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McCrae KR. Thrombocytopenia in Pregnancy. Platelets 2013. [DOI: 10.1016/b978-0-12-387837-3.00044-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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A Case of Microangiopathic Antiphospholipid-Associated Syndromes during Pregnancy: Review of the Literature. Case Rep Med 2012; 2012:827543. [PMID: 22811728 PMCID: PMC3395268 DOI: 10.1155/2012/827543] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Accepted: 04/25/2012] [Indexed: 11/25/2022] Open
Abstract
Microangiopathic antiphospholipid-associated syndromes (MAPSs) are reported as encompassing several conditions mainly affecting the microvasculature of selected organs: the liver in HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet); kidney, brain, and skin in TTP (thrombotic thrombocytopenic purpura). It is predominant in patients with catastrophic antiphospholipid syndrome (APS). A recent report suggests that APS is not only a thrombotic disease but also associated with microangiopathic features, and it can explain the greater prevalence of HELLP syndrome in these patients. We here report a case of MAPS during pregnancy associated with systemic lupus erythematosus (SLE) in early second trimester.
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Khellaf M, Loustau V, Bierling P, Michel M, Godeau B. [Thrombocytopenia and pregnancy]. Rev Med Interne 2012; 33:446-52. [PMID: 22742709 DOI: 10.1016/j.revmed.2012.05.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2012] [Accepted: 05/11/2012] [Indexed: 11/25/2022]
Abstract
The occurrence of thrombocytopenia during pregnancy is frequent (about 10%). Etiologies of thrombocytopenia are dominated by the gestational thrombocytopenia (>75%), which requires no exploration and no specific treatment; it usually occurs during the last trimester of pregnancy and corrects itself spontaneously after delivery. Other etiologies are: (1) immune thrombocytopenia (ITP) either primary or associated with other pathologies; ITP may appear early in the first trimester of pregnancy, (2) thrombotic microangiopathy syndromes, and (3) obstetric thrombocytopenia: eclampsia and HELLP syndrome (hemolysis elevated liver enzymes, and low platelet count). Treatment of pre-eclampsia and HELLP syndrome is based on resuscitative measures and symptomatic fetal extraction that will be discussed according to the term and severity of the case. The treatment of microangiopathy is based on resuscitation and plasma exchange. For ITP, no specific action is needed during pregnancy and only symptomatic patients with a platelet count less than 30×10(9)/L must receive a treatment. It is important to prepare the childbirth that can be vaginally except if there is an obstetric contraindication. A platelet count of 50×10(9)/L is required for the delivery, and of 75×10(9)/L in case of spinal anesthesia. Treatment implies a short course of corticosteroids associated with infusion of immunoglobulins in the most severe forms or in case of steroids resistance. There is a risk of neonatal thrombocytopenia requiring a control of the blood count for the baby at birth and within 5 days, newborns have to be treated if the platelet count is less than 20×10(9)/L.
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Affiliation(s)
- M Khellaf
- Service de médecine interne, centre de référence des cytopénies auto-immunes de l'adulte, université PARIS XII, hôpital Henri-Mondor, 51 avenue du Maréchal-de-Lattre-de-Tassigny, Créteil, France.
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Costedoat-Chalumeau N, Guettrot-Imbert G, Leguern V, Leroux G, Le Thi Huong D, Wechsler B, Morel N, Vauthier-Brouzes D, Dommergues M, Cornet A, Aumaître O, Pourrat O, Piette JC, Nizard J. Grossesse et syndrome des antiphospholipides. Rev Med Interne 2012; 33:209-16. [DOI: 10.1016/j.revmed.2012.01.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Accepted: 01/04/2012] [Indexed: 10/14/2022]
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Jo YY, Lee KC, Kim HS, Bae HK, Chang YJ. Anesthetic management of HELLP syndrome complicating primary antiphospholipid syndrome -A case report-. Korean J Anesthesiol 2012; 62:575-8. [PMID: 22778897 PMCID: PMC3384799 DOI: 10.4097/kjae.2012.62.6.575] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2011] [Revised: 05/20/2011] [Accepted: 05/24/2011] [Indexed: 12/05/2022] Open
Abstract
Antiphospholipid syndrome (APS) is defined as an autoimmune disorder characterized by recurrent thrombosis or obstetrical morbidity. A 29-year-old woman who was diagnosed with APS underwent emergency cesarean delivery at 23 weeks' gestation. She had a seizure attack and her laboratory findings were: AST/ALT 1459/1108 IU/L, LDH 1424 IU/L, 30% hematocrit, a platelet count of 43 × 103/ml and urine protein (4+). We describe the anesthetic experience of catastrophic HELLP syndrome with antiphospholipid syndrome and we review the relevant literature.
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Affiliation(s)
- Youn Yi Jo
- Department of Anesthesiology and Pain Medicine, Gachon University of Medicine and Science Gil Medical Center, Incheon, Korea
| | - Kyung Cheon Lee
- Department of Anesthesiology and Pain Medicine, Gachon University of Medicine and Science Gil Medical Center, Incheon, Korea
| | - Hong Soon Kim
- Department of Anesthesiology and Pain Medicine, Gachon University of Medicine and Science Gil Medical Center, Incheon, Korea
| | - Hyun Kyung Bae
- Department of Anesthesiology and Pain Medicine, Gachon University of Medicine and Science Gil Medical Center, Incheon, Korea
| | - Young Jin Chang
- Department of Anesthesiology and Pain Medicine, Gachon University of Medicine and Science Gil Medical Center, Incheon, Korea
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Appenzeller S, Souza FH, Wagner Silva de Souza A, Shoenfeld Y, de Carvalho JF. HELLP Syndrome and Its Relationship with Antiphospholipid Syndrome and Antiphospholipid Antibodies. Semin Arthritis Rheum 2011; 41:517-23. [DOI: 10.1016/j.semarthrit.2011.05.007] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2011] [Revised: 05/25/2011] [Accepted: 05/25/2011] [Indexed: 11/25/2022]
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Danza A, Ruiz-Irastorza G, Khamashta M. Antiphospohlipid syndrome in obstetrics. Best Pract Res Clin Obstet Gynaecol 2011; 26:65-76. [PMID: 22079775 DOI: 10.1016/j.bpobgyn.2011.10.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2011] [Accepted: 10/05/2011] [Indexed: 10/15/2022]
Abstract
Antiphospholipid syndrome is characterised by a variety of clinical and immunological manifestations. The clinical hallmarks of this syndrome are thrombosis and poor obstetric outcomes, including miscarriages, fetal loss and severe pre-eclampsia. The main antiphospholipid antibodies include lupus anticoagulant, anticardiolipin and anti-β2-glycoprotein I. The combination of aspirin and heparin is considered the standard of care for women with antiphospholipid syndrome and embryo-fetal losses; however, aspirin in monotherapy may have a place in women with recurrent early miscarriage. A good benefit-risk ratio of low-molecular-weight heparin in pregnancy thrombosis treatment has been reported. Warfarin must be avoided if possible throughout the first trimester of pregnancy. Adequate pregnancy management of women with antiphospholipid syndrome should include co-ordinated medical-obstetrical care, a close follow-up protocol and a good neonatal unit. Close blood pressure control and early detection of proteinuria, together with Doppler studies of the utero-placental circulation should be included in the management protocol.
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Affiliation(s)
- Alvaro Danza
- Autoimmune Diseases Research Unit, Department of Internal Medicine, Hospital Universitario Cruces, University of the Basque Country, Bizkaia, Spain
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59
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Thrombotic storm revisited: preliminary diagnostic criteria suggested by the thrombotic storm study group. Am J Med 2011; 124:290-6. [PMID: 21435416 DOI: 10.1016/j.amjmed.2010.10.018] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2010] [Revised: 10/05/2010] [Accepted: 10/07/2010] [Indexed: 11/22/2022]
Abstract
Physicians periodically encounter patients with an extraordinarily accelerated course of hypercoagulability who develop thromboses in multiple organ systems over days to weeks. Such patients may harbor underlying hypercoagulable clinical conditions, but their clinical course sets them apart from most patients with similar risk factors. Underlying triggers of "thrombotic storm" include pregnancy, inflammation, trauma, surgery, and infection. Aggressive anticoagulant therapy may control thrombotic storm, yet thrombotic storm may resume with even brief interruptions of anticoagulant therapy. The authors of this communication formed the Thrombotic Storm Study Group in order to identify clinical characteristics of such patients, thus constructing preliminary criteria to better define, identify, and study the course of patients deemed to have thrombotic storm. The characteristics culled from these 10 patients are: younger age (oldest was 38 years old at time of presentation); at least 2 arterial or venous (or both) thromboembolic events, typically in unusual sites with or without microangiopathy; unexplained recurrence; and frequently proceeded by a trigger. The following characteristics were not used in defining thrombotic storm: underlying malignancies; use of acute myocardial infarction as a defining arterial event in the setting of established coronary artery disease; use of cocaine; thrombotic complications expected with various intravascular devices; known paroxysmal nocturnal hemoglobinuria or myeloproliferative disorders; severe trauma; and premorbid conditions.
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Abstract
Historically, pregnancy in women with many inflammatory rheumatic diseases was not considered safe and was discouraged. Combined care allows these pregnancies to be managed optimally, with the majority of outcomes being favorable. Disease activity at the time of conception and anti-phospholipid antibodies are responsible for most complications. Disease flares, pre-eclampsia, and thrombosis are the main maternal complications, whereas fetal loss and intrauterine growth restriction are the main fetal complications. Antirheumatic drugs used during pregnancy and lactation to control disease activity are corticosteroids, hydroxychloroquine, sulphasalzine, and azathioprine. Vaginal delivery is possible in most circumstances, with cesarean section being reserved for complications.
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61
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Lee YH, Lee HS. Management of Pregnancy in Women with Systemic Lupus Erythematosus. JOURNAL OF RHEUMATIC DISEASES 2011. [DOI: 10.4078/jrd.2011.18.2.74] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Young Ho Lee
- Division of Rheumatology, Korea University Medical Center, Seoul, Korea
| | - Hye-Soon Lee
- Division of Rheumatology, Hanyang University Medical School, Seoul, Korea
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62
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Ruiz-Irastorza G, Khamashta MA. Complicated Pregnancies in Patients with Autoimmune Systemic Diseases. Autoimmune Dis 2011. [DOI: 10.1007/978-0-85729-358-9_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Abstract
Pregnancy, whether normal or complicated, induces change in nearly every system of the body. Because most rheumatologic disorders are multisystemic and often affect young women, it may be difficult to differentiate pregnancy-related change from new onset or exacerbation of rheumatic disease. Familiarity with common manifestations of pregnancy is important in evaluating young women of childbearing age,whether or not they have known rheumatologic disease. Presentation of new connective tissue disease during pregnancy is often associated with poorer prognosis, so it is especially important to distinguish between pregnancy-induced change and true autoimmune inflammation requiring prompt and aggressive therapy.
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Affiliation(s)
- Lisa R Sammaritano
- Rheumatology Division, Department of Medicine, Hospital for Special Surgery, Weill Cornell Medical College, 535 East 70th Street, New York, NY 10021, USA.
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64
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Clowse MEB. Managing contraception and pregnancy in the rheumatologic diseases. Best Pract Res Clin Rheumatol 2010; 24:373-85. [PMID: 20534371 DOI: 10.1016/j.berh.2009.12.004] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Most pregnancies in women with rheumatologic disease will result in the delivery of a healthy baby. Pregnancy can be particularly risky in women with active disease or on teratogenic medications, making contraception an important issue for these women. All women with rheumatologic disease have contraceptive options, including barrier methods, the intra-uterine device and progesterone-only medications. Active inflammatory disease, whether in the form of lupus, systemic vasculitis or myositis, places the pregnancy at increased risk. Pre-eclampsia is a particular risk for women with lupus or antiphospholipid syndrome and may be decreased by daily low-dose aspirin. Rheumatoid arthritis typically improves and does not have a major impact on pregnancy outcomes. The expected post-partum arthritis flare may be avoided by restarting medications soon after delivery. Judicious use of medication and close observation may be the keys to successful pregnancy in women with rheumatologic disease.
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Affiliation(s)
- Megan E B Clowse
- Department of Rheumatology & Immunology Duke University Health System, Durham, UK.
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Gómez-Puerta JA, Sanin-Blair J, Galarza-Maldonado C. Pregnancy and catastrophic antiphospholipid syndrome. Clin Rev Allergy Immunol 2009; 36:85-90. [PMID: 19052924 DOI: 10.1007/s12016-008-8100-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Antiphospholipid syndrome (APS) is clearly related to maternal morbidity. The most characteristic feature is pregnancy loss; however, several other serious complications had been reported including fetal growth restriction, uteroplacental insufficiency, fetal distress, pre-eclampsia, and HELLP syndrome. Herein, we review the different aspects of obstetric APS features, with special emphasis on its life-threatening variant known as catastrophic APS (Asherson's syndrome) and its relationship with a thrombotic microangiopathy such as HELLP syndrome.
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Delluc C, Costedoat-Chalumeau N, Leroux G, Imbert G, Le Thi Huong D, Vauthier-Brouzes D, Piette JC, Chazouilleres O, Cacoub P. Pathologies hépatiques et grossesse. Rev Med Interne 2009; 30:508-15. [DOI: 10.1016/j.revmed.2008.09.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2008] [Revised: 09/12/2008] [Accepted: 09/24/2008] [Indexed: 12/27/2022]
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Tincani A, Rebaioli CB, Andreoli L, Lojacono A, Motta M. Neonatal effects of maternal antiphospholipid syndrome. Curr Rheumatol Rep 2009; 11:70-6. [PMID: 19171114 DOI: 10.1007/s11926-009-0010-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Antiphospholipid antibodies (aPL) can impair the physiologic development of a fetus during pregnancy not only by causing thrombosis of the placental vessels, but also by directly binding throphoblast cells and modifying their functions. Consequently, the presence of aPL in pregnant women is linked to an increased rate of pregnancy complications. These include recurrent early miscarriages, late fetal losses, and hypertensive disorders of gestation. In this clinical setting, preeclampsia is usually early and severe and can be complicated by the syndrome of hemolysis, elevated liver enzymes, and low platelet count (HELLP syndrome). The close association between aPL and obstetric pathology supports the inclusion of these manifestations in the clinical classification criteria of antiphospholipid syndrome. About 30% of children born to mothers with aPL passively acquire these autoantibodies; fortunately, the occurrence of thrombosis seems extremely rare in these babies. The prospective ongoing studies of children born to antiphospholipid syndrome patients reassure us about their general good health; however, some data suggest that learning difficulties might occur, possibly related to in utero exposure to aPL.
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Affiliation(s)
- Angela Tincani
- Reumatologia e Immunologia Clinica, Spedali Civili e Università di Brescia, Brescia, Italy.
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68
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Haram K, Svendsen E, Abildgaard U. The HELLP syndrome: clinical issues and management. A Review. BMC Pregnancy Childbirth 2009; 9:8. [PMID: 19245695 PMCID: PMC2654858 DOI: 10.1186/1471-2393-9-8] [Citation(s) in RCA: 296] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2008] [Accepted: 02/26/2009] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The HELLP syndrome is a serious complication in pregnancy characterized by haemolysis, elevated liver enzymes and low platelet count occurring in 0.5 to 0.9% of all pregnancies and in 10-20% of cases with severe preeclampsia. The present review highlights occurrence, diagnosis, complications, surveillance, corticosteroid treatment, mode of delivery and risk of recurrence. METHODS Clinical reports and reviews published between 2000 and 2008 were screened using Pub Med and Cochrane databases. RESULTS AND CONCLUSION About 70% of the cases develop before delivery, the majority between the 27th and 37th gestational weeks; the remainder within 48 hours after delivery. The HELLP syndrome may be complete or incomplete. In the Tennessee Classification System diagnostic criteria for HELLP are haemolysis with increased LDH (> 600 U/L), AST (>or= 70 U/L), and platelets < 100 x 10(9)/L. The Mississippi Triple-class HELLP System further classifies the disorder by the nadir platelet counts. The syndrome is a progressive condition and serious complications are frequent. Conservative treatment (>or= 48 hours) is controversial but may be considered in selected cases < 34 weeks' gestation. Delivery is indicated if the HELLP syndrome occurs after the 34th gestational week or the foetal and/or maternal conditions deteriorate. Vaginal delivery is preferable. If the cervix is unfavourable, it is reasonable to induce cervical ripening and then labour. In gestational ages between 24 and 34 weeks most authors prefer a single course of corticosteroid therapy for foetal lung maturation, either 2 doses of 12 mg betamethasone 24 hours apart or 6 mg or dexamethasone 12 hours apart before delivery. Standard corticosteroid treatment is, however, of uncertain clinical value in the maternal HELLP syndrome. High-dose treatment and repeated doses should be avoided for fear of long-term adverse effects on the foetal brain. Before 34 weeks' gestation, delivery should be performed if the maternal condition worsens or signs of intrauterine foetal distress occur. Blood pressure should be kept below 155/105 mmHg. Close surveillance of the mother should be continued for at least 48 hours after delivery.
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Affiliation(s)
- Kjell Haram
- Department of Obstetrics and Gynaecology, Haukeland University Hospital, Bergen, Norway.
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d'Ythurbide G, Rousset P, Carbonne B, Cabane J, Fardet L, Tiev K, Kettaneh A. [Liver infarcts with early HELLP syndrome and probable catastrophic antiphospholipid syndrome]. Rev Med Interne 2009; 30:255-9. [PMID: 19131145 DOI: 10.1016/j.revmed.2008.09.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2007] [Revised: 09/22/2008] [Accepted: 09/25/2008] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Among microangiopathic disorders of pregnancy, catastrophic antiphospholipid syndrome (CAPS) is a maternal and fetal life-threatening disorder. Hepatic involvement of this multi-systemic disorder can be confused with HELLP syndrome, occurring usually later in the course of pregnancy. CASE REPORT We report a case of probable CAPS with hepatic disease in a pregnant woman at 13 week's gestation, with antiphospholipid syndrome and biological features of HELLP syndrome. Unspecific hepatic imaging, well-described in our case allowed undelayed therapy. CONCLUSION CAPS and HELLP syndrome, both severe microangiopathic disorders, may be associated. Nosological distinction does not modify treatment strategy, which is a maternal and foetal emergency, but their overlapping requires aggressive and early management.
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Affiliation(s)
- G d'Ythurbide
- Service de médecine interne, Université Pierre- et-Marie-Curie, 75012 Paris, France
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70
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Le syndrome HELLP : les dix commandements. Rev Med Interne 2009; 30:58-64. [DOI: 10.1016/j.revmed.2008.06.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2008] [Revised: 05/16/2008] [Accepted: 06/03/2008] [Indexed: 11/24/2022]
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71
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Wada Y, Sakamaki Y, Kobayashi D, Ajiro J, Moro H, Murakami S, Ooki I, Kikuchi A, Takakuwa K, Tanaka K, Sato T, Nakano M, Narita I. HELLP syndrome, multiple liver infarctions, and intrauterine fetal death in a patient with systemic lupus erythematosus and antiphospholipid syndrome. Intern Med 2009; 48:1555-8. [PMID: 19721303 DOI: 10.2169/internalmedicine.48.2284] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We report a case of HELLP syndrome, multiple liver infarctions, and intrauterine fetal death in a woman in the 17th week of pregnancy with SLE and APS who had been in remission on a regimen of low-dose prednisolone and aspirin. An increase in the dosage of corticosteroid together with intravenous heparin infusion led to improvement of the clinical symptoms, laboratory parameters, and multifocal low-density liver lesions detected by computed tomography. Early onset and signs of severe organ involvement are the characteristic features of HELLP syndrome associated with APS, and patients that are at risk should be followed up carefully.
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Affiliation(s)
- Yoko Wada
- Clinical Nephrology and Rheumatology, Department of Medicine II, Niigata University Graduate School of Medical and Dental Sciences, Niigata.
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Beucher G, Simonet T, Dreyfus M. Prise en charge du HELLP syndrome. ACTA ACUST UNITED AC 2008; 36:1175-90. [DOI: 10.1016/j.gyobfe.2008.08.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2008] [Accepted: 08/09/2008] [Indexed: 11/26/2022]
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74
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PAGALAVAN L. Antiphospholipid syndrome: a systemic and multidisciplinary disease. Int J Rheum Dis 2008. [DOI: 10.1111/j.1756-185x.2008.00343.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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75
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Baker WF, Bick RL. The clinical spectrum of antiphospholipid syndrome. Hematol Oncol Clin North Am 2008; 22:33-52, v-vi. [PMID: 18207064 DOI: 10.1016/j.hoc.2007.10.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Antiphospholipid syndrome (APS) is a disorder characterized by a wide variety of clinical manifestations. Virtually any organ system or tissue may be affected by the consequences of large- or small-vessel thrombosis. There is a broad spectrum of disease among individuals with antiphospholipid antibodies (aPL). Patients may exhibit clinical features suggesting APS but not fulfill the International Criteria for a "definite" diagnosis. Seronegative APS patients demonstrate typical idiopathic thromboses but aPL are not initially detected. Patients defined with definite APS demonstrate nearly identical sites of venous and arterial thrombosis, regardless of the presence or absence of systemic lupus erythematosus. Microangiopathic APS may present with isolated tissue and organ injury or as the overwhelming "thrombotic storm" observed in catastrophic APS.
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Affiliation(s)
- William F Baker
- David Geffen School of Medicine, Center for Health Sciences, University of California, Los Angeles, Los Angeles, CA, USA.
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77
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Asherson RA, Galarza-Maldonado C, Sanin-Blair J. The HELLP syndrome, antiphospholipid antibodies, and syndromes. Clin Rheumatol 2007; 27:1-4. [PMID: 17912576 DOI: 10.1007/s10067-007-0742-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2007] [Accepted: 08/30/2007] [Indexed: 01/29/2023]
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78
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George D, Vasanth L, Erkan D, Bass A, Salmon J, Lockshin MD. Primary antiphospholipid syndrome presenting as HELLP syndrome: a clinical pathology conference held by the Division of Rheumatology at Hospital for Special Surgery. HSS J 2007; 3:216-21. [PMID: 18751798 PMCID: PMC2504265 DOI: 10.1007/s11420-007-9043-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2007] [Accepted: 03/21/2007] [Indexed: 02/07/2023]
Affiliation(s)
- Diane George
- Department of Internal Medicine, St Lukes-Roosevelt Hospital Center, 1000 10th Avenue, New York, NY 10019, USA.
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79
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Merz WM, Gembruch U. Severe, early-onset hemolysis, elevated liver enzymes, and low platelet (HELLP) syndrome episode with spontaneous remission during pregnancy. J Matern Fetal Neonatal Med 2007; 20:631-2. [PMID: 17674282 DOI: 10.1080/14767050701449810] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
A case of a severe HELLP syndrome episode at 21 + 0 weeks of gestation is reported. Expectant management resulted in rapid improvement of all HELLP parameters. Subsequently preeclampsia developed and uteroplacental dysfunction deteriorated. Intrauterine fetal death occured at 22 + 3 weeks of gestation.
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Affiliation(s)
- Waltraut M Merz
- Department of Obstetrics and Prenatal Medicine, University of Bonn, Bonn, Germany.
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80
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Asherson RA, Spargo C, Gómez-Puerta JA. Partial HELLP syndrome in pregnancy complicated by recurrent deep vein thromboses and palmar skin lesions in a patient with prothrombin gene 20210a mutation and antiphospholipid antibodies: an unusual case. Clin Rheumatol 2007; 27:245-8. [PMID: 17610004 DOI: 10.1007/s10067-007-0683-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2007] [Accepted: 06/18/2007] [Indexed: 10/23/2022]
Abstract
A patient who developed thrombocytopenia and hypertension accompanied by high levels of antiphospholipid antibodies and abnormal liver function tests in the absence of a hemolytic anemia necessitating termination of pregnancy developed bilateral lower limb thromboses accompanied by painful maculo papular lesions on the palms of both hands a few days after ending the pregnancy. She was then also found to have a prothrombin gene G20210A mutation. She was treated with anticoagulation therapy, but her postpartum course was further complicated by pulmonary embolus. A Greenfield filter was inserted into the inferior vena cava. On low molecular weight heparin, her next pregnancy was uneventful and without any complications.
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Affiliation(s)
- Ronald A Asherson
- Division of Immunology, School of Pathology, University of the Witwatersrand School of Medicine, Johannesburg, South Africa
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81
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Tsirigotis P, Mantzios G, Pappa V, Girkas K, Salamalekis G, Koutras A, Giannopoulou V, Spirou K, Balanika A, Papageorgiou S, Travlou A, Dervenoulas J. Antiphospholipid syndrome: a predisposing factor for early onset HELLP syndrome. Rheumatol Int 2007; 28:171-4. [PMID: 17576561 DOI: 10.1007/s00296-007-0386-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2007] [Accepted: 05/28/2007] [Indexed: 12/27/2022]
Abstract
Hemolysis elevated liver enzymes low platelets syndrome (HELLP) is a relatively rare pregnancy-related thrombotic microangiopathic disorder, usually observed during the third trimester. Its incidence seems to be increased in patients with antiphospholipid syndrome (APS). In this report, we describe a 33-year-old pregnant woman with previously known primary APS who developed early onset HELLP syndrome during the 15th week of gestation. We also review the literature about this interesting relationship between APS and HELLP.
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Affiliation(s)
- Panagiotis Tsirigotis
- 2nd Department of Internal Medicine, Propaudeutic, University of Athens, ATTIKON General University Hospital, Athens, Greece.
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82
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Asherson RA, Pierangeli SS, Cervera R. Is there a microangiopathic antiphospholipid syndrome? Ann Rheum Dis 2007; 66:429-32. [PMID: 17360782 PMCID: PMC1856041 DOI: 10.1136/ard.2006.067033] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Abstract
Antiphospholipid syndrome (APS) is frequently associated with complications during pregnancy. Miscarriage and maternal thrombosis are the most common problems, but prematurity, intrauterine growth retardation, pregnancy-induced hypertensive disorders, and pulmonary hypertension can complicate pregnancy as well. The correct treatment of these women requires an accurate preconceptual counseling and a close collaboration between obstetricians and physicians. Doppler studies of the umbilical and uterine arteries play an important role in predicting APS-related complications during pregnancy.
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Affiliation(s)
- Guillermo Ruiz-Irastorza
- Department of Internal Medicine, Hospital de Cruces, University of the Basque Country, 48903-Bizkaia, Spain
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84
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Magy-Bertrand N, Vinzio S, Reny JL. Premier symposium franco-britannique sur le syndrome des antiphospholipides (Nice, 30 septembre 2006). Rev Med Interne 2007. [DOI: 10.1016/j.revmed.2006.12.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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85
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Salmon JE, Girardi G, Lockshin MD. The antiphospholipid syndrome as a disorder initiated by inflammation: implications for the therapy of pregnant patients. ACTA ACUST UNITED AC 2007; 3:140-7; quiz 1 p following 187. [PMID: 17334336 DOI: 10.1038/ncprheum0432] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2006] [Accepted: 12/20/2006] [Indexed: 11/08/2022]
Abstract
Arterial thrombosis, venous thrombosis and morbidity during pregnancy, or a combination of these events, are clinical outcomes associated with antiphospholipid antibodies produced by patients with antiphospholipid syndrome (APS). Our understanding of the etiology and pathogenesis of the syndrome is limited, but it has generally been considered a thrombophilic disease and treatment has focused on anticoagulation. Agents such as aspirin and heparin, administered alone or in combination, are empirical treatments that are used in the management of obstetric patients with APS. Clinical features, such as heart valve abnormalities, thrombocytopenia and livedo reticularis, suggest multiple pathogenic mechanisms and provide other therapeutic targets. Findings from research in animal models of APS challenge the dogma that this syndrome is a noninflammatory, thrombotic disease and provide evidence that activation of complement is crucial for complications in pregnancy. These studies, in addition to evidence of inflammatory-mediated tissue damage in placentae of patients with APS, suggest that therapy should also be directed towards preventing inflammation. This Review describes the potential mechanisms of tissue injury by antiphospholipid antibodies, the management of pregnant patients with APS and how heparin therapy might inhibit the pathogenic mediators of disease.
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Affiliation(s)
- Jane E Salmon
- Mary Kirkland Center for Lupus Research, New York, NY, USA.
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86
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Gómez-Puerta JA, Cervera R, Espinosa G, Asherson RA, García-Carrasco M, da Costa IP, Andrade DCO, Borba EF, Makatsaria A, Bucciarelli S, Ramos-Casals M, Font J. Catastrophic antiphospholipid syndrome during pregnancy and puerperium: maternal and fetal characteristics of 15 cases. Ann Rheum Dis 2007; 66:740-6. [PMID: 17223653 PMCID: PMC1954660 DOI: 10.1136/ard.2006.061671] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND The catastrophic variant of the antiphospholipid syndrome (APS) is a life-threatening form of presentation of this syndrome that can be triggered by several factors. AIM To describe the characteristics of patients who developed catastrophic APS triggered during pregnancy and puerperium. METHODS A review of the first 255 cases collected in the website-based "CAPS Registry" was undertaken. Three new and unpublished cases of catastrophic APS developed during pregnancy and puerperium were added. RESULTS Fifteen cases were identified. The mean (range) age was 27 (17-38) years. Most patients had a previous unsuccessful obstetric history. In 7 of 14 (50%) cases with available medical history, the catastrophic APS appeared during pregnancy, in 6 (43%) during the puerperium and in 1 (7%) after curettage for a fetal death. The main clinical and serological characteristics were similar to those patients with catastrophic APS triggered by other factors, except for a history of a higher prevalence of previous abortions (p<0.01). Several specific features were found, including the HELLP (haemolysis, elevated liver enzymes, low platelets) syndrome in 8 (53%) patients, placental infarctions in 4 (27%) patients, and pelvic vein thrombosis and myometrium thrombotic microangiopathy in 1 (7%) patient each. Mortality rate was high for the mothers (46%), and for the babies (54%). CONCLUSIONS It is important to consider the possibility of the development of catastrophic APS in those patients with signs of HELLP syndrome and multiorgan failure during pregnancy or puerperium, especially in those patients with previous history of abortions and/or thrombosis.
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Affiliation(s)
- José A Gómez-Puerta
- Servei de Malalties Autoimmunes, Hospital Clínic, Villarroel 170, 08036-Barcelona, Catalonia, Spain
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87
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88
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Sakhel K, Usta IM, Hannoun A, Arayssi T, Nassar AH. Liver infarction in a woman with systemic lupus erythematosus and secondary anti-phospholipid and HELLP syndrome. Scand J Rheumatol 2006; 35:405-8. [PMID: 17062444 DOI: 10.1080/03009740600588343] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
We report a 39-year-old primigravida, a case of systemic lupus erythematosus (SLE) and secondary anti-phospholipid syndrome (APS) with a smooth antenatal course who delivered by caesarean for non-reassuring foetal heart rate. On day 2 postoperatively, she developed a sudden severe colicky upper abdominal pain with tachypnoea, dyspnoea, and tachycardia, and blood pressure (BP) reaching 150/95 mmHg. Computed tomography of the abdomen revealed lesions consistent with liver infarction. She developed haemolytic anaemia, elevated liver enzymes, and low platelets (HELLP syndrome); heparin and methylprednisolone were started. On day 3, BP normalized, respiratory symptoms improved but abdominal symptoms persisted. Methylprednisolone was increased to 80 mg/day on day 8 when she had significant clinical response and was discharged on day 16. This case emphasizes that a morbid clinical course including liver infarction should be anticipated in patients with SLE and APS complicated with HELLP syndrome.
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Affiliation(s)
- K Sakhel
- Department of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon
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89
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Makatsariya A, Asherson RA, Bitsadze V, Baimuradova S, Akinshina S. Catastrophic antiphospholipid (Asherson's) syndrome and genetic thrombophilic disorders in obstetrics. Autoimmun Rev 2006; 6:89-93. [PMID: 17138250 DOI: 10.1016/j.autrev.2006.06.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Catastrophic antiphospholipid syndrome (CAPS) (Asherson's Syndrome), is a life-threatening condition characterized by a rapidly progressive thromboses resulting in a multiorgan dysfunction syndrome (MODS), evidence of systemic inflammatory response syndrome (SIRS) in the presence of antiphospholipid antibodies. CAPS differs from the classic APS by predominantly affecting small vessels, involvement of unusual organs, rapid onset of MODS, and the development of acute respiratory distress syndrome (ARDS) in 25% of patients, which is a feature of SIRS. Obstetric-related multiorgan failure may be a feature of a subset of CAPS more frequently than was previously thought. Patients with obstetric complications should be tested for antiphospholipid antibodies and genetic thrombophilia in order to institute early prophylaxis. Low-molecular-weight heparin is the drug of choice for preventing obstetric complications and CAPS due to its anticoagulant and anti-inflammatory properties.
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Affiliation(s)
- A Makatsariya
- Department of Obstetrics and Gynecology of Moscow Medical Academy, Noviy Arbat 7, 119017 Moscow, Russia
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90
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Abstract
PURPOSE OF REVIEW Pregnancy in patients with systemic lupus erythematosus is associated with a high risk of maternal disease exacerbation and adverse fetal outcome. This review summarizes recent published findings on lupus pregnancy. RECENT FINDINGS The literature is in agreement that for most women with inactive and stable systemic lupus erythematosus, pregnancy is safe for both mother and fetus. The main risk factors for adverse pregnancy course and outcome are active disease, nephritis with proteinuria, hypertension, and maternal serum antibodies to SS-A/Ro, SS-B/La, cardiolipin, beta2-glycoprotein I, and lupus anticoagulant. Recent studies have broadened our understanding of the immunological mechanism underlying congenital heart block induced by anti-Ro/La antibodies. In addition, the approach to oral contraceptives has been modified on the basis of two well controlled studies suggesting that they do not cause exacerbation of inactive or mild disease. SUMMARY Pregnancy in patients with systemic lupus erythematosus is safe and manageable provided the disease is stable. Patients should be evaluated before pregnancy for pregestational risk factors and be closely followed during pregnancy. In most cases of lupus flare during pregnancy, the disease can be safely managed.
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Affiliation(s)
- Yair Molad
- Rheumatology Unit, Rabin Medical Center, Beilinson Campus, Petah Tiqwa and Internal Medicine, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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91
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Abstract
Systemic lupus erythematosus is a chronic multi-system autoimmune disease that occurs predominantly in women of childbearing age. The risk of complications and adverse fetal outcomes in pregnant women with lupus is high. Moreover, pregnancy can cause flares of lupus disease activity necessitating maternal immunosuppressive intervention. Interestingly, many potential complications of pregnancy present as symptoms of lupus making diagnosis and treatment a challenge. Advancing technology and better understanding of the maternal-fetal dyad in lupus have improved outcomes in lupus pregnancies over the last 40 years. This article will briefly review the important issues in pregnancies complicated by lupus and provide a general guideline to physicians for monitoring and treatment.
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92
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Farley DM, Grainger DA, Tjaden BL, Frazier LM, Maki JE. Use of a gestational carrier for a patient with recurrent adverse pregnancy outcomes from early onset severe pre-eclampsia. Fertil Steril 2006; 87:189.e1-3. [PMID: 17084396 DOI: 10.1016/j.fertnstert.2006.04.050] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2005] [Revised: 04/10/2006] [Accepted: 04/10/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To describe the first reported case of gestational carrier treatment to prevent severe early onset pre-eclampsia. DESIGN Case report. SETTING A university-based reproductive endocrinology and infertility clinic and a tertiary care hospital. PATIENT(S) A 29-year-old woman and her husband with three consecutive pregnancies complicated by early onset severe pre-eclampsia causing fetal demises at 22 and 24 weeks gestation; a neonatal death at 25 weeks gestation; and life-threatening maternal hemolysis, elevated liver enzymes, and low platelets. INTERVENTION(S) An IVF procedure in the patient using her husband's sperm with the transfer of two embryos to a friend who offered to be a gestational carrier. MAIN OUTCOME MEASURE(S) Successful IVF cycle in the patient and uncomplicated pregnancy and delivery in the gestational carrier. RESULT(S) The gestational carrier achieved a pregnancy and progressed without complications to delivery of a healthy, 3.2-kg infant at 39 weeks gestation. CONCLUSION(S) The use of a gestational carrier deserves consideration as a treatment option in patients with poor reproductive histories because of early onset severe pre-eclampsia and hemolysis, elevated liver enzymes, and low platelets syndrome. This experience also suggests that development of pre-eclampsia may be in large part maternally rather than embryologically or paternally driven.
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Affiliation(s)
- Darren M Farley
- Department of Obstetrics and Gynecology, University of Kansas School of Medicine-Wichita, Wichita, Kansas 67226, USA
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93
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Schiessl B, Mylonas I, Kuhn C, Kunze S, Schulze S, Friese K, Jeschke U. Expression of Estrogen Receptor-α, Estrogen Receptor-β and Placental Endothelial and Inducible NO Synthase in Intrauterine Growth-Restricted and Normal Placentas. Arch Med Res 2006; 37:967-75. [PMID: 17045112 DOI: 10.1016/j.arcmed.2006.03.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2006] [Accepted: 03/31/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND Nitric oxide seems to play important roles in the physiology of placental blood circulation, although their expression in pathological placentas and their role is still unclear. Therefore, the aim of this study was to investigate the expression of estrogen receptor alpha (ERalpha), estrogen receptor beta (ERbeta) and the endothelial NO synthase (eNOS) and inducible NO synthase (iNOS) in intrauterine growth-restricted (IUGR) placentas, hemolysis, elevated liver enzymes, low platelets (HELLP) placentas and in normal healthy control placentas. METHODS Slides of paraffin-embedded placental tissue were obtained after delivery from patients diagnosed with IUGR, HELLP and normal term placentas and analyzed for eNOS and iNOS, as well as ERalpha/beta expression. Intensity of immunohistochemical reaction was analyzed using a semi-quantitative score, and statistical analysis was performed. In addition, Western blot experiments were performed for comparison of staining intensities obtained by immunohistochemistry and Western blot. RESULTS Expression of eNOS and iNOS is significantly reduced in trophoblast cells of placentas with HELLP. However, ERbeta expression in HELLP placentas demonstrated a significantly elevated expression intensity compared to normal controls. ERalpha expression was not significantly different in all three pathologies investigated. CONCLUSIONS We speculate that the increased ERbeta expression in both syncytiotrophoblast and extravillous trophoblast cells represents accelerated proliferation of placental tissue or can be seen as a compensatory effect in HELLP placentas.
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Affiliation(s)
- Barbara Schiessl
- 1st Department of Obstetrics and Gynaecology, Ludwig-Maximilians-University Munich, Maistrasse, Munich, Germany
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94
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Martin JN, Rose CH, Briery CM. Understanding and managing HELLP syndrome: the integral role of aggressive glucocorticoids for mother and child. Am J Obstet Gynecol 2006; 195:914-34. [PMID: 16631593 DOI: 10.1016/j.ajog.2005.08.044] [Citation(s) in RCA: 178] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2005] [Revised: 07/13/2005] [Accepted: 08/18/2005] [Indexed: 11/16/2022]
Abstract
Antepartum or postpartum HELLP syndrome constitutes an obstetric emergency that requires expert knowledge and management skills. The insidious and variable nature of disease presentation and progression challenges the clinician and complicates consensus on universally accepted diagnostic and classification criteria. A critical review of published research about this variant form of severe preeclampsia, focused primarily on what is known about the pathogenesis of this disorder as it relates to patient experience with corticosteroids for its management, leads to the conclusion that there is maternal-fetal benefit realized when potent glucocorticoids are aggressively used for its treatment. Although acknowledging the need for definitive multicenter trials to better define the limits of benefit and the presence of any maternal or fetal risk, and given an understanding of the nature of the disorder with its potential to cause considerable maternal morbidity and mortality, we recommend for the present that aggressively used potent glucocorticoids constitute the cornerstone of management for patients considered to have HELLP syndrome.
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Affiliation(s)
- James N Martin
- Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, MS, USA
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95
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Asherson RA. New subsets of the antiphospholipid syndrome in 2006: "PRE-APS" (probable APS) and microangiopathic antiphospholipid syndromes ("MAPS"). Autoimmun Rev 2006; 6:76-80. [PMID: 17138247 DOI: 10.1016/j.autrev.2006.06.008] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The concept of "probable" antiphospholipid syndrome (APS) is almost identical with several conditions which may presage the development of the APS with its major complications of large vessel thromboses resulting in deep vein occlusions in the lower limbs (DVT) particularly and strokes. These conditions comprising livedo reticularis, chorea, thrombocytopenia, fetal loss and valve lesions. These conditions, comprising livedo reticularis, chorea, thrombocytopenia, fetal loss and valve lesions may be followed, often years later by diagnosable APS. The issue whether these patients should be more aggressively treated on presentation in order to prevent the thrombotic complications. A new subset of the APS is proposed viz. microangiopathic antiphospholipid syndrome ("MAPS") comprising those patients presenting with thrombotic microangiopathy and demonstrable antiphospholipid antibodies who may share common although not identical provoking factors (e.g. infections, drugs), clinical manifestations and haematological manifestations (severe thrombocytopenia, hemolytic anaemia) and treatments viz. plasma exchange. Patients without large vessel occlusions may be included in the MAPS subset. These conditions include thrombotic thrombocytopenic purpura (TTP), hemolytic-uremic syndrome (HUS), and the HELLP syndrome. Patients with catastrophic antiphospholipid syndrome (CAPS) who do not demonstrate large vessel occlusions also fall into this group. Disseminated intravascular coagulation (DIC) has also been reported with demonstrable antiphospholipid antibodies and also manifests severe thrombocytopenia and small vessel occlusions. It may cause problems in differential diagnosis.
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Affiliation(s)
- Ronald A Asherson
- Division of Immunology, School of Pathology, University of the Witwatersrand, Johannesburg, South Africa 2000.
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96
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Asherson RA, Cervera R, Merrill JT. Thrombotic microangiopathic antiphospholipid syndromes: a continuum of conditions? ACTA ACUST UNITED AC 2006. [DOI: 10.2217/17460816.1.3.355] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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97
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Saavedra-Salinas MA, Carrillo-Vázquez SM, Jara-Quezada LJ, Miranda-Limón JM. [Treatment of systemic lupus erythematosus in the pregnant patient]. REUMATOLOGIA CLINICA 2005; 1 Suppl 2:S46-S51. [PMID: 21794290 DOI: 10.1016/s1699-258x(05)72772-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- M A Saavedra-Salinas
- Departamento de Reumatología. Unidad Médica de Alta Especialidad. CMN La Raza. Instituto Mexicano del Seguro Social. México DF. México
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99
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Abstract
Coagulation problems are very common in intensive care patients. It is important to recognize potential problems, perform a rapid assessment, and start therapy. The author reviews general clinical and laboratory approaches to diagnosis and treatment of the bleeding patient and to correction of coagulopathies. This review outlines a set of often catastrophic coagulation problems, which may present both thrombotic and bleeding challenges. These include heparin induced thrombocytopenia, thrombotic thrombocytopenic purpura, and disseminated intravascular coagulation.
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Affiliation(s)
- Thomas G DeLoughery
- Oregon Health & Science University, Hematology L586, 3181 SW Sam Jackson Park Road, Portland, OR 97201-3098, USA.
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