
==== Front
Cureus
Cureus
2168-8184
Cureus
2168-8184
Cureus Palo Alto (CA)

10.7759/cureus.67211
Pathology
Medical Education
Obstetrics/Gynecology
Incongruence of Hemolysis, Elevated Liver Enzyme, Low-Platelet Count Syndrome (HELLP) and Preeclampsia Criteria in Pregnancy: Implications for Medical Education and Obstetrics Training
Muacevic Alexander
Adler John R
Jenkins Jacob 1
Ferozuddin Aleena A 1
Mourad Jad 1
Abdulla Zayna Z 1
Oviedo Angelica 2
1 Physiology & Pathology, Burrell College of Osteopathic Medicine, Las Cruces, USA
2 Pathology and Laboratory Medicine, Burrell College of Osteopathic Medicine, Melbourne, USA
Angelica Oviedo aoviedo@burrell.edu
19 8 2024
8 2024
16 8 e6721119 8 2024
Copyright © 2024, Jenkins et al.
2024
Jenkins et al.
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 4.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
This article is available from https://www.cureus.com/articles/272156-incongruence-of-hemolysis-elevated-liver-enzyme-low-platelet-count-syndrome-hellp-and-preeclampsia-criteria-in-pregnancy-implications-for-medical-education-and-obstetrics-training
There is conflicting information in the medical literature regarding hemolysis, elevated liver enzymes, low platelet count syndrome (HELLP) and preeclampsia and whether they are subsets of a single disease or distinct complications of pregnancy. In numerous places, HELLP is described as a severe form or later stage of preeclampsia. However, a detailed medical literature search utilizing NCBI, PubMed, and Elicit: The AI Research Assistant clearly demonstrates that HELLP and preeclampsia are distinct diseases. While they share similarities, each one has unique diagnostic criteria, pathophysiology, and treatment. We believe that these entities should be taught as separate entities to medical students and residents because this will result in better patient care. Medical educational theories, including constructivism, demonstrate that initial learning experiences heavily influence future learning. The joining of HELLP and preeclampsia in medical school teaching materials is detrimental to students' and trainees' long-term understanding of these two serious complications of pregnancy.

constructivism
diagnostic criteria
medical training
obstetrics education
pregnancy-related complications
preeclampsia
hellp syndrome
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pmcEditorial

Hemolysis, elevated liver enzymes, and low platelet count syndrome (HELLP), a life-threatening complication of pregnancy, can occur anytime throughout pregnancy or even postpartum. Although HELLP has a prevalence of 0.5%-0.9%, it can cause severe maternal and fetal morbidity and mortality. The maternal mortality due to HELLP is reported to be between 0% and 24%, while the fetal mortality is nearly 37% [1].

Preeclampsia is also a serious pregnancy complication that can only be diagnosed after 20 weeks gestation and is characterized by high blood pressure and damage to maternal organs. This condition can also be life-threatening for both mother and fetus if left untreated. Preeclampsia is a common gestational complication with a prevalence of approximately 2%-15% of all pregnancies [2]. The maternal mortality rate is estimated between 1% and 30% worldwide [3].

Given that HELLP and preeclampsia are both serious complications of pregnancy, it is important to examine how they are taught throughout medical school and in obstetrics residency. The medical learning theory of constructivism states that students “construct” new knowledge by assimilating new material into what they already know [4]. Indeed, clinical diagnostic reasoning depends on constructivist processes. When a patient presents with a problem, the physician evaluates the history and physical based on their mental models of illness presentation that they have built up during prior training. Of course, if those mental models are incorrect, the next step of obtaining additional investigations such as blood tests will also be incorrect. The final diagnosis may then be erroneous due to the incorrect mental model of illness [5]. It is critical that students learn clinical content correctly in the first two years of medical school so that they can correctly assimilate new clinical knowledge in clerkship years and residency.

Upon thorough investigation, many of the resources used to educate medical students and obstetrics residents teach HELLP as a complication or subset of preeclampsia. However, we recommend that these entities be clearly distinguished in undergraduate medical education and obstetrics residency. In this editorial, we will explore the differences between HELLP and preeclampsia and recommend that these be taught as separate entities.

We conducted a literature review as follows. NCBI and PubMed were searched using the following words and phrases: ‘HELLP Syndrome,’ ‘Preeclampsia,’ ‘HELLP Outcomes,’ ‘HELLP Incidence and Prevalence,’ ‘Preeclampsia Mortality Rate,’ ‘Preeclampsia versus HELLP,’ ‘HELLP Syndrome precursor,’ ‘HELLP Syndrome in Preeclampsia,’ and ‘HELLP Syndrome and risk factor.' Chapter 18 of the textbook 'Robbins and Cotran Pathologic Basis of Disease 10th Edition' [6], Chapter 40 of the textbook 'Williams Obstetrics 26th Edition' [7], and Chapter 5 of 'Obstetric Intensive Care Manual 5th Edition' [8] were also read for a better understanding of HELLP and preeclampsia. Elicit: The AI Research Assistant was prompted using the following phrases or questions: ‘HELLP syndrome without hypertension’, ‘HELLP syndrome with multipara women’, ‘Can HELLP syndrome occur without hypertension’, ‘HELLP syndrome in multiparous women’. The database UptoDate [9] was searched using the phrase: ‘Preeclampsia and HELLP’. The references that resulted from these searches were reviewed and analyzed for their relevance to this subject.

Medical hypothesis

HELLP is frequently taught as a subset or complication of preeclampsia. Although both are complications of pregnancy, HELLP is a distinct clinical entity rather than a subset of preeclampsia. HELLP has different diagnostic criteria, pathophysiology, and treatment when compared to preeclampsia.

Support for hypothesis

Knowledge Sources Utilized by Medical Students and Obstetrics Residents Regarding HELLP and Preeclampsia

We reviewed multiple resources commonly used by medical students and obstetrics residents regarding HELLP and preeclampsia. For example, the major pathology textbook used in many US medical schools, 'Robbins and Cotran Pathologic Basis of Disease' [6], notes that a consequence of preeclampsia or eclampsia is HELLP. The book states that this may be due to various placental factors released. However, Robbins does not claim that elevated blood pressure is necessary for HELLP but notes that HELLP can be a consequence of preeclampsia, which does require the presence of elevated blood pressure. The professional association, American College of Obstetrics and Gynecology (ACOG), notes that 'Preeclampsia can cause HELLP,' on its website [10]. Additionally, 'Williams Obstetrics 26th Edition' [7] reports that preeclampsia can occur with HELLP, which typically results in worse outcomes. 'Williams Obstetrics 26th Edition,' however, did not elaborate on the possible causes of HELLP compared to preeclampsia. Another obstetrical textbook utilized by obstetrics residents, 'Obstetric Intensive Care Manual' [8], stated that HELLP is a severe form of preeclampsia and that the diagnosis may be hard to elucidate because blood pressure may be slightly elevated. It also noted that a diagnosis of HELLP is automatically a manifestation of severe preeclampsia. The classification of HELLP as a subset or complication of preeclampsia in study resources used in medical training leads to confusion since increased blood pressure is the sine qua non of preeclampsia but not of HELLP. We have summarized these educational resources in Table 1.

Table 1 Comparison of HELLP and preeclampsia sections in various educational resources

Commonly used educational resources do not describe HELLP and preeclampsia as separate entities.

Educational resource	Section on HELLP	Section on preeclampsia	Does the resource denote them as separate entities?	
Robbins and Cotran Pathologic Basis of Disease, 10th Edition	Yes	Yes	No	
Williams Obstetrics, 26th Edition	Yes	Yes	No	
Obstetric Intensive Care Manual, 5th Edition	Yes	Yes	No	
ACOG website	Yes	Yes	No	
UpToDate website	Yes	Yes	No	

HELLP and Preeclampsia Diagnostic Criteria

According to the Tennessee Classification System, the criteria for diagnosing HELLP include 'haemolysis with increased LDH (>600 U/L), AST ≥ 70 U/L), and platelets < 100 x 109/L.' [11]

Preeclampsia criteria include a systolic blood pressure of ≥140 mmHg or diastolic blood pressure of ≥90 mmHg on two separate readings at least four hours apart, or shorter interval timing of systolic blood pressure of 160 mm Hg or more or diastolic blood pressure of 110 mmHg or more, all of which must be identified after 20 weeks of gestation [12]. The criteria for the diagnosis of HELLP versus preeclampsia are shown in Table 2.

Table 2 Diagnostic criteria for Tennessee HELLP Classification and Preeclampsia

Summary of the diagnostic criteria for Tennessee HELLP Classification and Preeclampsia shows no overlap in criteria.

Diagnostic Criteria Summary	HELLP	Preeclampsia	
LDH (Lactate Dehydrogenase)	LDH≥ 600 IU/L	Not a criterion	
AST (Aspartate Aminotransferase)	AST ≥ 70 IU/L  	Not a criterion	
Platelets	Platelets ≤ 100,000/ μl	Not a criterion	
Systolic blood pressure	Not a criterion	≥140 mmHg	
Diastolic blood pressure	Not a criterion	≥90 mmHg	

The application of constructivist processes to medical student education has been shown to improve outcomes. A hospital-to-home transition of patient care workshop intervention that used constructivist theory improved medical students' knowledge, skills, and attitudes. That study showed that students exposed to the constructivist intervention had improved knowledge of the role of medication errors as a source of post-discharge adverse outcomes [13]. A separate study showed a 38% reduction in prescribing errors in a population of medical interns that underwent a constructivist informed feedback intervention designed to prevent prescribing errors [14].

Clinical Aspects of HELLP and Preeclampsia

Patients with HELLP typically present between 28 and 37 weeks of pregnancy or postpartum, within seven days of delivery [1]. In contrast, preeclampsia begins after 20 weeks of gestation [2].

HELLP is likely a manifestation of systemic inflammation and complement activation. Irregular placental development likely triggers this inflammatory response. The exact mechanism behind this reaction is yet to be fully understood. Additionally, a minority of HELLP cases have been linked to complement dysregulation resulting from preexisting thrombotic microangiopathies, manifesting with symptoms similar to hemolytic uremic syndrome [1]. The abnormal inflammatory factors cause apoptosis or necrosis of the maternal liver sinusoidal endothelial cells, which contributes to the elevated liver enzymes and hemolysis classically seen in HELLP [15].

In contrast, preeclampsia results from abnormal placentation with resulting placental endothelial dysfunction [12]. The clinical findings include new-onset hypertension, which may be accompanied by proteinuria. The underlying pathophysiology likely results from uteroplacental ischemia, which causes the release of a toxin, which then causes maternal hypertension. The disease can progress and result in multi-organ damage of the maternal liver, kidney, and brain [16]. 

Since the management for HELLP and preeclampsia are different, diagnostic criteria must be followed in order to provide effective treatments. The therapy for HELLP is focused on organ dysfunction [9], while preeclampsia treatment is heavily focused on the control of hypertension [8].

Conclusion

The initial presentation of educational content in the early years of medical education heavily influences later learning and consolidation of knowledge. Constructivist educational interventions have been shown to improve learning and outcomes in medical students and interns. As medical students and obstetrics residents progress in their careers, these initial experiences will contribute to the type of care they provide to their future patients. Commonly used resources demonstrate conflicting information regarding HELLP and preeclampsia. In addition, many research papers display inconsistency in distinguishing HELLP and preeclampsia. These diseases have distinct etiologies, pathophysiologies, and prognoses. We propose that these pregnancy complications should be taught as distinct entities since they have differing presentations, diagnostic criteria, and treatments. This has critical implications for the care of pregnant women, ultimately affecting both maternal and fetal outcomes.

Disclosures

Author Contributions

Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following:

Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work.

Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work.

Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Concept and design:  Angelica Oviedo, Aleena A. Ferozuddin, Zayna Z. Abdulla, Jacob Jenkins, Jad Mourad

Drafting of the manuscript:  Angelica Oviedo, Aleena A. Ferozuddin, Zayna Z. Abdulla, Jacob Jenkins, Jad Mourad

Critical review of the manuscript for important intellectual content:  Angelica Oviedo

Supervision:  Angelica Oviedo
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References

1 HELLP syndrome StatPearls Khalid F Mahendraker N Tonismae T Treasure Island, FL StatPearls Publishing 2023 https://www.ncbi.nlm.nih.gov/books/NBK560615/
2 Preeclampsia: recent advances in predicting, preventing, and managing the maternal and fetal life-threatening condition Int J Environ Res Public Health Chang KJ Seow KM Chen KH 2994 20 2023 36833689
3 HELLP syndrome Crit Care Nurs Clin North Am Adorno M Maher-Griffiths C Grush Abadie HR 277 288 34 2022 36049847
4 Learning theories 101: application to everyday teaching and scholarship Adv Physiol Educ Kay D Kibble J 17 25 40 2016 26847253
5 Constructivism: reflections on twenty five years teaching the constructivist approach in medical education Int J Med Educ Dennick R 200 205 7 2016 27344115
6 The female genital tract Robbins & Cotran Pathologic Basis of Disease, 10th Edition Ellenson LH Pirog EC 985 1036 Rochester, NY Elsevier 2021 https://onesearch.nihlibrary.ors.nih.gov/discovery/fulldisplay?docid=cdi_elsevier_sciencedirect_doi_10_1016_B978_0_323_53113_9_00022_4&context=PC&vid=01NIH_INST:NIH&lang=en&search_scope=NIHAll&adaptor=Primo%20Central&tab=NIHCampus&query=mesh,exact,Pathologic%20Processes,AND&offset=10
7 Preeclampsia syndrome Williams Obstetrics, 26e 688 710 New York, US McGraw Hill 2022 https://accessmedicine.mhmedical.com/content.aspx?bookid=2977&sectionid=263820327
8 Hypertensive emergencies Obstetric Intensive Care Manual, Fifth Edition Sibai BM New York, US McGraw Hill 2018 https://obgyn.mhmedical.com/content.aspx?bookid=2379&sectionid=185992160
9 HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets) 8 2024 2023 https://www.uptodate.com/contents/hellp-syndrome-hemolysis-elevated-liver-enzymes-and-low-platelets?search=hellp%20syndrom&source=search_result&selectedTitle=1%7E80&usage_type=default&display_rank=1
10 Preeclampsia and high blood pressure during pregnancy 8 2024 2022 https://www.acog.org/womens-health/faqs/preeclampsia-and-high-blood-pressure-during-pregnancy
11 The HELLP syndrome: clinical issues and management. A review BMC Pregnancy Childbirth Haram K Svendsen E Abildgaard U 8 9 2009 19245695
12 Preeclampsia StatPearls Karrar SA Martingano DJ Hong PL Treasure Island, FL StatPearls Publishing 2024 https://pubmed.ncbi.nlm.nih.gov/34033373/
13 Addressing medial student knowledge deficits in 'hospital-to-home' transitions of care using a constructivism theory-based workshop intervention Clin Teach Browne AC Murphy E Finn Y Cantillon P 0 2023
14 Can a novel constructivist theory-informed feedback intervention reduce prescribing errors? A pre-post study BMC Med Educ Coombes I Donovan P Bullock B Mitchell C Noble C 150 23 2023 36882779
15 HELLP syndrome-holistic insight into pathophysiology Medicina (Kaunas) Petca A Miron BC Pacu I 326 58 2022 35208649
16 Pre-eclampsia: pathogenesis, novel diagnostics and therapies Nat Rev Nephrol Phipps EA Thadhani R Benzing T Karumanchi SA 275 289 15 2019 30792480
