Maternal and Neonatal Outcomes in Women with HELLP Syndrome Undergoing Caesarean Delivery Under General and Neuraxial Anaesthesia: A Systematic Review and Narrative Synthesis.

BACKGROUND

Women with haemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome may require urgent caesarean delivery under general or neuraxial anaesthesia. This review aimed to describe the maternal and neonatal outcomes reported in women with HELLP syndrome undergoing caesarean delivery under general and neuraxial anaesthesia.

METHODS

PubMed, Embase, and CENTRAL were searched from inception to September 2025. Eligible studies reported the anaesthetic technique together with at least one maternal or neonatal outcome. Risk of bias was assessed using tools matched to study design - the JBI checklist for single-arm case series and ROBINS-I for non-randomised comparative studies - and the certainty of evidence was rated using GRADE. A structured narrative synthesis was performed; because the eligible evidence was observational and strongly affected by confounding by indication, the registered protocol was amended from a comparative to a descriptive synthesis and no meta-analysis was undertaken.

RESULTS

Seven observational studies were included. Across these studies, the review describes 369 caesarean deliveries in women with HELLP syndrome; an anaesthetic technique was documented for 328 of these - 169 underwent general anaesthesia and 159 underwent neuraxial anaesthesia - while for the remaining 41 the technique could not be reliably determined. Reporting of maternal and neonatal outcomes was inconsistent. Among studies that explicitly reported maternal mortality, study-level rates ranged from 0% to 30%; the upper value (11/37) came from an intensive-care cohort and reflects mortality among women with HELLP syndrome admitted to intensive care rather than a technique-specific or caesarean-specific risk. No study reported a confirmed neuraxial haematoma or permanent neurological deficit after neuraxial anaesthesia, although neurological surveillance and platelet timing were seldom described. Neonatal outcomes were variably reported. The certainty of evidence for all key outcomes was very low.

CONCLUSION

Caesarean delivery under both techniques has been reported without catastrophic neuraxial complications, but all five comparative studies were at serious risk of bias from confounding by indication, so reported differences likely reflect disease severity rather than the anaesthetic technique. Future studies should report platelet timing and neurological follow-up prospectively.

REGISTRATION: PROSPERO 2025 CRD420251248492.