HELLP Syndrome

Table of Contents

  1. Overview
  2. Acronym and Classification Systems
  3. Epidemiology and Risk Factors
  4. Pathophysiology
  5. Clinical Presentation
  6. Diagnosis and Laboratory Criteria
  7. Differential Diagnosis
  8. Management — Antepartum
  9. Management — Postpartum and Complications
  10. Fetal and Neonatal Outcomes
  11. Prognosis and Recurrence
  12. References
  13. Featured Videos

Overview

HELLP syndrome is a severe, life-threatening complication of pregnancy defined by the triad of Hemolysis, Elevated Liver enzymes, and Low Platelets. It most commonly arises in the third trimester of pregnancy, though it can appear postpartum, and is widely recognized as a variant or severe complication of preeclampsia. Approximately 10–20% of women with severe preeclampsia will develop HELLP syndrome, yet in up to 15% of HELLP cases the condition occurs entirely without the classic hallmarks of preeclampsia — namely hypertension and proteinuria — making timely recognition exceptionally challenging.

The overall incidence of HELLP syndrome is estimated at 0.1–0.8% of all pregnancies and 10–20% of cases of severe preeclampsia. The syndrome was first formally described and named by Dr. Louis Weinstein in 1982, who recognized the constellation of laboratory findings as a distinct and dangerous entity rather than a subset of standard preeclampsia. Prior to Weinstein's landmark paper, many women with HELLP were misdiagnosed as having gallbladder disease, gastritis, peptic ulcer disease, viral hepatitis, or idiopathic thrombocytopenic purpura — misdiagnoses that delayed potentially life-saving intervention.

Risk is highest in multiparous women and those of older maternal age. White and Hispanic women appear to be at somewhat higher risk than Black women, though HELLP can affect any pregnant patient. Because its presenting symptoms are so nonspecific — right upper quadrant pain, nausea, malaise — the diagnosis must be actively sought with laboratory testing in any third-trimester patient who seems unwell. Rapid recognition is critical: HELLP can deteriorate to hepatic rupture, disseminated intravascular coagulation (DIC), eclampsia, acute kidney injury, and maternal death within hours if not identified and managed promptly.

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Acronym and Classification Systems

The acronym HELLP encapsulates the three defining laboratory abnormalities:

Two formal classification systems exist, each with distinct clinical utility:

Tennessee Classification (Sibai)

Developed by Dr. Baha Sibai, the Tennessee system is the most widely cited in clinical practice and research. It distinguishes between:

Mississippi Triple-Class System (Martin)

Developed by Dr. James Martin, this system classifies HELLP according to platelet nadir, providing more granular prognostic stratification:

Understanding both classification systems is important because different institutions and published studies reference one or the other, and management thresholds — especially around platelet transfusion, delivery timing at borderline gestational ages, and corticosteroid use — are often tied to class designation.

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Epidemiology and Risk Factors

HELLP syndrome affects approximately 0.1–0.8% of all pregnancies worldwide. In women with severe preeclampsia, the incidence rises sharply to 10–20%. In the United States, HELLP complicates an estimated 48,000 pregnancies annually. Globally, it is a major contributor to maternal mortality, particularly in low- and middle-income countries where access to intensive care and blood product support is limited.

The syndrome predominantly affects women in the third trimester, with the peak incidence between 27 and 37 weeks of gestation. However, approximately 10% of cases present before 27 weeks, and about 30% of cases manifest in the postpartum period — typically within 48 hours of delivery but occasionally beyond that window. Postpartum HELLP is the most treacherous subset because healthcare providers and patients are often no longer vigilant for obstetric complications once delivery has occurred.

Established risk factors include:

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Pathophysiology

HELLP syndrome arises from the same fundamental endothelial dysfunction cascade that underlies preeclampsia, but with particular tropism for the hepatic vasculature. The sequence of events is now understood to begin long before clinical symptoms appear:

Step 1 — Abnormal placentation: In normal pregnancy, cytotrophoblast cells invade the maternal spiral arteries during the first and early second trimester, remodeling them into wide, low-resistance vessels capable of sustaining high placental blood flow. In HELLP and preeclampsia, this invasion is shallow and incomplete. The spiral arteries remain narrow, high-resistance vessels, resulting in chronic placental hypoperfusion and ischemia throughout pregnancy.

Step 2 — Release of anti-angiogenic factors: The ischemic placenta responds by releasing excessive quantities of two potent anti-angiogenic proteins into the maternal circulation: sFlt-1 (soluble FMS-like tyrosine kinase 1) and sEng (soluble endoglin). sFlt-1 acts as a decoy receptor that sequesters free VEGF (vascular endothelial growth factor) and PlGF (placental growth factor), stripping the maternal endothelium of survival signals it depends on. sEng similarly antagonizes TGF-beta signaling. Together, these circulating factors cause widespread maternal endothelial dysfunction.

Step 3 — Endothelial injury and platelet activation: Damaged maternal endothelium becomes thrombogenic — it loses its normal anti-platelet and anti-coagulant properties and begins to activate platelets and the coagulation cascade. Platelets adhere to injured vessel walls, aggregate, and are consumed at a rate that exceeds production, producing thrombocytopenia. Fibrin strands form in the microvasculature, and red blood cells traveling through these fibrin meshes are sheared apart, creating the characteristic schistocytes (fragmented red blood cells visible on peripheral smear) that define microangiopathic hemolytic anemia.

Step 4 — Hepatic pathology: The liver's sinusoidal vasculature is exquisitely sensitive to endothelial injury in HELLP. Fibrin deposits accumulate in the periportal and perisinusoidal spaces, obstructing hepatic blood flow and causing hepatocyte necrosis. This leads to elevated AST and ALT. As the liver swells, the hepatic capsule (Glisson's capsule) is stretched, producing the characteristic severe right upper quadrant pain that is the most common presenting symptom. In 0.9–2% of HELLP cases, hepatic swelling progresses to subcapsular hematoma — a hemorrhagic collection between the liver and its capsule. Rupture of this hematoma, occurring in approximately 1% of HELLP cases, is catastrophic and carries a maternal mortality rate of 35–60%.

Step 5 — Platelet nadir and recovery timeline: A critical but often misunderstood feature of HELLP is that platelet counts continue to fall for 24–48 hours after delivery before the process begins to reverse. This occurs because the anti-angiogenic factors and activated complement pathways remain in the maternal circulation even after placental removal, continuing to drive endothelial injury temporarily. Recovery — rising platelets, falling LFTs and LDH — typically begins 48–72 hours postpartum and is complete within 96–120 hours in uncomplicated cases.

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Clinical Presentation

HELLP syndrome is notorious for its nonspecific presentation. The symptoms so closely mimic common benign conditions — gallbladder disease, gastritis, peptic ulcer disease, viral hepatitis, or a stomach flu — that misdiagnosis occurs in a substantial proportion of cases, sometimes for days. Any pregnant or recently postpartum woman with these complaints should be evaluated with laboratory testing until HELLP is excluded.

Core symptoms and their frequencies:

Physical examination findings: RUQ or epigastric tenderness on palpation (the most reliable exam finding); hypertension in approximately 85% of patients (systolic ≥140 or diastolic ≥90 mmHg); absent hypertension in up to 15% — a crucial point because providers who look only for high blood pressure will miss a minority of cases entirely. Jaundice, when present, signals significant hemolysis and hepatic injury and indicates severe disease. Edema is common. Neurological examination is usually normal unless eclampsia has supervened.

Proteinuria: present in approximately 86% of cases, but absent in 14% — another reminder that the classic preeclampsia triad (hypertension + proteinuria + edema) is not a requirement for HELLP diagnosis.

Timing — when HELLP presents:

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Diagnosis and Laboratory Criteria

The diagnosis of HELLP syndrome rests entirely on laboratory criteria. There is no single pathognomonic clinical finding; the diagnosis is confirmed when the characteristic constellation of laboratory abnormalities is present in a pregnant or peripartum patient.

Tennessee Criteria (Most Widely Used)

1. Hemolysis — at least two of the following:

2. Elevated Liver Enzymes:

3. Low Platelets:

Additional Laboratory Tests

A complete evaluation for HELLP should include:

Monitoring Frequency

In active HELLP syndrome, laboratory values must be monitored every 6–12 hours. The disease can evolve from partial to full HELLP, and from Class 3 to Class 1, within a single day. Serial CBC and LFT trending determines both the trajectory of disease and the timing of interventions such as platelet transfusion and delivery.

Imaging

Routine liver imaging is not required for diagnosis of uncomplicated HELLP. However, hepatic ultrasound or CT abdomen is indicated when subcapsular hematoma is suspected — particularly in any HELLP patient with sudden worsening of RUQ pain, hemodynamic instability, or unexplained drop in hemoglobin. CT with contrast provides the most accurate characterization of hematoma size, extension, and presence of active hemorrhage or rupture.

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Differential Diagnosis

The combination of hemolytic anemia, thrombocytopenia, and hepatic injury in a pregnant or peripartum patient raises a differential that includes several conditions requiring fundamentally different treatments. Misidentification can be fatal.

1. Thrombotic Thrombocytopenic Purpura (TTP): Like HELLP, TTP produces microangiopathic hemolytic anemia (schistocytes on smear) and thrombocytopenia. The key distinguishing feature is ADAMTS13 activity below 10% in TTP (normal in HELLP). TTP is also characterized by more prominent neurological symptoms (altered consciousness, stroke, focal deficits), fever, and severe renal impairment in a pentad pattern, though not all five features need be present. TTP is not pregnancy-specific but is more common in pregnancy. Critically, TTP does NOT respond to delivery — it requires urgent plasma exchange (plasmapheresis). Delivering a preterm fetus for a condition that requires plasma exchange, not obstetric intervention, represents a serious management error.

2. Hemolytic Uremic Syndrome (HUS): HUS shares microangiopathic hemolytic anemia and thrombocytopenia with HELLP but is dominated by acute kidney injury rather than hepatic involvement. Typical HUS follows Shiga-toxin-producing E. coli (usually O157:H7) infection with diarrheal prodrome. Atypical HUS (aHUS) results from complement pathway dysregulation and may recur in subsequent pregnancies. ADAMTS13 is normal in HUS. Treatment of aHUS is eculizumab (complement inhibitor), not delivery.

3. Acute Fatty Liver of Pregnancy (AFLP): AFLP is the most dangerous mimicker of HELLP because both are obstetric liver emergencies occurring in the third trimester, and both are treated with delivery. Key differentiating features:

4. Immune Thrombocytopenic Purpura (ITP): ITP causes isolated thrombocytopenia without hemolysis and without liver enzyme elevation. Antiplatelet antibodies (anti-GPIIb/IIIa) are present in most cases. ITP is chronic and does not cause the acute deterioration seen in HELLP. Treatment is steroids, IVIG, or rituximab — not delivery.

5. Antiphospholipid Syndrome (APS): Can cause thrombocytopenia, pregnancy loss, and endothelial activation, and may precipitate preeclampsia and HELLP. APS and HELLP can coexist; positive antiphospholipid antibody titers in the setting of HELLP should prompt hematology consultation.

6. Acute cholecystitis, choledocholithiasis, Budd-Chiari syndrome: These must be excluded by ultrasound in any pregnant patient with RUQ pain. Ultrasound will demonstrate gallstones, biliary dilation, or hepatic vein thrombosis in these conditions, while HELLP will show a normal biliary tree (or subcapsular hematoma in advanced cases).

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Management — Antepartum

Delivery is the only definitive cure for HELLP syndrome. All management before delivery is supportive — stabilizing the mother, protecting the fetus where gestational age allows, and preparing for safe delivery. The gestational age at presentation is the central variable that drives decision-making.

Delivery Threshold by Gestational Age

Greater than or equal to 34 weeks gestation: immediate delivery. At or beyond 34 weeks, fetal lung maturity is sufficient and the risks of continued intrauterine exposure to a deteriorating maternal environment outweigh any benefit of further expectant management. Induction of labor is appropriate if the cervix is favorable and the maternal condition is stable. Cesarean section is indicated for standard obstetric indications (malpresentation, failed induction, fetal distress) — HELLP alone is not an indication for cesarean.

Less than 34 weeks gestation: short-term stabilization followed by delivery within 24–48 hours. The primary reason to delay delivery briefly at less than 34 weeks is to administer corticosteroids for fetal lung maturity. Betamethasone 12 mg intramuscular every 24 hours for two doses accelerates pulmonary surfactant synthesis in the fetal lung, substantially reducing the risk of respiratory distress syndrome (RDS) in the premature neonate. This 24–48 hour window is the maximum acceptable delay — if the maternal condition deteriorates at any point during this period, delivery must proceed immediately regardless of whether the full corticosteroid course has been completed.

Before 27–28 weeks: the decision is individualized and involves a high-stakes conversation between the obstetric team, neonatology, and the patient. Fetal viability, parental wishes, and the severity of maternal disease all factor in. Extreme prematurity carries high neonatal morbidity and mortality, but maternal deterioration in severe HELLP Class 1 at any gestational age demands delivery.

Maternal Stabilization (Concurrent with Delivery Planning)

1. Magnesium sulfate for seizure prophylaxis: Given to all patients with HELLP or severe preeclampsia. Loading dose: 4–6 g intravenously over 15–20 minutes. Maintenance: 1–2 g/hour by continuous infusion. Magnesium prevents eclamptic seizures by mechanisms including NMDA receptor antagonism and cerebral vasodilation. Toxicity monitoring is essential: loss of deep tendon reflexes occurs at serum magnesium 7–10 mEq/L, respiratory depression at greater than 12 mEq/L. Calcium gluconate 1 g IV is the antidote and must be at the bedside at all times. Magnesium is renally cleared; reduce or hold the infusion if urine output falls below 25–30 mL/hour.

2. Antihypertensive therapy: Blood pressure at or above 160 mmHg systolic or 110 mmHg diastolic is a hypertensive emergency in pregnancy — this threshold is associated with maternal stroke, the leading cause of maternal death in severe preeclampsia and HELLP. First-line agents include:

Target blood pressure is less than 160/110 mmHg. Do not treat blood pressure below 150/100 aggressively — excessive antihypertensive therapy can reduce uteroplacental perfusion and worsen fetal compromise. ACE inhibitors and angiotensin receptor blockers (ARBs) are strictly contraindicated in pregnancy due to fetotoxicity (renal dysgenesis, oligohydramnios, neonatal renal failure).

3. Platelet transfusion: Indications are not standardized across centers but reasonable consensus thresholds are:

Each apheresis unit of platelets typically raises the count by 30,000–50,000/µL transiently. Because platelets are rapidly consumed in active HELLP, the benefit is short-lived; transfusion is timed to immediately precede the procedure rather than given hours before.

Corticosteroids for HELLP (Dexamethasone)

High-dose dexamethasone has been used to accelerate biochemical recovery in HELLP and may facilitate brief prolongation of pregnancy at very preterm gestational ages to complete the fetal lung maturity course. The most commonly used regimen is dexamethasone 10 mg IV every 12 hours antepartum. Biochemical improvements — rising platelet count, falling AST and LDH — are typically seen within 24–48 hours. However, the evidence base is controversial: multiple randomized controlled trials, including a definitive double-blind placebo-controlled trial (Fonseca et al., 2005), found that dexamethasone improves laboratory parameters but does not reduce clinically meaningful maternal morbidity or mortality outcomes. Dexamethasone for fetal lung maturity (betamethasone preferred) is different from dexamethasone for HELLP treatment — these are separate indications with different agents and goals.

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Management — Postpartum and Complications

Delivery resolves the underlying cause of HELLP by removing the dysfunctional placenta, but the disease does not resolve immediately. The postpartum period carries its own dangers and requires sustained vigilance.

Postpartum Monitoring and Supportive Care

Platelet counts and liver function tests must continue to be monitored every 6–12 hours postpartum because the platelet nadir — the lowest point of the platelet count during the illness — characteristically occurs 24–48 hours after delivery. A patient whose platelets were 60,000/µL at delivery may have a nadir of 25,000/µL on postpartum day 1. Recovery begins thereafter, with platelets rising and liver enzymes falling, and most women achieve full biochemical recovery within 96–120 hours postpartum.

Magnesium sulfate is continued for 24–48 hours postpartum for ongoing seizure prophylaxis. During this period, careful fluid management is essential — postpartum women are at risk for pulmonary edema from fluid mobilization and third-space fluid shifts, and magnesium further impairs myocardial contractility. Strict intake and output monitoring with a Foley catheter is standard in the immediate postpartum management of HELLP.

Antihypertensive therapy: Hypertension frequently persists or worsens in the first several postpartum days before gradually resolving over weeks. Oral antihypertensives (nifedipine XL, labetalol, or methyldopa for breastfeeding women) are continued until blood pressure normalizes — typically within 6–12 weeks postpartum, though some women require longer-term therapy.

Subcapsular Hepatic Hematoma

Subcapsular hematoma of the liver is a rare but potentially lethal complication occurring in 0.9–2% of HELLP cases. Suspect it in any HELLP patient who develops sudden severe worsening of RUQ pain, a precipitous drop in hemoglobin without an obvious source of bleeding, or hemodynamic instability. Confirmatory imaging is hepatic ultrasound at the bedside for unstable patients, or CT abdomen with contrast for stable patients (provides superior anatomic detail).

Management depends on whether rupture has occurred:

Plasma Exchange for Refractory HELLP

In the minority of patients whose HELLP syndrome does not resolve within 72–96 hours postpartum — particularly those with Class 1 disease or where TTP cannot be confidently excluded — plasma exchange (plasmapheresis) is an important therapeutic option. Plasma exchange removes circulating anti-angiogenic factors, microangiopathic mediators, and complement activation products, while simultaneously replacing ADAMTS13 and other protective plasma proteins. Multiple case series and small trials support its use in refractory postpartum HELLP, and it is the definitive treatment if retrospective ADAMTS13 testing reveals activity below 10% consistent with TTP.

Disseminated Intravascular Coagulation (DIC)

DIC develops in 4–38% of HELLP cases and represents a shift from the localized coagulopathy of platelet consumption to a systemic, uncontrolled activation of both coagulation and fibrinolysis. Signs include prolonged PT and aPTT, low fibrinogen (below 200 mg/dL is concerning; below 100 mg/dL requires urgent replacement), elevated D-dimer, and clinical bleeding from venipuncture sites, surgical wounds, or mucosal surfaces. Treatment is delivery plus replacement of consumed coagulation factors with fresh frozen plasma, cryoprecipitate (for fibrinogen), and platelet transfusion.

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Fetal and Neonatal Outcomes

Fetal and neonatal outcomes in HELLP syndrome are primarily determined by two variables: gestational age at delivery and placental function. Because HELLP demands early delivery — often preterm — the neonatal consequences are substantially shaped by the hazards of prematurity.

Perinatal mortality ranges from 6% to 37% across published series, reflecting wide variation in disease severity and gestational age distribution across study populations. The highest mortality occurs in deliveries before 28 weeks of gestation, where prematurity-related complications dominate. In high-resource settings with modern neonatal intensive care, perinatal survival at 28 weeks or greater has improved dramatically over the past two decades.

Intrauterine growth restriction (IUGR) is present in a significant proportion of fetuses exposed to HELLP, because the same placental insufficiency that drives maternal disease also reduces oxygen and nutrient delivery to the fetus. IUGR fetuses are at heightened risk for fetal distress during labor, intrapartum cesarean section, and neonatal metabolic complications.

Neonatal thrombocytopenia occurs in 15–38% of neonates born to mothers with HELLP syndrome. The mechanism involves transplacental transfer of anti-endothelial antibodies and activated complement, as well as direct effects of the maternal microangiopathic process on the fetal platelet-producing megakaryocytes. Neonatal platelet counts should be checked at birth and monitored for the first several days of life; spontaneous recovery is expected but neonates with very low counts (below 20,000/µL) may require platelet transfusion.

Respiratory distress syndrome (RDS) affects premature neonates delivered before lung maturity is achieved. Antenatal corticosteroids (betamethasone) substantially reduce RDS incidence and severity but do not eliminate it, particularly at very early gestational ages. Surfactant therapy administered by neonatologists at birth has transformed outcomes for premature infants with RDS.

Long-term neurodevelopmental outcomes for survivors of HELLP-associated prematurity are generally favorable when birth occurs at or after 32 weeks with appropriate NICU care. Deliveries before 28 weeks carry meaningful risks of intraventricular hemorrhage, periventricular leukomalacia, and long-term neurocognitive impairment. Early infant developmental follow-up with neurodevelopmental specialists is recommended for all infants born before 34 weeks in the setting of HELLP.

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Prognosis and Recurrence

Maternal mortality from HELLP syndrome ranges from 1–3% in high-income countries with modern critical care capabilities to as high as 25% in resource-limited settings where timely access to platelet transfusion, intensive care, and surgical management of hepatic rupture is unavailable. The causes of maternal death include intracranial hemorrhage (from hypertensive emergency), hepatic rupture with exsanguination, respiratory failure from pulmonary edema, and multi-organ failure in the setting of severe DIC. Eclampsia (seizures) complicates 7–9% of HELLP cases and independently worsens prognosis.

Major maternal complications and their frequencies:

Recurrence risk in subsequent pregnancies: The risk of HELLP recurrence in a subsequent pregnancy is 2–27%, with wide variation attributable to underlying maternal thrombophilia, antiphospholipid syndrome, and other risk factors. Even when full HELLP does not recur, women who have had HELLP are at substantially higher risk for preeclampsia, gestational hypertension, and IUGR in future pregnancies. All subsequent pregnancies should be managed as high-risk, with early prenatal care, serial blood pressure monitoring, and low-dose aspirin beginning at 12–16 weeks (which reduces but does not eliminate recurrent preeclampsia risk).

Long-term cardiovascular risk: HELLP syndrome, like preeclampsia, is now understood to be not merely an obstetric complication but also a marker of lifetime cardiovascular vulnerability. Women who have had HELLP carry a significantly elevated lifetime risk of hypertension, coronary artery disease, stroke, and end-stage renal disease compared to age-matched women with uncomplicated pregnancies. The placental dysfunction that drives HELLP may reveal pre-existing subclinical endothelial dysfunction that will manifest as cardiovascular disease decades later. These women should receive counseling about long-term cardiovascular risk, be screened for hypertension and metabolic syndrome at primary care visits, and be encouraged to adopt heart-healthy lifestyle behaviors. Blood pressure, lipids, and fasting glucose should be checked annually beginning no later than age 40.

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References

  1. Weinstein L. Syndrome of hemolysis, elevated liver enzymes, and low platelet count: a severe consequence of hypertension in pregnancy. Am J Obstet Gynecol. 1982;142(2):159–167. PMID: 7055379
  2. Sibai BM. Diagnosis, controversies, and management of the syndrome of hemolysis, elevated liver enzymes, and low platelet count. Obstet Gynecol. 2004;103(5):981–991. PMID: 15121573
  3. Martin JN Jr, Rinehart BK, May WL, Magann EF, Terrone DA, Blake PG. The spectrum of severe preeclampsia: comparative analysis by HELLP (hemolysis, elevated liver enzyme levels, and low platelet count) syndrome classification. Am J Obstet Gynecol. 1999;180(6):1373–1384. PMID: 10368474
  4. Haram K, Svendsen E, Abildgaard U. The HELLP syndrome: clinical issues and management. A review. BMC Pregnancy Childbirth. 2009;9:8. PMID: 19245695
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  6. van Runnard Heimel PJ, Franx A, Schobben AF, Huisjes AJ, Derks JB, Bruinse HW. Maternal complications in women with HELLP syndrome. J Clin Gastroenterol. 2009;43(10):e192–e196. PMID: 19488006
  7. Sibai BM, Ramadan MK. Acute renal failure in pregnancies complicated by hemolysis, elevated liver enzymes, and low platelets. Am J Obstet Gynecol. 1993;168(5):1682–1690. PMID: 8498424
  8. Vigil-De Gracia P. Maternal deaths due to eclampsia and HELLP syndrome. Int J Gynaecol Obstet. 2009;104(2):90–94. PMID: 19062001
  9. Barton JR, Sibai BM. Diagnosis and management of hemolysis, elevated liver enzymes, and low platelets syndrome. Clin Perinatol. 2004;31(4):807–833. PMID: 15519427
  10. Magann EF, Bass D, Chauhan SP, Sullivan DL, Martin RW, Martin JN Jr. Antepartum corticosteroids: disease stabilization in patients with the syndrome of hemolysis, elevated liver enzymes, and low platelets (HELLP). Am J Obstet Gynecol. 1994;171(4):1148–1153. PMID: 7977545
  11. O'Brien JM, Shumate SA, Satchwell SL, Milligan DA, Barton JR. Maternal benefit of corticosteroid therapy in patients with HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome: impact at less than 32 weeks' gestation. Am J Obstet Gynecol. 2002;186(3):475–479. PMID: 11904611
  12. Fonseca JE, Méndez F, Cataño C, Arias F. Dexamethasone treatment does not improve the outcome of women with HELLP syndrome: a double-blind, placebo-controlled, randomized clinical trial. Am J Obstet Gynecol. 2005;193(5):1591–1598. PMID: 16260208

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