Anaesthesia for caesarean section in patients with preterm HELLP syndrome: literature review, personal experience and possible guidelines

Introduction HELLP syndrome is considered a severe form of preeclampsia. The acronym HELLP was first suggested by Weinstein in 1982 and describes Haemolysis (H), Elevated Liver enzymes (EL) and Low platelets (LP)(1). Both regional and general anaesthesia are potentially associated with complications in HELLP syndrome. As low platelet count and liver dysfunction are a risk factor for the development of lumbar epidural haematoma, and even cerebral subdural haematoma formation in case of neuraxial anaesthesia, spinal and epidural anaesthesia have been considered for a long time as a contra-indication (2-6). Although in the early nineties general anaesthesia was recommended as the technique of choice, impaired liver function and an altered metabolism of anaesthetic agents (such as slow degradation of choline-ester drugs due to lower concentrations of pseudocholine-esterase) may complicate general anaesthesia (7), besides the risk of enhanced hepatotoxicity following the use of volatile substances, difficult intubation and haemodynamic perturbations during induction and incision (2,3,7-9). The minimum platelet count above which it is safe to perform spinal or epidural anaesthesia is still unknown, but several studies suggest that this may be safely done at thrombocyte counts less than 100.000 mm3 (9-14). None of these studies contains data specific for patients with HELLP syndrome.