessive production of thrombin which can lead to life
threatening thrombus and bleeding. There are many clinical conditions that can lead to
DIC, one of which is HELLP syndrome. HELLP complicates 1 in 1000 pregnancies, and
DIC occurs in up to twenty percent of patients with this disorder. Our case is a 45 year
old female who presented with mild Pre-eclampsia that rapidly deteriorated to HELLP
and DIC.
Case: A 45 yo F G2P0010 at 32 weeks and 2 days with a twin pregnancy presented to
the hospital after spontaneous rupture of her membranes. She was not in labor or in any
distress but had several elevated blood pressures in the 130/90 range. Pre-eclampsia
labs at that time were normal. Due to premature rupture of membranes, she was treated
with latency antibiotics and betamethasone to enhance fetal lung maturity. On day 6 of
her hospital stay she went into labor, now at 33 weeks and 1 day. She was delivered via
cesarean section without complications and minimal blood loss. Several hours after
surgery she developed a blood pressure of 178/95 and a heart rate of 102. At that time
labs were again sent which revealed: creatinine 1.13 mg/dl, AST 57 Iu/L, ALT 43 Iu/L,
platelets 93 x 10 3 /mcl, p/c ratio: 5.3. She was diagnosed with pre-eclampsia and treated
with labetolol for blood pressure control and magnesium for seizure prophalaxis. The
next morning she became hypotensive with a blood pressure of 70/40 and with a heart
rate of 121. Labs were notable for a coagulopathy with a hemoglobin of 6.3 g/dl,
platelets of 126 x 10 3 /mcl, undetectable fibrinogen and elevated fibrin split products. DIC
was diagnosed and treated with blood transfusions and FFP. A CT of her abdomen and
pelvis done to evaluate for bleeding revealed free fluid, creating concern for
hemorrhage. Her renal function continued to worsen with a peak creatinine of 1.52
mg/dl. Despite multiple blood transfusions her hemoglobin level remained unstable. She
eventually required bilateral uterine artery embolization which resulted in stabilization of
her hemoglobin and vital signs. After 48 hours her clinical picture improved and
laboratory abnormalities returned to normal.
Discussion: DIC is a life threatening disorder that can be caused by multiple obstetrical
conditions. Most commonly during pregnancy it occurs in the setting of amniotic fluid
embolism, abruptio placenta or septic abortion, but can also be seen with both preeclampsia
and HELLP syndrome. In our case, a patient with HELLP syndrome quickly
developed severe DIC with hemorrhage. Twenty percent of patients who are diagnosed
with pre-eclampsia go on to develop HELLP syndrome, and up to 84% of those with
HELLP syndrome develop renal failure. In addition, pre-eclampsia can be complicated
by DIC in 7% of cases. Maintaining a high index of clinical suspicion for DIC in patients
diagnosed with pre-eclampsia and HELLP syndrome can greatly decrease associated
morbidity and mortality.