BACKGROUND: Hepatic hemorrhage occurs in less than 5% of patients with 
hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome but it is a 
profound cause of maternal/perinatal morbidity and mortality.
OBJECTIVES: To determine when liver bleeding occurs during the development of 
HELLP syndrome.
SEARCH STRATEGY: The English literature was searched for all reports of HELLP 
syndrome associated with liver bleeding.
SELECTION CRITERIA: Eighty-seven case summaries of liver bleeding in the setting 
of HELLP syndrome were included. The standard definition of HELLP syndrome was 
used with expansion into the Mississippi classification system, supplemented by 
patients with partial HELLP syndrome.
DATA COLLECTION AND ANALYSIS: Demographic and clinical data were collected and 
recorded in an Excel database.
MAIN RESULTS: Liver bleeding was detected in 18 (20.7%) patients with class 1 
HELLP syndrome, 24 (27.6%) with class 2 HELLP syndrome, and 12 (13.8%) with 
class 3 or partial HELLP syndrome. In 33 (37.9%) patients, the exact class of 
HELLP syndrome at the time liver bleeding was detected could not be determined 
from the published descriptions.
CONCLUSIONS: Liver bleeding can occur early during HELLP syndrome development, 
not only in patients with advanced, class 1 illness.