Date:
Patient:
MRN:
Clincian: (Obstetrician, Maternal-Fetal Medicine Specialist)
Reason for Visit:
Evaluation for suspected or confirmed HELLP syndrome
Review of laboratory results (liver function tests, platelets)
Monitoring of maternal and fetal well-being
Discussion of treatment plan and delivery considerations
History of Present Illness:
Briefly describe the patient’s current gestational age and presentation:
Onset and severity of symptoms (epigastric pain, nausea, vomiting)
Headache
Visual disturbances (blurred vision)
New onset right upper quadrant tenderness
Previous medical history (pre-existing hypertension, chronic liver disease)
Prenatal history (previous HELLP syndrome, preeclampsia)
Past Medical History:
Underlying medical conditions (chronic hypertension, autoimmune diseases)
Previous surgeries or hospitalizations
Family History:
Family history of preeclampsia or HELLP syndrome (may suggest increased risk)
Social History:
Smoking history (increases risk of preeclampsia and HELLP)
Physical Exam:
Vital Signs:
Elevated blood pressure (characteristic of preeclampsia)
Consider mentioning tachycardia (rapid heart rate) if present.
Abdominal exam:
Right upper quadrant tenderness may be present.
Neurologic exam:
Assess for confusion, lethargy, or other signs of central nervous system involvement (severe cases).
Labs:
Liver function tests (LFTs):
Elevated AST (aspartate aminotransferase) and ALT (alanine aminotransferase) enzymes suggest liver damage.
Platelet count:
Thrombocytopenia (low platelet count) is a hallmark feature of HELLP syndrome.
Hemoglobin and hematocrit:
May be decreased due to microangiopathic hemolysis (red blood cell destruction).
Consider mentioning other labs ordered as needed (coagulation studies, blood type and Rh factor).
Imaging:
Imaging studies are not diagnostic for HELLP syndrome but may be performed for other reasons during pregnancy (ultrasound for fetal assessment).
Assessment:
Summarize the diagnosis (suspected or confirmed HELLP syndrome) based on clinical presentation and laboratory findings.
Assess the severity of HELLP syndrome based on specific criteria (blood pressure levels, platelet count, liver function test abnormalities).
Plan:
Outline the treatment plan based on the severity of HELLP syndrome and gestational age:
Severe cases or cases with worsening symptoms:
Immediate delivery may be necessary to improve maternal and fetal outcomes.
Hospitalization for close monitoring and aggressive management.
Medications:
Magnesium sulfate for seizure prophylaxis (eclampsia risk).
Antihypertensive medications to control blood pressure.
Corticosteroids for severe cases or concerns about fetal lung maturity.
Less severe cases with close monitoring:
Hospitalization for monitoring maternal and fetal well-being.
Repeat laboratory tests to track trends.
Potential for expectant management with close monitoring if fetal lung maturity is adequate and maternal condition remains stable.
Consider mentioning the involvement of a multidisciplinary team (obstetrician, neonatologist, maternal-fetal medicine specialist) in managing complex cases.
Prognosis:
Briefly discuss the prognosis. Early diagnosis and prompt management are crucial for improving maternal and fetal outcomes.
Emphasize the potential risks associated with HELLP syndrome (placental abruption, eclampsia, HELLP syndrome recurrence in future pregnancies).
Education:
Document any education provided to the patient regarding:
The nature of HELLP syndrome and its potential complications
The importance of hospitalization and close monitoring
The potential risks and benefits of delivery depending on the severity of the case
The importance of ongoing prenatal care in future pregnancies
Notes:
Include any additional relevant information not covered above, such as the patient’s understanding of the diagnosis, treatment plan, and delivery considerations.
Document the patient’s emotional state and offer support or referral for mental health services if needed.
Disclaimer: This is a template and should be adapted to the specific needs of each patient. It is important to consult with an obstetrician or maternal-fetal medicine specialist for diagnosis, treatment recommendations, and prognosis.