Long-term maternal and subsequent pregnancy outcomes 5 years after hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome

Value of proteinuria in evaluating the severity of HELLP and its maternal and neonatal outcomes

BACKGROUND

HELLP syndrome refers to a group of clinical syndromes characterized by hemolysis, elevated liver enzymes and low platelet, and the evidence on the association between proteinuria and the severity of HELLP and its maternal and neonatal outcomes is rare.

METHODS

106 pregnant women were assigned to the proteinuric group (24-hUPro ≥ 0.3 g, 79 cases) and the non-proteinuric group (24-hUPro < 0.3 g, 27 cases). The proteinuric group was further divided into three subgroups: mild group (24-hUPro:0.3-2.0 g, 33 cases), moderate group (24-hUPro:2.0-5.0 g, 21 cases) and severe group (24-hUPro: ≥5.0 g, 25 cases). The general clinical data, laboratory indexes, complications and pregnancy outcome and adverse neonatal outcomes of HELLP with or without proteinuric were analyzed.

RESULTS

Compared with proteinuric group, the non-albuminuric group or in the three proteinuric subgroups of HELLP pregnant women's, increased proteinuria was associated with earlier onset gestations, higher incidence of abdominal pain, skin jaundice, headache, blurred vision (p < 0.05 respectively), and also the higher levels of ALT, AST, LDH, Fib, APTT, ATII, proportions of tubular urine and lower levels of ALB, PLT (p < 0.05 respectively). In the three subgroups of the proteinuric group, the ratio of fetal growth restriction, cesarean section and postpartum hemorrhage were compared, and the difference was statistically significant (p < 0.05 respectively). Compared with the proteinuric group, the non-proteinuric group had higher birth weight, birth length, and lower SGA, admission rate in NICU (p < 0.05 respectively). In the three subgroups of the proteinuric group, significant differences were identified in the adverse outcomes of newborns (p < 0.05 respectively), and the incidence of adverse outcomes in neonates tended to be higher. Significant differences were identified in birth weight, birth length, and lower SGA and NICU occupancy rate among the three subgroups (p < 0.05 respectively).

CONCLUSIONS

HELLP syndrome is a severe complication of pregnancy, involving multiple systems of the whole body. It has posed a great challenge to obstetricians for its acute onset, dangerous condition, rapid progress, and great harm. Thus, insights into HELLP syndrome should be gained, and early diagnosis, early treatment and timely termination of pregnancy should be conducted to reduce the incidence of maternal and fetal adverse outcomes and improve maternal and fetal prognosis.

Risk Prediction Model of Early-Onset Preeclampsia Based on Risk Factors and Routine Laboratory Indicators

Background: Globally, 10-15% of maternal deaths are statistically attributable to preeclampsia. Compared with late-onset PE, the severity of early-onset PE remains more harmful with higher morbidity and mortality. Objective: To establish an early-onset preeclampsia prediction model by clinical characteristics, risk factors and routine laboratory indicators were investigated from pregnant women at 6 to 10 gestational weeks. Methods: The clinical characteristics, risk factors, and 38 routine laboratory indicators (6-10 weeks of gestation) including blood lipids, liver and kidney function, coagulation, blood count, and other indicators of 91 early-onset preeclampsia patients and 709 normal controls without early-onset preeclampsia from January 2010 to May 2021 in Peking University Third Hospital (PUTH) were retrospectively analyzed. A logistic regression, decision tree model, and support vector machine (SVM) model were applied for establishing prediction models, respectively. ROC curves were drawn; area under curve (AUCROC), sensitivity, and specificity were calculated and compared. Results: There were statistically significant differences in the rates of diabetes, antiphospholipid syndrome (APS), kidney disease, obstructive sleep apnea (OSAHS), primipara, history of preeclampsia, and assisted reproductive technology (ART) (p < 0.05). Among the 38 routine laboratory indicators, there were no significant differences in the levels of PLT/LYM, NEU/LYM, TT, D-Dimer, FDP, TBA, ALP, TP, ALB, GLB, UREA, Cr, P, Cystatin C, HDL-C, Apo-A1, and Lp(a) between the two groups (p > 0.05). The levels of the rest indicators were all statistically different between the two groups (p < 0.05). If only 12 risk factors of PE were analyzed with the logistic regression, decision tree model, and support vector machine (SVM), and the AUCROC were 0.78, 0.74, and 0.66, respectively, while 12 risk factors of PE and 38 routine laboratory indicators were analyzed with the logistic regression, decision tree model, and support vector machine (SVM), and the AUCROC were 0.86, 0.77, and 0.93, respectively. Conclusions: The efficacy of clinical risk factors alone in predicting early-onset preeclampsia is not high while the efficacy increased significantly when PE risk factors combined with routine laboratory indicators. The SVM model was better than logistic regression model and decision tree model in early prediction of early-onset preeclampsia incidence.

First-Trimester Screening for HELLP Syndrome—Prediction Model Based on MicroRNA Biomarkers and Maternal Clinical Characteristics

We evaluated the potential of cardiovascular-disease-associated microRNAs for early prediction of HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome. Gene expression profiling of 29 microRNAs was performed on whole peripheral venous blood samples collected between 10 and 13 weeks of gestation using real-time RT-PCR. The retrospective study involved singleton pregnancies of Caucasian descent only diagnosed with HELLP syndrome (n = 14) and 80 normal-term pregnancies. Upregulation of six microRNAs (miR-1-3p, miR-17-5p, miR-143-3p, miR-146a-5p, miR-181a-5p, and miR-499a-5p) was observed in pregnancies destined to develop HELLP syndrome. The combination of all six microRNAs showed a relatively high accuracy for the early identification of pregnancies destined to develop HELLP syndrome (AUC 0.903, p < 0.001, 78.57% sensitivity, 93.75% specificity, cut-off > 0.1622). It revealed 78.57% of HELLP pregnancies at a 10.0% false-positive rate (FPR). The predictive model for HELLP syndrome based on whole peripheral venous blood microRNA biomarkers was further extended to maternal clinical characteristics, most of which were identified as risk factors for the development of HELLP syndrome (maternal age and BMI values at early stages of gestation, the presence of any kind of autoimmune disease, the necessity to undergo an infertility treatment by assisted reproductive technology, a history of HELLP syndrome and/or pre-eclampsia in a previous gestation, and the presence of trombophilic gene mutations). Then, 85.71% of cases were identified at a 10.0% FPR. When another clinical variable (the positivity of the first-trimester screening for pre-eclampsia and/or fetal growth restriction by the Fetal Medicine Foundation algorithm) was implemented in the HELLP prediction model, the predictive power was increased further to 92.86% at a 10.0% FPR. The model based on the combination of selected cardiovascular-disease-associated microRNAs and maternal clinical characteristics has a very high predictive potential for HELLP syndrome and may be implemented in routine first-trimester screening programs.

HELLP Syndrome—Holistic Insight into Pathophysiology

HELLP syndrome, also known as the syndrome of hemolysis, elevated liver enzymes, and low platelets, represents a severe pregnancy complication typically associated with hypertension. It is associated with increased risks of adverse complications for both mother and fetus. HELLP occurs in 0.2–0.8% of pregnancies, and, in 70–80% of cases, it coexists with preeclampsia (PE). Both of these conditions show a familial tendency. A woman with a history of HELLP pregnancy is at high risk for developing this entity in subsequent pregnancies. We cannot nominate a single worldwide genetic cause for the increased risk of HELLP. Combinations of multiple gene variants, each with a moderate risk, with concurrent maternal and environmental factors are thought to be the etiological mechanisms. This review highlights the significant role of understanding the underlying pathophysiological mechanism of HELLP syndrome. A better knowledge of the disease’s course supports early detection, an accurate diagnosis, and proper management of this life-threatening condition.

Evidence of Anxiety, Depression and Learning Impairments following Prenatal Hypertension

Background: Hypertensive disorders of pregnancy, such as Preeclampsia (PreE) and HELLP (hemolysis, elevated liver enzyme, low platelet) syndrome, affects approximately 5–10% of pregnancies and increases the risk of women developing disorders, such as anxiety or depression, in the postpartum period. Using preclinical rodent models, we set out to determine whether rats with a history of PreE or HELLP had evidence of anxiety, depression or cognitive impairment and whether immune suppression during pregnancy prevented these changes in mood and/or cognition. Methods: Timed-pregnant rats were infused with sFlt-1 and/or sEng to induce PreE or HELLP beginning on gestational day 12. After delivery, a battery of validated behavioral assays was used to assess post-partum depression, anxiety and learning. Results: There was no negative effect on maternal pup interaction due to PreE or HELLP; however, hypertensive dams spent more time immobile in the forced swim test (p < 0.0001). Hypertensive dams also spent less time in the open area of the open field (p = 0.001). There were no significant changes in recognition memory (p = 0.08); however, spatial learning was impaired in hypertensive dams (p = 0.003). Immobility time in the forced swim test was positively correlated with increased circulating S100B (p = 0.04), while increased time spent in the outer zones of the open field was negatively correlated with BDNF levels (p < 0.0001). Conclusion: The results from this study suggest that hypertensive pregnancy disorders are associated with depression, anxiety and learning impairments in the post-partum period.

Depression, anxiety and posttraumatic stress disorder six months following preeclampsia and normotensive pregnancy: a P4 study

Background

Mental health is an integral part of overall health. Mental health disorders following childbirth are common and poor maternal mental health has consequences for both the mother and her infant. Preeclampsia is also relatively common in pregnancy but there is little known about the intersection between these two important conditions. Gaining a better understanding of the psychological consequences following preeclampsia is important, especially the link with depression, anxiety and posttraumatic stress disorder. If women who experience preeclampsia are recognised as being at increased risk of poor mental health, targeted screening in the postpartum period should be implemented.

Aims

To describe the prevalence and symptom severity of depression, anxiety and posttraumatic stress disorder at six months postpartum in women, who had a diagnosis of preeclampsia, compared to those who had normal blood pressure in pregnancy.

Methods

The mental health component of the prospective cohort study, the Postpartum, Physiology, Psychology and Paediatric follow-up study (P4 Study) was used. Women diagnosed with preeclampsia (n = 90) and those who were normotensive during pregnancy (n = 302) completed the Edinburgh Postnatal Depression Scale, General Anxiety Disorder Scale, and the Posttraumatic Stress Diagnostic Scale or Posttraumatic Stress Diagnostic Sclae-5 at six months postpartum.

Results

At six months postpartum, depressive scores were similar in both groups but a higher proportion of women from the preeclampsia group scored above the threshold for depression (2% v 7% p = 0.04). There were no differences between the groups in the prevalence or severity of anxiety or PTSD. However, more women in the preeclampsia group reported their birth experience as a traumatic event (1% vs 7%, p = 0.01). On correlation testing and modelling, booking Edinburgh Postnatal Depression Scale score, any mental health history, experiencing birth as traumatic and the General Anxiety Disorder Scale score were independent predictors of postpartum Edinburgh Postnatal Depression Scale scores.

Conclusion

The postpartum clinical care of women with preeclampsia often focusses on the immediate physical health issues, but these women may also benefit from mental health screening. Targeted screening of preeclamptic women in the postpartum period may lead to more timely referral and initiation of treatment.

Trial registration

Retrospectively registered on 18/11/2013 with the Australian and New Zealand Clinical Trials Registry. Registration Number: ACTRN12613001260718.

Psychological factors and coping strategies in pregnancies complicated by hypertension: A cluster-analytic approach

BACKGROUND

Hypertensive disorders are important causes of maternal and perinatal morbidity and death. Considering the role of both physical and psychological factors in pregnancies complicated by hypertension, the aim of this study is to examine psychological factors and coping strategies in pregnancies complicated by hypertension.

METHODS

Cross-sectional study. A sample of 552 pregnant women, 343 with pregnancies complicated by hypertension, were assessed in terms of depression, anxiety, stress and coping.

RESULTS

The hypertensive group had higher scores of depression, stress and anxiety than the control one. Coping strategies were different between hypertensive and control groups (except for confrontive and self-reliant coping styles). When splitting up the hypertensive group into gestational hypertension, chronic hypertension and preeclampsia syndrome, differences between this new classification reached the statistical level. Our data suggests that women with preeclampsia have more symptoms of depression and worse coping strategies - they are less optimistic and more fatalistic. However, after a cluster analysis, two different subgroups of hypertensive women were found: one with worst coping strategies and more vulnerability to negative affective states and another with better coping and more resilient to mental health problems.

LIMITATIONS

Data were cross-sectional. We excluded women with some comorbidities, such as a diagnosis of kidney disease, diabetes or fetal malformation.

CONCLUSIONS

It is important to consider distinct profiles of pregnant women, in order to be able to better understand the peculiarities of mental health and coping during the gestation, especially in pregnancies complicated by hypertension.

Effects of a Case Management Program for Women With Pregnancy-Induced Hypertension

BACKGROUND

Pregnancy-induced hypertension (PIH) is a leading cause of maternal and fetal morbidity and mortality. Although case management programs have been proposed to improve maternal and fetal outcomes in high-risk pregnancies, limited data are available regarding the effect of case management on women with PIH.

PURPOSE

The aim of this study was to evaluate the effect of an antepartum case management program on stress, anxiety, and pregnancy outcomes in women with PIH.

METHODS

A quasi-experimental research design was employed. A convenience sample of women diagnosed with PIH, including preeclampsia, was recruited from outpatient clinics at a medical center in southern Taiwan. Sixty-two women were assigned randomly to either the experimental group (n = 31) or the control group (n = 31). The experimental group received case management for 8 weeks, and the control group received routine clinical care. Descriptive statistics, independent t or Mann-Whitney U tests, chi-square or Fisher's exact tests, paired t test, and generalized estimating equations were used to analyze the data.

RESULTS

The average age of the participants was 35.1 years (SD = 4.5). No significant demographic or clinical differences were found between the control and experimental groups. The results of the generalized estimating equations showed significantly larger decreases in stress and anxiety in the experimental group than in the control group. No significant differences were identified between the two groups with respect to infant birth weeks, infant birth weight, average number of medical visits, or frequency of hospitalization.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

The nurse-led case management program was shown to have short-term positive effects on the psychosocial outcomes of a population of Taiwanese patients with PIH. These results have important clinical implications for the healthcare administered to pregnant women, particularly in terms of improving the outcomes in those with PIH.

Modulation of preeclampsia by the cholinergic anti-inflammatory pathway: Therapeutic perspectives

The cholinergic anti-inflammatory pathway (CAP) is vital for the orchestration of the immune and inflammatory responses under normal and challenged conditions. Over the past two decades, peripheral and central circuits of CAP have been shown to be critically involved in dampening the inflammatory reaction in a wide array of inflammatory disorders. Additionally, emerging evidence supports a key role for CAP in the regulation of the female reproductive system during gestation as well as in the advent of serious pregnancy-related inflammatory insults such as preeclampsia (PE). Within this framework, the modulatory action of CAP encompasses the perinatal maternal and fetal adverse consequences that surface due to antenatal PE programming. Albeit, a considerable gap still exists in our knowledge of the precise cellular and molecular underpinnings of PE/CAP interaction, which hampered global efforts in safeguarding effective preventive or therapeutic measures against PE complications. Here, we summarize reports in the literature regarding the roles of peripheral and reflex cholinergic neuroinflammatory pathways of nicotinic acetylcholine receptors (nAChRs) in reprogramming PE complications in mothers and their progenies. The possible contributions of α7-nAChRs, cholinesterases, immune cells, adhesion molecules, angiogenesis, and endothelial dysfunction to the interaction have also been reviewed.

Preeclampsia before 26 weeks of gestation: Obstetrical prognosis for the subsequent pregnancy

INTRODUCTION

Gestational age at delivery seems to be a risk factor of recurrence of preeclampsia. The objective of this study was to analyze adverse pregnancy outcomes and recurrence of preeclampsia during the subsequent pregnancy in women with a history of pre-eclampsia delivered before 26 weeks of gestation.

MATERIAL AND METHOD

We performed a retrospective study in two French tertiary care hospitals between 2000 and 2018. Patients with a history of pre-eclampsia delivered before 26 weeks of gestation were analyzed. Information on the immediate subsequent pregnancy was collected. Adverse composite outcome was defined as recurrent preeclampsia, HELLP syndrome, placental abruption, fetal growth restriction <3rd percentile or <10^e percentile with Doppler abnormalities, maternal death and fetal death.

RESULTS

Among the 107 patients who met the criteria, 48 were analyzed for a subsequent pregnancy. Seventeen women (35.4 %) developed an adverse composite outcome, occurring for 15 women (31.2 %) before 34 weeks. Ten women (20.8 %) developed a recurrent preeclampsia occurring for 5 women (10.4 %) before 34 weeks. We related 3 HELLP syndromes, 1 placental abruption, 9 fetal growth restrictions, 3 fetal deaths and no maternal death. Compared to baseline normotensive women, chronic hypertension was significantly associated with an increased risk of adverse composite outcome (19.3 vs 58.8 %, p-value 0.014).

CONCLUSION

In our population, preeclampsia with delivery before 26 weeks is associated with 35.4 % of adverse composite outcomes and 20.8 % of recurrent preeclampsia during the immediate subsequent pregnancy. These results justify the importance of an ongoing monitoring of these patients during subsequent pregnancy.

Preeclampsia beyond pregnancy: long-term consequences for mother and child

Preeclampsia is defined as new-onset hypertension after the 20th wk of gestation along with evidence of maternal organ failure. Rates of preeclampsia have steadily increased over the past 30 yr, affecting ∼4% of pregnancies in the United States and causing a high economic burden (22, 69). The pathogenesis is multifactorial, with acknowledged contributions by placental, vascular, renal, and immunological dysfunction. Treatment is limited, commonly using symptomatic management and/or early delivery of the fetus (6). Along with significant peripartum morbidity and mortality, current research continues to demonstrate that the consequences of preeclampsia extend far beyond preterm delivery. It has lasting effects for both mother and child, resulting in increased susceptibility to hypertension and chronic kidney disease (45, 54, 115, 116), yielding lifelong risk to both individuals. This review discusses recent guideline updates and recommendations along with current research on these long-term consequences of preeclampsia.

Comparing acute fatty liver of pregnancy from hemolysis, elevated liver enzymes, and low platelets syndrome

Acute fatty liver of pregnancy (AFLP) and hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome are both associated with significant maternal and perinatal morbidity and mortality. Because of the overlap of several clinical and laboratory findings differentiation can sometimes be difficult. Both disorders have been of interest for more than 100 years, however they were not completely characterized until the early 1980s. It was not until the 1980s that AFLP and HELLP syndrome, and more specifically their clinical, laboratory, and pathologic findings, were further differentiated in the literature. More recently, the pathophysiologic mechanisms have been elucidated. In this review, we outline the similarities and differences in the clinical presentation, laboratory findings, maternal and perinatal outcomes, and clinical recovery for women diagnosed with these two syndromes. From our observations, we suggest that levels of fibrinogen, creatinine, cholesterol, and total bilirubin be used to assist with differentiating AFLP from HELLP syndrome upon admission in women presenting with either suspected disease. The rationale for identifying the specific conditions is that clinical consequences for recovery vary considerably. Specifically, AFLP is associated with significantly more hepatic and renal dysfunction as well as coagulopathy. Fortunately, both conditions can be managed with supportive measures with overall improved perinatal outcomes including morbidity and mortality.

Enabling pregnant women and their physicians to make informed medication decisions using artificial intelligence

The role of artificial intelligence (AI) in healthcare for pregnant women. To assess the role of AI in women’s health, discover gaps, and discuss the future of AI in maternal health. A systematic review of English articles using EMBASE, PubMed, and SCOPUS. Search terms included pregnancy and AI. Research articles and book chapters were included, while conference papers, editorials and notes were excluded from the review. Included papers focused on pregnancy and AI methods, and pertained to pharmacologic interventions. We identified 376 distinct studies from our queries. A final set of 31 papers were included for the review. Included papers represented a variety of pregnancy concerns and multidisciplinary applications of AI. Few studies relate to pregnancy, AI, and pharmacologics and therefore, we review carefully those studies. External validation of models and techniques described in the studies is limited, impeding on generalizability of the studies. Our review describes how AI has been applied to address maternal health, throughout the pregnancy process: preconception, prenatal, perinatal, and postnatal health concerns. However, there is a lack of research applying AI methods to understand how pharmacologic treatments affect pregnancy. We identify three areas where AI methods could be used to improve our understanding of pharmacological effects of pregnancy, including: (a) obtaining sound and reliable data from clinical records (15 studies), (b) designing optimized animal experiments to validate specific hypotheses (1 study) to (c) implementing decision support systems that inform decision-making (11 studies). The largest literature gap that we identified is with regards to using AI methods to optimize translational studies between animals and humans for pregnancy-related drug exposures.

Probability and outcomes of second pregnancy after HELLP syndrome in the first: A population-based registry study

INTRODUCTION

Some studies have suggested that women may avoid further pregnancies after experiencing a pregnancy affected by a hypertensive disorder. Large population-based studies are needed to better understand the outcomes of later pregnancies among women who have a history of hypertensive disorders of pregnancy. The aims of the study were to assess outcomes of the second pregnancy and second delivery rate among women experiencing Hemolysis, elevated liver enzymes and low platelet count (HELLP) syndrome in their first pregnancy.

MATERIAL AND METHODS

This population-based registry study included all women with a first delivery registered in the Medical Birth Registry of Norway from 1999 to 2014 (n = 418 897). Logistic regression was used to estimate odds ratios (ORs) with 95% confidence intervals (CIs) for adverse outcomes of the second delivery and the probability of no second delivery among women with HELLP syndrome in first pregnancy compared with women without HELLP syndrome. We also compared outcomes in the first and second pregnancies among women with HELLP syndrome in first.

RESULTS

HELLP syndrome occurred in 0.24% of first pregnancies (n = 1006). Among women with HELLP syndrome in their first pregnancy, adverse outcomes were substantially less frequent in the second pregnancy: preterm deliveries declined from 56.0% to 14.2%, and small for gestational age from 6.6% to 2.8%. More than 75% had no hypertensive disorder in their second pregnancy. Still, compared with women without a history of HELLP syndrome, ORs for adverse outcomes in second pregnancies were increased: preterm birth (OR 3.7, 95% CI 2.8-4.8), small for gestational age (OR 2.7, 95% CI 1.6-4.8), perinatal death (OR 3.1, 95% CI 1.4-7.0), placental abruption (OR 4.2, 95% CI 1.8-9.4) and hypertensive complication (OR 8.3, 95% CI 6.7-10.3). HELLP syndrome did not influence the probability of a second delivery.

CONCLUSIONS

Among women with HELLP syndrome in their first pregnancy, the occurrence of adverse pregnancy outcomes was substantially reduced in the second pregnancy. However, compared with unaffected women, they were still at greater risk of pregnancy complications.

Depression, Anxiety, and Post-traumatic Stress Disorder Following a Hypertensive Disorder of Pregnancy: A Narrative Literature Review

Introduction: Pregnancy and childbirth can be a source of anxiety and worry for women. This is probably more so for women with a complicated pregnancy. Anxiety and worry may contribute to, or exacerbate, mental health disorders including depression and post-traumatic stress disorder (PTSD). Mental health is an integral part of health and well-being and poor mental health can be detrimental to the woman's welfare and her infant's behavior and cognitive development. It may be undetected, potentially leading to a burden on the woman, her family, the health system, and society. Women with complicated pregnancies, such as those with hypertensive disorders of pregnancy (HDP), may be at greater risk of poor mental health. The aim of this review was to examine whether there is an association between depression, anxiety, and PTSD in postpartum women with a history of HDP.

Methods: A narrative literature review was undertaken. Using the key search terms: preeclampsia, gestational hypertension, hypertensive disorders, pregnancy complications, depression, anxiety, and post-traumatic stress disorder; electronic databases were searched to determine what is known about depression, anxiety, and PTSD after HDP.

Results: In total, 17 publications were included. The relationship between HDP and depression, anxiety, and PTSD was variable between studies and inconsistent. Although some studies reported no significant association, there is a trend for increased prevalence and symptom severity of depression, anxiety, and PTSD following HDP. This trend was particularly evident following the more severe presentations of HDP. It was uncertain whether this association was due to the hypertensive disorder itself, the sequelae of the HDP, such as giving birth to a preterm baby, or it predated the pregnancy.

Conclusions: Women who experience HDP may be at increased risk of developing postpartum depression, anxiety, and PTSD. Awareness of, and screening for, these mental health disorders in the postpartum period will alert clinicians to the need for additional follow-up and referral for women following HDP. More research on the benefits and risks of such an approach is needed.

Prediction model development of late-onset preeclampsia using machine learning-based methods

Preeclampsia is one of the leading causes of maternal and fetal morbidity and mortality. Due to the lack of effective preventive measures, its prediction is essential to its prompt management. This study aimed to develop models using machine learning to predict late-onset preeclampsia using hospital electronic medical record data. The performance of the machine learning based models and models using conventional statistical methods were also compared. A total of 11,006 pregnant women who received antenatal care at Yonsei University Hospital were included. Maternal data were retrieved from electronic medical records during the early second trimester to 34 weeks. The prediction outcome was late-onset preeclampsia occurrence after 34 weeks’ gestation. Pattern recognition and cluster analysis were used to select the parameters included in the prediction models. Logistic regression, decision tree model, naïve Bayes classification, support vector machine, random forest algorithm, and stochastic gradient boosting method were used to construct the prediction models. C-statistics was used to assess the performance of each model. The overall preeclampsia development rate was 4.7% (474 patients). Systolic blood pressure, serum blood urea nitrogen and creatinine levels, platelet counts, serum potassium level, white blood cell count, serum calcium level, and urinary protein were the most influential variables included in the prediction models. C-statistics for the decision tree model, naïve Bayes classification, support vector machine, random forest algorithm, stochastic gradient boosting method, and logistic regression models were 0.857, 0.776, 0.573, 0.894, 0.924, and 0.806, respectively. The stochastic gradient boosting model had the best prediction performance with an accuracy and false positive rate of 0.973 and 0.009, respectively. The combined use of maternal factors and common antenatal laboratory data of the early second trimester through early third trimester could effectively predict late-onset preeclampsia using machine learning algorithms. Future prospective studies are needed to verify the clinical applicability algorithms.

Hypertension, Anxiety, and Blood-Brain Barrier Permeability Are Increased in Postpartum Severe Preeclampsia/Hemolysis, Elevated Liver Enzymes, and Low Platelet Count Syndrome Rats

Hypertension and inflammation during pregnancy are suggested to contribute to the development of postpartum depression and anxiety. Using a rat model of severe preeclampsia and hemolysis, elevated liver enzymes, and low platelet count syndrome, which displays both hypertension and inflammation during pregnancy, we evaluated whether rats were prone to develop depression or anxiety in the postpartum period. On gestational day 12, miniosmotic pumps infusing sFlt-1 (soluble fms-like tyrosine kinase-1) and sEng (soluble endoglin) were placed into rats, a subset of these rats was infused with 2 mg/kg of Orencia (abatacept) the following day to determine whether immune suppression via T-cell depletion prevented any changes in maternal depression or anxiety-like behavior. All rats, including normal pregnant (NP) controls, delivered between gestational days 21 and 22. Postpartum severe preeclamptic rats buried significantly more marbles compared with NP rats ( P=0.002) and Orencia-treated rats ( P=0.05). Severe preeclamptic rats spent significantly more time in closed arms of the elevated plus maze compared with NP rats ( P=0.009) and Orencia-treated rats ( P=0.05). Severe preeclamptic rats were hypertensive compared with NP ( P=0.03) and Orencia-treated rats ( P=0.01). Finally, severe preeclamptic rats had increased blood-brain barrier permeability compared with NP rats ( P=0.03), which was reversed in Orencia-treated rats ( P=0.008). These results suggest that severe preeclampsia/hemolysis, elevated liver enzymes, and low platelet count syndrome during pregnancy contributes to an increase in anxiety-like behavior, blood-brain barrier permeability, and hypertension in the postpartum. The current results suggest that T-cell suppression during pregnancy can also help prevent chronic hypertension and increased anxiety in the postpartum period.

Copper and ceruloplasmin levels are closely related to the severity of preeclampsia

Objective: The aim of this study was to investigate the maternal serum concentrations of copper (Cu) and ceruloplasmin (CP) in patients with mild preeclampsia, severe preeclampsia, hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome, and to determine their association with the severity of the disease.Methods: This study was carried out at the largest tertiary care health center in the southeast region in Turkey and Department of Obstetrics and Gynecology, Dicle University Hospital. A total of 179 pregnant women, including 58 healthy pregnant women and 71 mild preeclampsia, 26 severe preeclampsia, and 24 HELLP syndrome cases classified according to the American College of Obstetricians and Gynecologists' 2013 guidelines were included in this prospective study. Blood samples were taken from all the pregnant women to evaluate the serum Cu and CP levels. The Cu level was determined via atomic absorption/emission spectroscopy, while the serum CP level was assessed with a nephelometric assay using an automatic image analyzer. Spearman's rank correlation tests were used to determine the correlations between the serum levels of the antioxidative markers and the preeclampsia severity.Results: The mean ± SD of the Cu was 81.2 ± 11.84 µg/dl in the mild preeclampsia cases and 160.2 ± 20.89 µg/dl in the severe preeclampsia cases (p < .001). The mean ± SD of the CP was 33.0 ± 4.81 mg/dl in the mild preeclampsia cases and 65.3 ± 9.17 mg/dl in the severe preeclampsia cases (p < .001). The Cu and CP levels were significantly higher in the patients with HELLP syndrome, which is an advanced and more severe form of severe preeclampsia, than in the mild and severe preeclampsia patients (p < .001 and p < .001, respectively). Therefore, the serum Cu and CP levels were correlated with the severity of preeclampsia (r = 859, p < .001 and r = 786, p < .001, respectively). In addition, there was a positive correlation between the serum Cu and CP levels and the systolic and diastolic blood pressure values and aspartate amino transferase levels (AST), and a negative correlation between the serum Cu and CP levels and the platelet count.Conclusion: This was the first study in which the ceruloplasmin and Cu levels were investigated in HELLP syndrome patients. When considering the results obtained in the present study, there were significant relationships between the Cu, CP levels which are the markers of oxidative stress and the preeclampsia severity.

HELLP syndrome, risk factors in first and second pregnancy: a population-based cohort study

INTRODUCTION

HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count) may have specific risk factors and risk factors varying from first to second pregnancy. The aims of the study were to estimate the risk of HELLP syndrome by potential risk factors in first and second pregnancy, respectively.

MATERIAL AND METHODS

A population-based cohort study including all women in Norway having their first baby (≥22 gestational weeks) during 1999 to 2014, registered in the Medical Birth Registry (n = 418 897). A subset of women with at least two births (n = 249 070) was used for estimates in second pregnancy. Relative risks with 95% CIs for HELLP syndrome were estimated using logistic regression and adjusted for maternal age and year of childbirth.

RESULTS

Body mass index ≥30 kg/m² and diabetes were associated with HELLP syndrome in first, but not in second pregnancy. Chronic hypertension and multiple pregnancy were associated with HELLP syndrome both in first and second pregnancy. In second pregnancy the strongest risk factors were a history of HELLP syndrome or preterm preeclampsia in the first. The risk was inversely correlated with gestational age at first delivery. The overall relative risk for recurrence of HELLP syndrome was 54.4 (95% CI 34.3-86.2) and 129.5 (95% CI 45.7-367.2) after HELLP syndrome before 29 weeks of gestation in first pregnancy.

CONCLUSIONS

Important risk factors for HELLP syndrome differ from first to second pregnancy. HELLP syndrome in second pregnancy is rare, but the relative risk is very high in women with HELLP syndrome or preterm preeclampsia in their first pregnancy.

Maternal cardiac function after HELLP syndrome: an echocardiography study

OBJECTIVE

To evaluate maternal hemodynamics in asymptomatic women with a previous pregnancy affected by hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome and compare the findings to those of women with previous pre-eclampsia (PE) and controls with a previous uncomplicated pregnancy.

METHODS

Women with a history of PE (n = 60) or HELLP syndrome (n = 49) and matched healthy controls (n = 60) underwent echocardiography at 6 months to 4 years after delivery, recording left ventricular (LV) dimensions, ejection fraction (LVEF) and mass, right ventricular (RV) tricuspid annular plane systolic excursion and fractional area change (FAC). Diastolic filling (E/A and E/E' ratios) and tissue Doppler imaging were evaluated for both ventricles and the myocardial performance index was calculated.

RESULTS

Only women with previous HELLP syndrome showed significant LV concentric hypertrophy (20.4%). However, in both HELLP and PE groups, LV concentric remodeling (46.9% and 46.7%, respectively), diastolic dysfunction (expressed as altered E/A and E/E' ratios) and reduced LVEF (14.3% and 21.7%, respectively) were documented. RV variables did not differ significantly between cases and controls, except for FAC and E/E' ratio, which were slightly impaired in women with previous HELLP syndrome compared to those with previous PE (16.3% vs 10.0%, P = 0.04; 14.3% vs 3.3%, P = 0.03, respectively).

CONCLUSIONS

The significant overlap of echocardiographic features in women with previous PE and HELLP syndrome suggests that these two conditions share the same pathophysiology. However, HELLP syndrome may lead to more severe cardiovascular remodeling in the short to medium term after delivery. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Preventing cardiovascular disease after hypertensive disorders of pregnancy: Searching for the how and when

Background

Women with a history of a hypertensive disorder during pregnancy (HDP) have an increased risk of cardiovascular events. Guidelines recommend assessment of cardiovascular risk factors in these women later in life, but provide limited advice on how this follow-up should be organized.

Design

Systematic review and meta-regression analysis.

Methods

The aim of our study was to provide an overview of existing knowledge on the changes over time in three major modifiable components of cardiovascular risk assessment after HDP: blood pressure, glucose homeostasis and lipid levels. Data from 44 studies and up to 6904 women with a history of a HDP were compared with risk factor levels reported for women of corresponding age in the National Health And Nutrition Examination Survey, Estudio Epidemiólogico de la Insuficiencia Renal en España and Hong Kong cohorts (N = 27,803).

Results

Compared with the reference cohort, women with a HDP presented with higher mean blood pressure. Hypertension was present in a higher rate among women with a previous HDP from 15 years postpartum onwards. At 15 years postpartum (±age 45), one in five women with a history of a HDP suffer from hypertension. No differences in glucose homeostasis parameters or lipid levels were observed.

Conclusions

Based on our analysis, it is not possible to point out a time point to commence screening for cardiovascular risk factors in women after a HDP. We recommend redirection of future research towards the development of a stepwise approach identifying the women with the highest cardiovascular risk.

Syndromes of Thrombotic Microangiopathy

Thrombotic thrombocytopenia purpura (TTP) and the hemolytic uremic syndrome (HUS) are rare thrombotic microangiopathies that can be rapidly fatal. Although the acquired versions of TTP and HUS are generally highest on this broad differential, multiple rarer entities can produce a clinical picture similar to TTP/HUS, including microangiopathic hemolysis, renal failure, and neurologic compromise. More recent analysis has discovered a host of genetic factors that can produce microangiopathic hemolytic syndromes. This article discusses the current understanding of thrombotic microangiopathy and outlines the pathophysiology and causative agents associated with each distinct syndrome as well as the most accepted treatments.

Anesthetic considerations for liver diseases unique to pregnancy

Liver diseases that are most unique to pregnancy consist of hyperemesis gravidarum, acute fatty liver of pregnancy, intrahepatic cholestasis of pregnancy, and hemolysis, elevated liver enzymes and low platelets syndrome. In this review, risk factors, etiology, symptoms, diagnosis, prognosis and treatment of each entity followed by principles of anesthetic management based on the case reports or retrospective records will be addressed.

HELLP syndrome: a diagnostic conundrum with severe complications

The HELLP (haemolysis, elevated liver enzymes, low platelets) syndrome is believed to be part of the spectrum of pre-eclampsia, which falls within the category of hypertensive disorders of pregnancy. Maternal and fetal complications are more severe in HELLP as opposed to pre-eclampsia alone. We describe a 26-year-old primigravida woman with no medical history who presents with signs of HELLP with marked transaminitis and mild disseminated intravascular coagulation at 35 weeks of gestation who required emergent delivery of the fetus; the patient also sustained acute kidney injury requiring continuous veno-venous hemodiafiltration and a prolonged intensive care unit admission. Remarkably, with supportive care, all laboratory derangements, including renal function, normalised after 4 weeks. We discuss the diagnostic conundrum when faced with the possible diagnosis of HELLP in discriminating from its many imitators in order to assume proper treatment.

Pre-eclampsia

Pre-eclampsia affects 3-5% of pregnancies and is traditionally diagnosed by the combined presentation of high blood pressure and proteinuria. New definitions also include maternal organ dysfunction, such as renal insufficiency, liver involvement, neurological or haematological complications, uteroplacental dysfunction, or fetal growth restriction. When left untreated, pre-eclampsia can be lethal, and in low-resource settings, this disorder is one of the main causes of maternal and child mortality. In the absence of curative treatment, the management of pre-eclampsia involves stabilisation of the mother and fetus, followed by delivery at an optimal time. Although algorithms to predict pre-eclampsia are promising, they have yet to become validated. Simple preventive measures, such as low-dose aspirin, calcium, and diet and lifestyle interventions, show potential but small benefit. Because pre-eclampsia predisposes mothers to cardiovascular disease later in life, pregnancy is also a window for future health. A collaborative approach to discovery and assessment of the available treatments will hasten our understanding of pre-eclampsia and is an effort much needed by the women and babies affected by its complications.

Anesthetic considerations in HELLP syndrome

BACKGROUND

HELLP syndrome (hemolysis, elevated liver enzymes, low platelets) is an obstetric complication with heterogonous presentation and multisystemic involvement. It is characterized by microangiopathic hemolytic anemia, elevated liver enzymes by intravascular breakdown of fibrin in hepatic sinusoids and reduction of platelet circulation by its increased consumption.

METHODS

In terms of these patients' anesthetic management, it is essential to consider some details: (1) effective, safe perioperative management by a multidisciplinary approach, and quick, good communication among clinical specialists to achieve correct patient management; (2) neuroaxial block, particularly spinal anesthesia, is the first choice to do the cesarean if there is only moderate, but not progressive thrombocytopenia; (3) if a general anesthesia is required, it is necessary to control the response to stress produced by intubation, especially in patients with either severe high blood pressure or neurological signs, or to prevent major cerebral complications; (4) invasive techniques, e.g., as tracheostomy, arterial, and deep-vein canalization, should be considered; (5) if contraindication for neuroaxial anesthesia exists, rapid sequence intubation with general anesthesia should be regarded as an emergency in patients with full stomach; (6) increased risk of difficult airways should be taken into account.

RESULTS

Optimal patient management can be chosen after considering the risks and benefits of each anesthetic technique, and based on good knowledge of these patients' pathophysiological conditions.

CONCLUSION

Later, close patient monitoring is recommended for potential development of hemorrhagic complications, disseminated intravascular coagulation (DIC), or eclampsia.

The Epidemiology of Liver Diseases Unique to Pregnancy in a US Community: A Population-Based Study

BACKGROUND & AIMS

Little is known in the United States about the epidemiology of liver diseases that develop only during (are unique to) pregnancy. We investigated the incidence of liver diseases unique to pregnancy in Olmsted County, Minnesota, and long-term maternal and fetal outcomes.

METHODS

We identified 247 women with liver diseases unique to pregnancy from 1996 through 2010 using the Rochester Epidemiology Project database. The crude incidence rate was calculated by the number of liver disease cases divided by 35,101 pregnancies.

RESULTS

Of pregnant women with liver diseases, 134 had preeclampsia with liver dysfunction, 72 had hemolysis-associated increased levels of liver enzymes and low-platelet (HELLP) syndrome, 26 had intrahepatic cholestasis of pregnancy, 14 had hyperemesis gravidarum with abnormal liver enzymes, and 1 had acute fatty liver of pregnancy. The crude incidence of liver diseases unique to pregnancy was 0.77%. Outcomes were worse among women with HELLP or preeclampsia than the other disorders--of women with HELLP, 70% had a premature delivery, 4% had abruptio placentae, 3% had acute kidney injury, and 3% had infant death. Of women with preeclampsia, 56.0% had a premature delivery, 4% had abruptio placentae, 3% had acute kidney injury, and 0.7% had infant death. After 7 median years of follow-up (range, 0-18 years), 14% of the women developed recurrent liver disease unique to pregnancy; the proportions were highest in women with initial hyperemesis gravidarum (36%) or intrahepatic cholestasis of pregnancy (35%). Women with preeclampsia were more likely to develop subsequent hepatobiliary diseases.

CONCLUSIONS

We found the incidence of liver disease unique to pregnancy in Olmsted County, Minnesota, to be lower than that reported from Europe or US tertiary referral centers. Maternal and fetal outcomes in Olmsted County were better than those reported from other studies, but fetal mortality was still high (0.7%-3.0%). Women with preeclampsia or HELLP are at higher risk for peripartum complications and subsequent development of comorbidities.

Depression and anxiety in pregnancy and postpartum in women with mild and severe preeclampsia

BACKGROUND

Risk for anxiety and depression is increased in women with high-risk pregnancy. The aim of this study was to evaluate anxiety and depression in women with mild and severe preeclampsia at admission and 6 weeks postpartum.

MATERIALS AND METHODS

In this cohort study, 122 preeclamptic women who were admitted to the Public hospital and Tamin Ejtemaee hospital of Mashhad were included. Selection was done by convenience sampling method. Beck Depression Inventory II (BDI-II) and Spielberger State-Trait Anxiety Inventory (STAI) were completed at admission and 6 weeks after delivery. Data were analyzed by SPSS 16 using Chi-square, Fisher's exact test, Mann-Whitney U test, and Repeated measurement.

RESULTS

The mean depression score was 4.81 ± 4.09 at admission and 11.17 ± 5.5 at 6 weeks postpartum. The mean of trait anxiety was 42.5 ± 10.5 at admission and 32.3 ± 6.5 at 6 weeks postpartum, and the mean of state anxiety score at admission was 43.09 ± 9.5 and at 6 weeks postpartum was 31.99 ± 5.9. There was a significant difference between the scores of depression (F = 3.8, P < 0.001), state anxiety (F = 1.52, P < 0.001), and trait anxiety (F = 1.5, P < 0.001) at admission and 6 weeks postpartum. No significant differences were found between severity of preeclampsia and the scores of depression, state anxiety, and trait anxiety at admission and 6 weeks postpartum.

CONCLUSIONS

The mean score of state and trait anxiety decreased significantly in preeclamptic women from admission to 6 weeks postpartum, but the mean score of depression increased. Severity of preeclampsia was not an independent risk factor of depression and anxiety.

The mother--the long-term implications on metabolic and cardiovascular complications

There is cumulating evidence linking the occurrence of pregnancy complications, including miscarriage, stillbirth, hypertensive disorders of pregnancy, gestational diabetes mellitus, preterm birth, and fetal growth restriction, with increased future risk of type 2 diabetes mellitus, and hospitalization and death due to cardiovascular and cerebrovascular diseases. Such association is largely related to genetic predisposition and shared pathophysiological mechanisms and changes, which may precede the index pregnancy. Awareness of this association would allow identification of the at-risk women for implementation of preventive measures to reduce the recurrence risk of these complications and mitigate the future development of metabolic and cardiovascular diseases worldwide.

Maternal plasma fetuin-A concentration is lower in patients who subsequently developed preterm preeclampsia than in uncomplicated pregnancy: a longitudinal study

Objective: Fetuin-A is a negative acute phase protein reactant that acts as a mediator for lipotoxicity, leading to insulin resistance. Intravascular inflammation and insulin resistance have been implicated in the mechanisms of disease responsible for preeclampsia (PE). Maternal plasma concentrations of fetuin-A at the time of diagnosis of preterm PE are lower than in control patients with a normal pregnancy outcome. However, it is unknown if the changes in maternal plasma fetuin-A concentrations precede the clinical diagnosis of the disease. We conducted a longitudinal study to determine whether patients who subsequently developed PE had a different profile of maternal plasma concentrations of fetuin-A as a function of gestational age (GA) than those with uncomplicated pregnancies. Methods: A longitudinal case-control study was performed and included 200 singleton pregnancies in the following groups: (1) patients with uncomplicated pregnancies who delivered appropriate for gestational age (AGA) neonates (n = 160); and (2) patients who subsequently developed PE (n = 40). Longitudinal samples were collected at each prenatal visit and scheduled at 4-week intervals from the first or early second trimester until delivery. Plasma fetuin-A concentrations were determined by ELISA. Analysis was performed using mixed-effects models. Results: The profiles of maternal plasma concentrations of fetuin-A differ between PE and uncomplicated pregnancies. Forward analysis indicated that the rate of increase of plasma fetuin-A concentration in patients who subsequently developed PE was lower at the beginning of pregnancy (p = 0.001), yet increased faster mid-pregnancy (p = 0.0017) and reached the same concentration level as controls by 26 weeks. The rate of decrease was higher towards the end of pregnancy in patients with PE than in uncomplicated pregnancies (p = 0.002). The mean maternal plasma fetuin-A concentration was significantly lower in patients with preterm PE at the time of clinical diagnosis than in women with uncomplicated pregnancies (p < 0.05). In contrast, there were no significant differences in maternal plasma fetuin-A concentration in patients who developed PE at term. Conclusions: (1) The profile of maternal plasma concentrations of fetuin-A over time (GA) in patients who develop PE is different from that of normal pregnant women; (2) the rate of change of maternal plasma concentrations of fetuin-A is positive (increases over time) in the midtrimester of normal pregnancy, and negative (decreases over time) in patients who subsequently develop PE; (3) at the time of diagnosis, the maternal plasma fetuin-A concentration is lower in patients with preterm PE than in those with a normal pregnancy outcome; however, such differences were not demonstrable in patients with term PE.

Plasma from patients with HELLP syndrome increases blood-brain barrier permeability

Circulating inflammatory factors and endothelial dysfunction have been proposed to contribute to the pathophysiology of hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. To date, the occurrence of neurological complications in these women has been reported, but few studies have examined whether impairment in blood-brain barrier (BBB) permeability or cerebrovascular reactivity is present in women having HELLP syndrome. We hypothesized that plasma from women with HELLP syndrome causes increased BBB permeability and cerebrovascular dysfunction. Posterior cerebral arteries from female nonpregnant rats were perfused with 20% serum from women with normal pregnancies (n = 5) or women with HELLP syndrome (n = 5), and BBB permeability and vascular reactivity were compared. Plasma from women with HELLP syndrome increased BBB permeability while not changing myogenic tone and reactivity to pressure. Addition of the nitric oxide (NO) synthase inhibitor N(ω)-nitro-L-arginine methyl ester caused constriction of arteries that was not different with the different plasmas nor was dilation to the NO donor sodium nitroprusside different between the 2 groups. However, dilation to the small- and intermediate-conductance, calcium-activated potassium channel activator NS309 was decreased in vessels exposed to HELLP plasma. Thus, increased BBB permeability in response to HELLP plasma was associated with selective endothelial dysfunction.

Genetic aspects of preeclampsia and the HELLP syndrome

Both preeclampsia and the HELLP syndrome have their origin in the placenta. The aim of this study is to review genetic factors involved in development of preeclampsia and the HELLP syndrome using literature search in PubMed. A familial cohort links chromosomes 2q, 5q, and 13q to preeclampsia. The chromosome 12q is coupled with the HELLP syndrome. The STOX1 gene, the ERAP1 and 2 genes, the syncytin envelope gene, and the −670 Fas receptor polymorphisms are involved in the development of preeclampsia. The ACVR2A gene on chromosome 2q22 is also implicated. The toll-like receptor-4 (TLR-4) and factor V Leiden mutation participate both in development of preeclampsia and the HELLP syndrome. Carriers of the TT and the CC genotype of the MTHFR C677T polymorphism seem to have an increased risk of the HELLP syndrome. The placental levels of VEGF mRNA are reduced both in women with preeclampsia and in women with the HELLP syndrome. The BclI polymorphism is engaged in development of the HELLP syndrome but not in development of severe preeclampsia. The ACE I/D polymorphism affects uteroplacental and umbilical artery blood flows in women with preeclampsia. In women with preeclampsia and the HELLP syndrome several genes in the placenta are deregulated. Preeclampsia and the HELLP syndrome are multiplex genetic diseases.

Long-term maternal morbidity and mortality associated with ischemic placental disease

Ischemic placental disease can have long-term maternal health implications. In this article, we discuss the three conditions of ischemic placental disease (preeclampsia, fetal growth restriction, and abruption placenta) and its associated long-term maternal morbidity. Retrospective observational studies comparing pregnancies complicated by ischemic placental disease to uncomplicated pregnancies suggest an increased long-term risk of hypertension, cardiovascular death, metabolic syndrome, and cerebrovascular disease. This association is much stronger in women who had an indicated-preterm delivery due to ischemic placental disease. It is important to adequately counsel women who are diagnosed with these conditions about their future health risks. Increased awareness of the potential health risks and multidisciplinary collaboration remains paramount to instituting the appropriate screening and preventative strategies (i.e., behavior modification) for affected women.

Balancing the benefits and risks: lessons learned from the therapeutic interventions of a case with severe preeclampsia

BACKGROUND AND OBJECTIVE

Preeclampsia is a multiple organ dysfunction syndrome (MODS) for its typical and atypical manifestations including hypertension, proteinuria, HELLP syndrome, hypertensive encephalopathy and coagulopathy. Optimal management for such patients is determined from an assessment of the balance between benefits and risks of anesthetic and obstetric therapeutic strategies.

CASE REPORT

A 35-year-old pregnant woman, with one past uncomplicated pregnancy presented at 29 weeks to our medical institute as an emergency with dizziness, chest distress, palpitation, blurred vision and vaginal bleeding. After physical examination and laboratory tests, the patient was diagnosed with severe preeclampsia, HELLP syndrome, placental abruption, and MODS. The patient also presented spinal and pelvic deformity, fixation of articulus mandibularis, and tracheal displacement because of a traffic accident 11 years ago. Therefore, urgent cesarean section was performed under general anesthesia with nasal tracheal intubation using a guide wire. The patient was discharged directly home from the obstetric intensive care unit on the 7(th) postoperative day with normal blood pressure and full recovery of organic function.

CONCLUSIONS

This case merits further discussion on the anesthesia considerations concerning how to make a clinical decision when treating such a patient. Neuraxial block is the first choice for preeclampsia patients undergoing cesarean section when a moderate but not progressive thrombocytopenia exists. When general anesthesia is decided, adequate sedation and analgesia is needed to better control the stress response to intubation especially in patients with neurological signs, and to prevent major cerebral complications.

Differentiating scleroderma renal crisis from other causes of thrombotic microangiopathy in a postpartum patient

Thrombotic thrombocytopenic purpura (TTP), hemolytic uremic syndrome (HUS), and scleroderma renal crisis (SRC) all present with features of thrombotic microangiopathy. Distinguishing among these entities is critical, however, as treatments differ and may be mutually exclusive. We describe the case of a 25-year-old woman with an undefined mixed connective tissue disease who presented 6 weeks post-partum with fever, transient aphasia, thrombocytopenia, hemolytic anemia, and acute kidney injury eventually requiring initiation of hemodialysis. Renal biopsy revealed thrombotic microangiopathy. Renal function did not improve despite immediate initiation of plasma exchange, and an angiotensin-converting enzyme (ACE) inhibitor was initiated following discontinuation of plasma exchange. At last follow up, she remained dialysis dependent. Due to the myriad causes of thrombotic microangiopathy and potential for diagnostic uncertainty, the patient's response to therapy should be closely monitored and used to guide modification of therapy.

Hypertension and pregnancy

Hypertension in pregnancy is increasing in prevalence and incidence and its treatment becoming more commonplace. Associated complications of pregnancy, including end-organ damage, preeclampsia, eclampsia, and postpartum eclampsia, are leading sources of maternal and fetal morbidity and mortality, requiring an emergency physician to become proficient with their identification and treatment. This article reviews hypertension in pregnancy as it relates to outcomes, with special emphasis on preeclampsia, eclampsia, and postpartum eclampsia.

Pathogenesis of the syndrome of hemolysis, elevated liver enzymes, and low platelet count (HELLP): a review

HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome is serious for the mother and the offspring. HELLP occurs in 0.2-0.8% of pregnancies and in 70-80% of cases it coexists with preeclampsia (PE). This review concerns the pathogenetic mechanisms of HELLP syndrome with an emphasis on differences between HELLP and early onset PE. The syndromes show a familial tendency. A previous HELLP pregnancy is associated with an increased risk of HELLP as well as PE in subsequent pregnancies, indicating related etiologies. No single world-wide genetic cause for excessive risk of HELLP or PE has been identified. Combinations of multiple gene variants, each with a moderate risk, with contributing effects of maternal and environmental factors, are probable etiological mechanisms. Immunological maladaptation is the most probable trigger of the insult to the invading trophoblast. This insult occurs early in the first trimester, as indicated by marker molecules in maternal blood. The levels of fetal messenger RNAs in maternal blood at gestational weeks 15-20 are significantly more abnormal in HELLP than in PE, suggesting that the insult is more extensive in HELLP. High levels of HLA-DR in maternal blood in women with HELLP may suggest a similarity to the rejection reaction. In third trimester placentas, gene derangement is more extensive in HELLP. Anti-angiogenic factors released into maternal blood induce the maternal syndromes. Maternal blood levels of anti-angiogenic sFlt1 are similar, but endoglin and Fas Ligand levels are possibly higher in HELLP than in PE. These factors trigger the vascular endothelium, resulting in an enhanced inflammatory response which is stronger in HELLP. Activated coagulation and complement, with high levels of activated leucocytes, inflammatory cytokines, TNF-α, and active von Willebrand factor, induce thrombotic microangiopathy with platelet-fibrin thrombi in microvessels. The angiopathy results in consumption of circulating platelets, causes hemolysis in affected microvessels and reduces portal blood flow in the liver. Placental Fas Ligand damages hepatocytes, resulting in periportal necrosis. In about one half of women with HELLP, activation of coagulation factors and platelets precipitates disseminated intravascular coagulation, which in a minority becomes uncompensated and contributes to life-threatening multiorgan failure.

Women's experiences of preeclampsia: Australian action on preeclampsia survey of women and their confidants

INTRODUCTION

The experience of normal pregnancy is often disrupted for women with preeclampsia (PE).

MATERIALS AND METHODS

Postal survey of the 112 members of the consumer group, Australian Action on Pre-Eclampsia (AAPEC).

RESULTS

Surveys were returned by 68 women (61% response rate) and from 64 (57%) partners, close relatives or friends. Respondents reported experiencing pre-eclampsia (n = 53), eclampsia (n = 5), and/or Hemolysis, Elevated Liver enzymes, and Low Platelets (HELLP syndrome) (n = 26). Many women had no knowledge of PE prior to diagnosis (77%) and, once diagnosed, did not appreciate how serious or life threatening it was (50%). Women wanted access to information about PE. Their experience contributed substantial anxiety towards future pregnancies. Partners/friends/relatives expressed fear for the woman and/or her baby and had no prior understanding of PE.

CONCLUSIONS

The PE experience had a substantial effect on women, their confidants, and their babies and affected their approach to future pregnancies. Access to information about PE was viewed as very important.

Preeclampsia as a female-specific risk factor for chronic hypertension

Preeclampsia is a complication of pregnancy that has also long term effects on maternal health. Several epidemiologic studies have shown an increased risk for cardiovascular morbidity (relative risk [RR] 2.3) and mortality (RR 2.3) in women after a history of preeclampsia. The chance to develop chronic hypertension afterwards is twofold to 10 times higher in affected women, compared with women after normotensive pregnancies. As hypertension is a major cardiovascular risk factor, early detection and treatment is mandatory to reduce the risk of future cardiovascular disease. Data on (cost)-effectiveness of cardiovascular screening programs in women after preeclampsia are currently lacking and there are no recommendations yet for prevention in the guidelines. We recommend regularly preventive blood pressure measurements after high risk pregnancies. More research is needed to identify women who will profit most of early intervention.