Imitators of severe pre-eclampsia/eclampsia

Two pregnant women with immune-mediated thrombotic thrombocytopenic purpura: A case report

Thrombotic thrombocytopenic purpura (TTP) during pregnancy is life-threatening. We encountered two pregnant women with immune-mediated TTP (iTTP). A 40-year-old primigravida woman was referred at 19 gestational weeks (GWs) owing to iTTP. She received plasma exchange (PE) and steroid therapies and delivered a live infant at 27 GWs by cesarean delivery. A 29-year-old primigravida woman was referred owing to intrauterine fetal death and thrombocytopenia at 20 GWs. She was diagnosed with iTTP and received PE therapy. She required additional PE and steroid therapies owing to relapse. Before her second pregnancy, she received prednisolone and hydroxychloroquine according to the therapy for systemic lupus erythematosus (SLE). She had induced labor at 37 GWs owing to decrease plasma level of a disintegrin-like and metalloproteinase with thrombospondin type 1 motif 13 (ADAMTS13) activity. Close monitoring of plasma ADAMTS13 activity level and treatments for underlying SLE may prevent iTTP relapse and lead to a good prognosis.

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.

Cord blood gas results of pregnancies complicated by preeclampsia and the relationship of these results with the amount of proteinuria

AIM

To evaluate whether there is a statistically significant difference between the cord blood gas parameters of pregnancies complicated with preeclampsia and uncomplicated pregnancies and to show whether the amount of proteinuria affects fetal cord blood gas parameters in pregnancies complicated with preeclampsia.

METHODS

The study was designed retrospectively. Between 2016 and 2019, the neonatal results and cord blood gas results of 109 pregnant women who were diagnosed with preeclampsia and 75 nonpreeclamptic randomly selected pregnant women were compared. The preeclampsia group was divided into groups according to amount of proteinuria. SPSS 21.0 statistics program was used, and comparative analysis was carried out.

RESULTS

The data of the 109 preeclampsia cases and 75 control groups included in the study were compared, and there was no statistical difference between the fetal cord blood gas parameters between the groups (p > 0.05). The median first and fifth minute Apgar scores were found significantly lower in the preeclampsia group compared to the control group (6, 8 and 8, 9, respectively; p < 0.001). Also, the amount of proteinuria does not alter cord blood gas parameters (p > 0.05).

CONCLUSION

Preeclampsia poses a risk for the neonatal period as it reduces the neonatal Apgar scores due to the chronic hypoxic process it creates. However, it was observed that the amount of proteinuria, which is one of the diagnostic criteria, did not affect neonatal results on Apgar scores or fetal cord blood gas parameters.

Diagnosis of HELLP Syndrome: A 10-Year Survey in a Perinatology Centre

HELLP (Hemolysis, Elevated Liver enzymes, Low Platelet count) syndrome is a severe and rapidly progressing condition that requires distinct diagnostic considerations. The aim of this study was to evaluate the impact of the Mississippi triple-class system on the HELLP syndrome diagnosis, treatment, and outcomes in a perinatology centre during a 10-year period, and consider its effectiveness and necessity in everyday practice. A retrospective observational cohort study was carried out using the medical records of a tertiary perinatology centre with the diagnosis of HELLP syndrome from the period of time between 2005 and 2014. The patients who fit the HELLP syndrome diagnosis were grouped by the Mississippi triple-class system. The means of diagnosis and treatment outcomes within those groups were analysed statistically. There was insufficient statistical evidence of the blood pressure levels corresponding to the severity of patients’ condition (p > 0.05 in all of the groups). The clinical presentation varied within all of the classes, and the only objective means of diagnosis and evaluation of progression of the condition were laboratory tests. Even though HELLP syndrome is considered a hypertensive multi-organ disorder of pregnancy, the level of hypertension does not correlate to the severity of the condition; hence, the diagnosis should be based on biochemical laboratory evidence. Vigilance in suspicion and the recognition of HELLP syndrome and appropriate treatment are essential in order to ensure better maternal and neonatal outcomes.

Abdelazim and AbuFaza ELLP syndrome as a variant of HELLP syndrome: Case reports

Background:

The hemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome is a serious complication in pregnancy occurring in 0.5–0.9% of all pregnancies and in 10–20% of cases with severe pre-eclampsia. Previous studies described HELLP syndrome without hemolysis without any further details.

Objectives:

This report represents the criteria for the diagnosis of Abdelazim and AbuFaza elevated liver enzymes, low platelet count (ELLP) syndrome as a variant of HELLP syndrome.

Case Reports:

A 39-year-old woman, pregnant 32 weeks’ gestation, previous five cesarean sections, admitted with severe pre-eclampsia (blood pressure 160/110 mmHg, proteinuria +3, 700 mg proteins/24 h urine, and protein/creatinine ratio ≥0.9 in spot urine sample). Laboratory investigation showed elevated liver enzymes, low platelet (PLT) count, and no evidence of hemolysis. A 31-year-old woman, pregnant 33⁺⁴ weeks’ gestation, previous one cesarean section, admitted with severe pre-eclampsia (blood pressure 170/120 mmHg, proteinuria +2, 1200 mg proteins/24 h urine, and protein/creatinine ratio 1.1 in spot urine sample). Laboratory investigations showed elevated liver enzymes, low PLT count, and no evidence of hemolysis. Both patients delivered by cesarean section after stabilization of their blood pressure and dexamethasone for induction of fetal lung maturity and MgSO₄ for prevention of eclampsia. Both patients had uneventful intraoperative and postoperative stay in the hospital. The liver enzymes and the PLT count were completely normal on the 5^th postoperative day, and they were discharged from the hospital in good general condition.

Conclusion:

Abdelazim and AbuFaza ELLP syndrome is variant of HELLP syndrome without hemolysis in women with severe pre-eclampsia. Abdelazim and AbuFaza ELLP syndrome diagnostic criteria are as follows: (1) Elevated liver enzymes; (2) Low PLT count; and (3) Absence of hemolysis (normal total and unconjugated bilirubin, absence of schizocytes, and polychromatic red cells in peripheral blood smear, and normal reticulocyte count).

A Case Report of the Nutrition Support for a Patient with HELLP Syndrome

A 30-year-old female patient, 18 weeks gestational age, with no prior medical history was admitted to hospital complaining severe right upper quadrant pain. The patient was admitted to intensive care unit (ICU) after emergency surgery to treat intraperitoneal hemorrhage caused by rupture of liver hematoma. Despite the absence of high blood pressure, the patient was diagnosed with hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome on the basis of abnormal levels of blood aspartate aminotransferase/alanine aminotransferase, lactate dehydrogenase, total bilirubin, direct bilirubin, C-reactive protein (CRP) and platelet along with liver damage and proteinuria. While in ICU, the patient was given total parenteral nutrition (TPN) and enteral nutrition (EN) for –20 days because oral feeding was impractical. In the early stage, TPN supply was not sufficient to meet the elevated nutritional demand induced by disease and surgery. Nevertheless, continuous care of nutrition support team enabled satisfactory EN and, subsequently, oral feeding which led to improvement in patient outcome.

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.

Current best practice in the management of hypertensive disorders in pregnancy

Preeclampsia is a potentially serious complication of pregnancy with increasing significance worldwide. Preeclampsia is the cause of 9%–26% of global maternal mortality and a significant proportion of preterm delivery, and maternal and neonatal morbidity. Incidence is increasing in keeping with the increase in obesity, maternal age, and women with medical comorbidities entering pregnancy. Recent developments in the understanding of the pathophysiology of preeclampsia have opened new avenues for prevention, screening, and management of this condition. In addition it is known that preeclampsia is a risk factor for cardiovascular disease in both the mother and the child and presents an opportunity for early preventative measures. New tools for early detection, prevention, and management of preeclampsia have the potential to revolutionize practice in the coming years. This review presents the current best practice in diagnosis and management of preeclampsia and the hypertensive disorders of pregnancy.

Revisiting HELLP syndrome

HELLP syndrome was first described in 1982 by Weinstein et al. and the term HELLP refers to an acronym used to describe the clinical condition that leads to hemolysis, elevated liver enzymes and low platelets. The syndrome frequency varies from 0.5 to 0.9% pregnancies and manifests preferentially between the 27th and 37th week of gestation. Approximately 30% of cases occur after delivery. Although the etiopathogenesis of this syndrome remains unclear, histopathologic findings in the liver include intravascular fibrin deposits that presumably may lead to hepatic sinusoidal obstruction, intrahepatic vascular congestion, and increased intrahepatic pressure with ensuing hepatic necrosis, intraparenchymal and subcapsular hemorrhage, and eventually capsular rupture. Typical clinical symptoms of HELLP syndrome are pain in the right upper quadrant abdomen or epigastric pain, nausea and vomiting. However, this syndrome can present nonspecific symptoms and the diagnosis may be difficult to be established. Laboratory tests and imaging exams are essential for differential diagnosis with other clinical conditions. Treatment of HELLP syndrome with corticosteroids, targeting both lung maturation of the fetus is still an uncertain clinical value. In conclusion, three decades after the tireless efforts of Dr. Weinstein to characterize HELLP syndrome, it remains a challenge to the scientific community and several questions need to be answered for the benefit of pregnant women.

Assessment of clinical outcomes and prescribing behavior among inpatients with severe preeclampsia and eclampsia: an Indian experience

Objectives:

The study aims to evaluate the management, maternal-fetal outcomes, and prescription behavior among inpatients with severe preeclampsia and eclampsia.

Materials and Methods:

This prospective cohort study in a tertiary referral center was conducted in 164 inpatient pregnant women who fulfilled the inclusion criteria. The study was conducted between November 2005 and February 2007. The patients were followed-up till delivery. Antepartum and intrapartum care and maternal and perinatal outcome were noted. Chief outcome measures were maternal and perinatal mortality and drug use indicators.

Results:

Median age at delivery of the women was 25 (22-28) years. Majority were suffering from antepartum eclampsia (52.5%), followed by preeclampsia (31%) and postpartum eclampsia (16.5%). Nulliparity (61.6%) was more common in eclampsia, while multiparity in preclamptic group. A total of 48% had preterm delivery. Most presented with headache (50%) and hyperreflexia (29%). Only 15% presented with all three prodromal symptoms and 86% had hypertension. There was increased morbidity, operative intervention, and admission to intensive care unit. Most babies (67%) weighed <2.5 kg and had poor outcome. The maternal mortality was 0.4/1000. Average number of drugs prescribed in patients of preeclampsia, antepartum eclampsia, and postpartum eclampsia were 13.2, 14.9, and 14.2, respectively. Antibiotics (24.6%) were the most common class of the drugs prescribed in all the groups, followed by vitamin and calcium supplements (22.7%) and antihypertensives (13.5%). Most common antihypertensive used were calcium channel blockers and anticonvulsant magnesium sulphate.

Conclusions:

There was increased maternal and perinatal morbidity. Protocols for the management of eclampsia, including antihypertensive and anticonvulsant therapies, should be available and reviewed regularly to improve the standard of care and reduce the prevalence of this dangerous condition.

Acute subdural haemorrhage in the postpartum period as a rare manifestation of possible HELLP (haemolysis, elevated liver enzymes, and low-platelet count) syndrome: a case report

Background

The HELLP syndrome (haemolysis, elevated liver enzymes, and low-platelet count) occurs in about 0.5 to 0.9% of all pregnancies. With occurrence of thrombocytopaenia, it signals for several potentially lethal conditions such as complete or partial HELLP syndrome, thrombotic thrombocytopaenic purpura and acute fatty liver of pregnancy.

Case presentation

A previously healthy 27-year-old, Sinhala ethnic primigravida with pregnancy-induced hypertension was admitted at 38 weeks of gestation with lower abdominal pain and a blood pressure of 140/90 mmHg. She underwent emergency Caesarian section due to faetal distress giving birth to a healthy baby girl. Since postpartum day one, she was having intermittent fever spikes. All the routine investigations were normal in the first three weeks. Platelet count started dropping from post-partum day-20 onwards. On day-23, she had developed a seizure and computed tomography scan brain showed a subdural haemorrhage. She had a platelet count of 22,000 × 10⁹/liter and was managed conservatively. She also had elevated liver enzymes, lactate dehydrogenase and bilirubin levels. Blood picture on day-24 showed haemolytic anemia. On day- 36, patient again developed seizures and she was having intermittent fever with generalized headache and signs of meningism. Computed tomography scan revealed an acute on chronic subdural haemorrhage.

Conclusions

Hypertensive disorders in pregnancy should be managed as high-risk throughout the postpartum period. Development of thrombocytopaenia can be considered as an early warning sign for HELLP, thrombotic thrombocytopaenic purpura or acute fatty liver of pregnancy which are lethal conditions. Prompt recognition of intracranial haemorrhages and early neurosurgical intervention is lifesaving.

Regional anesthesia in patients with pregnancy induced hypertension

Pregnancy induced hypertension is a hypertensive disorder, which occurs in 5% to 7% of all pregnancies. These parturients present to the labour and delivery unit ranging from gestational hypertension to HELLP syndrome. It is essential to understand the various clinical conditions that may mimic preeclampsia and the urgency of cesarean delivery, which may improve perinatal outcome. The administration of general anesthesia (GA) increases morbidity and mortality in both mother and baby. The provision of regional anesthesia when possible maintains uteroplacental blood flow, avoids the complications with GA, improves maternal and neonatal outcome. The use of ultrasound may increase the success rate. This review emphasizes on the regional anesthetic considerations when such parturients present to the labor and delivery unit.

Effects of plasma exchange combined with continuous renal replacement therapy on acute fatty liver of pregnancy

BACKGROUND

Acute fatty liver of pregnancy (AFLP) in the third trimester or early postpartum period can lead to fatal liver damage. Its traditional therapy is not very effective in facilitating hepatic recovery. The safety and effect of plasma exchange (PE) in combination with continuous renal replacement therapy (CRRT) (PE+CRRT) for AFLP still needs evaluation.

METHODS

Five AFLP patients with hepatic encephalopathy and renal failure were subjected to PE+CRRT in our department from 2007 to 2012. Their symptoms, physical signs and results were observed, and all relevant laboratory tests were compared before and after PE+CRRT.

RESULTS

All the 5 patients were well tolerated to the therapy. Four of them responded to the treatment and showed improvement in clinical symptoms/signs and laboratory results, and they were cured and discharged home after the treatment. One patient succeeded in bridging to transplantation for slowing down hepatic failure and its complications process after 2 treatment sessions. Intensive care unit stay and hospital stay were 9.4 (range 5-18) and 25.0 days (range 11-42), respectively.

CONCLUSION

PE+CRRT is safe and effective and should be used immediately at the onset of hepatic encephalopathy and/or renal failure in patients with AFLP.

Mechanisms and management of hypertension in pregnant women

Hypertension is the most common medical disorder encountered during pregnancy. A recent report highlighted hypertensive disorders as one of the major causes of pregnancy-related maternal deaths in the United States. Significant advances in our understanding of preeclampsia, a form of hypertension unique to pregnancy, have occurred in recent years. The optimal timing and choice of therapy for hypertensive pregnancy disorders involves carefully weighing the risk-versus-benefit ratio for each individual patient, with an overall goal of improving maternal and fetal outcomes. In this review, we summarize the mechanisms thought to be involved, review the current management guidelines for hypertensive pregnancy disorders as recommended by international guideline groups, and outline some newer perspectives on management.

Biochemistry of HELLP syndrome

The HELLP syndrome is a serious complication of pregnancy characterized by hemolysis (H), elevated liver (EL) enzymes, and low platelet (LP) count that occurs in 0.2-0.6% of all pregnancies and in 10-20% of cases with severe preeclampsia and frequently leads to adverse maternal and perinatal outcome. The exact pathobiology of HELLP syndrome has not been clearly defined. As it is considered a form or a complication of severe preeclampsia, it likely has its origin in aberrant placental development and function resulting in ischemia-producing oxidative stress. However, there is still a debate on whether HELLP must be considered a severe form of preeclampsia or a separate disease entity. It can be described as a placenta-induced disease, as is preeclampsia itself, but with a more acute and predominant inflammatory process typically targeting the liver and with a greater activation of the coagulation system. This occurs during a disordered immunologic process and may be due to a genetic predisposition. In this review, we discuss the main biochemical characteristics of HELLP syndrome, particularly focusing on molecular aspects of placental involvement and maternal systemic responses.

Immune thrombocytopenia in pregnancy

Management of immune thrombocytopenia in pregnancy can be a complex and challenging task and may be complicated by fetal-neonatal thrombocytopenia. Although fetal intracranial hemorrhage is a rare complication of immune thrombocytopenia in pregnancy, invasive studies designed to determine the fetal platelet count before delivery are associated with greater risk than that of fetal intracranial hemorrhage and are discouraged. Moreover, the risk of neonatal bleeding complications does not correlate with the mode of delivery, and cesarean section should be reserved only for obstetric indications.

The HELLP syndrome: clinical issues and management. A Review

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.

Understanding and managing HELLP syndrome: the integral role of aggressive glucocorticoids for mother and child

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.

Fetal fatty acid oxidation disorders, their effect on maternal health and neonatal outcome: impact of expanded newborn screening on their diagnosis and management

Mitochondrial fatty acid oxidation disorders (FAOD) are recessively inherited errors of metabolism. Newborns with FAOD typically present with hypoketotic hypoglycemia, metabolic acidosis, hepatic failure, and cardiomyopathy. Late presentations include episodic myopathy, neuropathy, retinopathy, and arrhythmias. Sudden unexpected death can occur at any age and can be confused with sudden infant death syndrome. Some FAOD are associated with intrauterine growth restriction, prematurity, and pregnancy complications in the heterozygous mother, such as severe preeclampsia, acute fatty liver of pregnancy (AFLP), or hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome. Maternal pregnancy complications occur primarily in mothers carrying a fetus with long-chain l-3-hydroxyacyl CoA dehydrogenase deficiency or general trifunctional protein deficiencies. FAOD as a group represent the most common inborn errors of metabolism, and presymptomatic diagnosis of FAOD is the key to reduce morbidity and avoid mortality. The application of tandem mass spectrometry to newborn screening provides an effective means to identify most FAOD patients presymptomatically. At the beginning of 2005, 36 state newborn screening programs have mandated or adopted this technology resulting in a marked increase in the number of asymptomatic neonates with FAOD diagnosed. To ensure the long-term benefits of such screening programs, pediatricians and other health care providers must be educated about these disorders and their treatment.