(840) HELLP syndrome at less than 23 weeks gestation: a systematic literature review

Objective: We performed a systematic review to evaluate the typical presentation and maternal and fetal outcomes in pregnancies complicated by early-onset HELLP syndrome.

Study Design:
PubMed, Ovid MedLine, and clinicaltrials.gov were queried from inception through 10 September 2021 with no language restriction with the terms ‘HELLP syndrome,’ ‘HELLP,’ ‘hemolysis, elevated liver enzymes, low platelets,’ ‘hemolysis, elevated liver enzymes, low platelets syndrome,’ ‘pre-viable,’ ‘peri-viable,’ ‘previable,’ ‘periviable,’ ‘first trimester,’ ‘second trimester,’ ‘before 23 weeks,’ ‘ < 23 weeks,’ ‘ < 23 week gestation,’ and ‘before 23 weeks gestation.’ Abstracts, unpublished studies and review articles were excluded, yielding 24 studies and an additional case from our institution that met our inclusion criteria. The PRISMA guidelines were followed in extracting data.


Results: 26 women had 29 pregnancies complicated by early-onset HELLP syndrome, including 3/7 (43%) subsequent pregnancies with recurrent HELLP. The most common presenting symptoms were hypertension (17/26, 65%), abdominal pain (17/26, 65%), headache (7/26, 27%), edema (6/26, 23%), and nausea (6/26, 23%). LDH ≥600 IU/L was observed in 8/12 (67%) cases while thrombocytopenia and elevated liver enzymes were reported in 23/26 (88%) cases. Significant maternal complications were encountered in 8/27 (30%) cases. The most common complications were hepatic (4/27, 15%), respiratory (4/27, 15%) and CNS (3/27, 11%). In 17/29 (59%) cases pregnancy was terminated. Perinatal mortality was 57% (4/7). 5/29 (17%) cases reported early fetal death, 2/29 (7%) cases reported stillbirth, and 2/29 (7%) cases reported neonatal demise. Living neonates were reported in 3/29 (10%) cases, all delivered at 23 weeks gestation. No maternal deaths were reported. APLS was diagnosed in 7/15 (47%) cases.

Conclusion: Early-onset HELLP syndrome presents with similar symptoms as those seen in later gestation. Hepatic, respiratory, and CNS complications are most common, with typical hematologic complications less frequently reported. Maternal outcomes are favorable while fetal outcomes are poor.