Diagnosis and management of hemolysis, elevated liver enzymes, and low platelets syndrome

First-trimester predictive models for adverse pregnancy outcomes-a base for implementation of strategies to prevent cardiovascular disease development

Introduction

This study aimed to establish efficient, cost-effective, and early predictive models for adverse pregnancy outcomes based on the combinations of a minimum number of miRNA biomarkers, whose altered expression was observed in specific pregnancy-related complications and selected maternal clinical characteristics.

Methods

This retrospective study included singleton pregnancies with gestational hypertension (GH, n = 83), preeclampsia (PE, n = 66), HELLP syndrome (n = 14), fetal growth restriction (FGR, n = 82), small for gestational age (SGA, n = 37), gestational diabetes mellitus (GDM, n = 121), preterm birth in the absence of other complications (n = 106), late miscarriage (n = 34), stillbirth (n = 24), and 80 normal term pregnancies. MiRNA gene expression profiling was performed on the whole peripheral venous blood samples collected between 10 and 13 weeks of gestation using real-time reverse transcription polymerase chain reaction (RT-PCR).

Results

Most pregnancies with adverse outcomes were identified using the proposed approach (the combinations of selected miRNAs and appropriate maternal clinical characteristics) (GH, 69.88%; PE, 83.33%; HELLP, 92.86%; FGR, 73.17%; SGA, 81.08%; GDM on therapy, 89.47%; and late miscarriage, 84.85%). In the case of stillbirth, no addition of maternal clinical characteristics to the predictive model was necessary because a high detection rate was achieved by a combination of miRNA biomarkers only [91.67% cases at 10.0% false positive rate (FPR)].

Conclusion

The proposed models based on the combinations of selected cardiovascular disease-associated miRNAs and maternal clinical variables have a high predictive potential for identifying women at increased risk of adverse pregnancy outcomes; this can be incorporated into routine first-trimester screening programs. Preventive programs can be initiated based on these models to lower cardiovascular risk and prevent the development of metabolic/cardiovascular/cerebrovascular diseases because timely implementation of beneficial lifestyle strategies may reverse the dysregulation of miRNAs maintaining and controlling the cardiovascular system.

Bone development in fetuses with intrauterine growth restriction caused by maternal endocrine-metabolic dysfunctions

Intrauterine growth restriction (IUGR) affects a large proportion of infants, particularly in underdeveloped countries. Among the main causes of IUGR, maternal endocrine-metabolic dysfunction is highlighted, either due to its high incidence or due to the severity of the immediate and mediated changes that these dysfunctions cause in the fetus and the mother. Although the effects of endocrine and metabolic disorders have been widely researched, there are still no reviews that bring together and summarize the effects of these conditions on bone development in cases of IUGR. Therefore, the present literature review was conducted with the aim of discussing bone changes observed in fetuses with IUGR caused by maternal endocrine-metabolic dysfunction. The main endocrine dysfunctions that occur with IUGR include maternal hyperthyroidism, hypothyroidism, and hypoparathyroidism. Diabetes mellitus, hypertensive disorders, and obesity are the most important maternal metabolic dysfunctions that compromise fetal growth. The bone changes reported in the fetus are, for the most part, due to damage to cell proliferation and differentiation, as well as failures in the synthesis and mineralization of the extracellular matrix, which results in shortening and fragility of the bones. Some maternal dysfunctions, such as hyperthyroidism, have been widely studied, whereas conditions such as hypoparathyroidism and gestational hypertensive disorders require further study regarding the mechanisms underlying the development of bone changes. Similarly, there is a gap in the literature regarding changes related to intramembranous ossification, as most published articles only describe changes in endochondral bone formation associated with IUGR. Furthermore, there is a need for more research aimed at elucidating the late postnatal changes that occur in the skeletons of individuals affected by IUGR and their possible relationships with adult diseases, such as osteoarthritis and osteoporosis.

Thrombotic Microangiopathy in Pregnancy: Current Understanding and Management Strategies

Thrombotic microangiopathy (TMA) represents a heterogeneous group of disorders characterized by microvascular thrombosis and end-organ damage. Pregnancy-associated thrombotic microangiopathy (p-TMA) has emerged as a distinct clinical entity with unique diagnostic challenges. Identifying the specific form of p-TMA is critical for appropriate and timely management. This review offers a comprehensive overview of the various forms of thrombotic microangiopathies associated with pregnancy, highlighting our current understanding of their pathophysiology and the evolving landscape of diagnosis and treatment for each.

Systematic development of ionizable lipid nanoparticles for placental mRNA delivery using a design of experiments approach

Ionizable lipid nanoparticles (LNPs) have gained attention as mRNA delivery platforms for vaccination against COVID-19 and for protein replacement therapies. LNPs enhance mRNA stability, circulation time, cellular uptake, and preferential delivery to specific tissues compared to mRNA with no carrier platform. However, LNPs are only in the beginning stages of development for safe and effective mRNA delivery to the placenta to treat placental dysfunction. Here, we develop LNPs that enable high levels of mRNA delivery to trophoblasts in vitro and to the placenta in vivo with no toxicity. We conducted a Design of Experiments to explore how LNP composition, including the type and molar ratio of each lipid component, drives trophoblast and placental delivery. Our data revealed that utilizing C12-200 as the ionizable lipid and 1,2-dioleoyl-sn-glycero-3-phosphoethanolamine (DOPE) as the phospholipid in the LNP design yields high transfection efficiency in vitro. Analysis of lipid molar composition as a design parameter in LNPs displayed a strong correlation between apparent pKa and poly (ethylene) glycol (PEG) content, as a reduction in PEG molar amount increases apparent pKa. Further, we present one LNP platform that exhibits the highest delivery of placental growth factor mRNA to the placenta in pregnant mice, resulting in synthesis and secretion of a potentially therapeutic protein. Lastly, our high-performing LNPs have no toxicity to both the pregnant mice and fetuses. Our results demonstrate the feasibility of LNPs as a platform for mRNA delivery to the placenta, and our top LNP formulations may provide a therapeutic platform to treat diseases that originate from placental dysfunction during pregnancy.

Hypertension in Pregnancy: What We Now Know

PURPOSE OF REVIEW

Hypertensive disorders of pregnancy remain a highly morbid condition that affects both the mother and fetus, complicate approximately 10% of pregnancies worldwide, and contribute to immediate and long-term cardiovascular outcomes. There is still much to learn regarding pathogenesis and treatment goals.

RECENT FINDINGS

There is updated information on the pathogenesis of preeclampsia and treatment thresholds for HTN in pregnancy. l-Kynurenine, a metabolite of the essential amino acid l-tryptophan, has been implicated in preeclampsia as decreased levels were found in a uninephrectomized pregnant mouse model of preeclampsia, where replacement of l-kynurenine rescued the preeclamptic state. Further, data from CHIPS (The Control of HTN in Pregnancy Study) and CHAP (Chronic HTN and Pregnancy) trials demonstrate not only the safety of lowering blood pressure to either a diastolic goal of 85 mmHg (CHIPS) or less than 160/105 mmHg (CHAP) without detriment to the fetus but the CHAPS trial has also shown a decrease in the rate of preeclampsia in the treatment group.

SUMMARY

We will summarize the different types of hypertensive disorders in pregnancy, updates on the pathogenesis of preeclampsia, and appropriate HTN management based on the latest evidence in order to better care for mother and child.

Therapeutic plasma exchange in postpartum HELLP syndrome: a case report

BACKGROUND

Postpartum hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is more difficult to treat than HELLP syndrome during pregnancy. We describe a case of postpartum HELLP syndrome that responded to plasma exchange (PE) therapy.

CASE PRESENTATION

A 30-year-old primipara woman was hospitalized for gestational hypertension at 33 weeks of gestation and underwent an emergent cesarean section at 36 weeks and 6 days of gestation due to rapidly progressing pulmonary edema. After delivery, liver dysfunction and a rapid decrease in platelet count were observed, and the patient was diagnosed with severe HELLP syndrome. She experienced multiple organ failure despite intensive care, and PE therapy was initiated. Her general condition dramatically stabilized within a few hours of PE therapy.

CONCLUSION

It is controversial whether PE therapy should be used primarily in the management of HELLP syndrome, but early initiation of PE therapy could be effective for severe HELLP syndrome.

Management of Ruptured Subcapsular Liver Hematoma as a Result of Hemolysis, Elevated Liver Enzyme, and Low Platelet Syndrome in a Rural Facility

Subcapsular liver hematoma is a rare complication of hemolysis, elevated liver enzyme, and low platelet (HELLP) syndrome. This case depicts a previously healthy 27-year-old primigravida at 39 weeks' gestation who presented with severe abdominal pain and was diagnosed with HELLP syndrome based on vital signs and laboratory values. While arranging transport to a regional perinatal care facility she became acutely unstable with maternal hypotension and resultant fetal bradycardia. An emergent cesarean section was performed and a ruptured subcapsular liver hematoma was diagnosed intraoperatively. She was successfully managed with supportive care and surgical intervention and was discharged from the hospital on postoperative day 6. Here we review the indications and methods of conservative and surgical management of subcapsular liver hematoma as a result of HELLP syndrome.

One-third of patients with eclampsia at term do not have an abnormal angiogenic profile

OBJECTIVES

An abnormal angiogenic profile is present in about one-half of women with preeclampsia at term. Few studies examined the roles of angiogenic biomarkers in eclampsia. The aims of this study were to determine (1) whether the degree of an anti-angiogenic state, reflected by a low placental growth factor (PlGF) to soluble fms-like tyrosine kinase-1 (sFlt-1) ratio, in women with eclampsia differed from that of women with severe preeclampsia; and (2) the prevalence of women who had an abnormal angiogenic profile at the diagnoses of preterm and term eclampsia.

METHODS

A cross-sectional study was conducted to include women in the following groups: (1) uncomplicated pregnancy (n=40); (2) severe preeclampsia (n=50); and (3) eclampsia (n=35). Maternal serum concentrations of PlGF and sFlt-1 were determined by immunoassays.

RESULTS

Women with preterm, but not term, eclampsia had a more severe anti-angiogenic state than those with severe preeclampsia (lower PlGF and PlGF/sFlt-1 ratio, each p<0.05). However, the difference diminished in magnitude with increasing gestational age (interaction, p=0.005). An abnormal angiogenic profile was present in 95% (19/20) of women with preterm eclampsia but in only 67% (10/15) of women with eclampsia at term.

CONCLUSIONS

Angiogenic biomarkers can be used for risk assessment of preterm eclampsia. By contrast, a normal profile of angiogenic biomarkers cannot reliably exclude patients at risk for eclampsia at term. This observation has major clinical implications given that angiogenic biomarkers are frequently used in the triage area as a test to rule out preeclampsia.

Lipid Nanoparticle Composition Drives mRNA Delivery to the Placenta

Ionizable lipid nanoparticles (LNPs) have gained attention as mRNA delivery platforms for vaccination against COVID-19 and for protein replacement therapies. LNPs enhance mRNA stability, circulation time, cellular uptake, and preferential delivery to specific tissues compared to mRNA with no carrier platform. However, LNPs have yet to be developed for safe and effective mRNA delivery to the placenta as a method to treat placental dysfunction. Here, we develop LNPs that enable high levels of mRNA delivery to trophoblasts in vitro and to the placenta in vivo with no toxicity. We conducted a Design of Experiments to explore how LNP composition, including the type and molar ratio of each lipid component, drives trophoblast and placental delivery. Our data revealed that a specific combination of ionizable lipid and phospholipid in the LNP design yields high transfection efficiency in vitro . Further, we present one LNP platform that exhibits highest delivery of placental growth factor mRNA to the placenta in pregnant mice, which demonstrates induced protein synthesis and secretion of a therapeutic protein. Lastly, our high-performing LNPs have no toxicity to both the pregnant mice and fetuses. Our results demonstrate the feasibility of LNPs as a platform for mRNA delivery to the placenta. Our top LNPs may provide a therapeutic platform to treat diseases that originate from placental dysfunction during pregnancy.

Refeeding Syndrome With Hyperemesis Gravidarum: A Case Report

Refeeding syndrome refers to a clinical condition whereby biochemical abnormalities such as hypokalemia, hypomagnesemia, and mainly hypophosphatemia occur upon recommencement of feeding, typically in malnourished catabolic patients. A 36-year-old female presented at 30 weeks gestation with hyperemesis gravidarum. During this admission, the patient developed transaminitis with low platelets prompting suspicion of hemolysis, elevated liver enzymes low platelets (HELLP) syndrome, but the concurrent findings of severe hypophosphatemia and rhabdomyolysis were not in favor of HELLP syndrome but that of refeeding syndrome. These clinical entities proved to be a diagnostic dilemma but, ultimately, the patient was managed under refeeding syndrome. The multidisciplinary approach amongst gastroenterology, internal medicine, obstetrics, hematology, and dietetics departments led to the slowing up of the titration of caloric feeds, which ultimately led to full recovery.

Maternal and foetal outcomes following natural vaginal versus caesarean section (c-section) delivery in women with bleeding disorders and carriers

BACKGROUND

Bleeding disorders are uncommon but may pose significant bleeding complications during pregnancy, labour and following delivery for both the woman and the foetus. While many bleeding disorders in women tend to improve in pregnancy, thus decreasing the haemorrhagic risk to the mother at the time of delivery, some do not correct or return quite quickly to their pre-pregnancy levels in the postpartum period. Therefore, specific measures to prevent maternal bleeding and foetal complications during childbirth, are required. The safest method of delivery to reduce morbidity and mortality in these women is controversial. This is an update of a previously published review.

OBJECTIVES

To assess the optimal mode of delivery in women with, or carriers of, bleeding disorders.

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Coagulopathies Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the Cochrane Pregnancy and Childbirth Group's Trials Register as well as trials registries and the reference lists of relevant articles and reviews. Date of last search of the Group's Trials Registers: 21 June 2021.

SELECTION CRITERIA

Randomised controlled trials and quasi-randomised controlled clinical trials investigating the optimal mode of delivery in women with, or carriers of, any type of bleeding disorder during pregnancy were eligible for the review.

DATA COLLECTION AND ANALYSIS

No trials matching the selection criteria were eligible for inclusion.

MAIN RESULTS

No trials matching the selection criteria were eligible for inclusion.

AUTHORS' CONCLUSIONS

The review did not identify any randomised controlled trials investigating the safest mode of delivery and associated maternal and foetal complications during delivery in women with, or carriers of, a bleeding disorder. In the absence of high quality evidence, clinicians need to use their clinical judgement and lower level evidence (e.g. from observational trials, case studies) to decide upon the optimal mode of delivery to ensure the safety of both mother and foetus. Given the ethical considerations, the rarity of the disorders and the low incidence of both maternal and foetal complications, future randomised controlled trials to find the optimal mode of delivery in this population are unlikely to be carried out. Other high quality controlled studies (such as risk allocation designs, sequential design, and parallel cohort design) are needed to investigate the risks and benefits of natural vaginal and caesarean section in this population or extrapolation from other clinical conditions that incur a haemorrhagic risk to the baby, such as platelet alloimmunisation.

Physiological characterization of an arginine vasopressin rat model of preeclampsia

Rodent models have contributed greatly to our understanding of preeclampsia (PE) progression in humans, however to-date no model has been able to effectively replicate the clinical presentation of the disease. This study aimed to provide a thorough physiological characterization of the arginine vasopressin (AVP)-induced rat model of PE to determine its applicability in studying the pathophysiology of PE. Female Sprague Dawley rats (n = 24) were separated into four groups (n = 6 per group) viz., pregnant AVP, pregnant saline, non-pregnant AVP, and non-pregnant saline. All animals received a continuous dose of either AVP (150 ng/h) or saline via subcutaneous mini osmotic pumps for 18 days. Full physiological characterization of the model included measuring systolic and diastolic blood pressure, and collecting urine and blood samples for biochemical analysis. AVP infusion significantly increased blood pressure and urinary protein levels in the pregnant rats (p < 0.05). Biochemical markers measured, differed significantly in the AVP-treated vs the pregnant saline groups (p < 0.05). Placental and individual pup weight decreased significantly in the pregnant AVP vs pregnant saline group (p < 0.05). The physiological and hematological data confirm the usefulness of this rat model in the study of PE, since AVP-induced vasoconstriction increases peripheral resistance and successfully mimics the pathological changes associated with PE development in humans.Abbreviations: PE: preeclampsia; AVP: arginine vasopressin; ISSHP: International Society for the Study of Hypertension in Pregnancy; ACOG: American College of Obstetricians and Gynecologists; RUPP: reduced uterine perfusion pressure; sFlt-1: soluble fms-like tyrosine kinase; VEGF: vascular endothelial growth factor; PlGF: placental growth factor; AVP: arginine vasopressin; PAVP: pregnant AVP-treated; PS: pregnant saline; GD: gestational day; ALT: alanine transaminase; NAVP: non-pregnant AVP-treated; NS: non-pregnant saline; AST: aspartate aminotransferase; HDL: high-density lipoprotein; RBC: red blood cell; RAAS: renin-angiotensin aldosterone system; HELLP: hemolysis, elevated liver enzymes, low platelet.

Hypertensive Disorders of Pregnancy

Preeclampsia is a hypertensive disorder of pregnancy that is a leading cause of maternal and perinatal morbidity and mortality. The condition presents heterogeneously at varying gestational ages. Primary prevention for preeclampsia with low-dose aspirin is recommended for patients with clinical risk factors. Despite extensive research, there is no clearly defined pathophysiology for preeclampsia or treatment for preeclampsia besides delivery of the placenta. Delivery of patients with preeclampsia without severe features is indicated in the early term period at 37 weeks' gestation and sooner if the patient develops severe preeclampsia. Management of preterm preeclampsia is guided by close assessment of the status of the pregnant woman and fetus, blood pressure control, and surveillance for any clinical progression to a more severe form of preeclampsia that may require preterm delivery. In a preterm gestation affected by preeclampsia, expectant management is intended to provide neonatal benefit though it does assume some maternal risk. Future research will hopefully further delineate the pathophysiology of the condition with the ultimate goal of finding a treatment to avoid associated morbidity and preterm delivery.

Preeclampsia: The Need for a Biological Definition and Diagnosis

The centuries-old approach to the prevention of eclampsia and its associated maternal morbidity and mortality is based on the recognition of the presence of premonitory signs and symptoms such as hypertension and proteinuria. The spectrum of preceding signs and symptoms came to be known as preeclampsia, which is debatably considered to be an early stage on a clinical continuum possibly leading to eclampsia. The premonitory signs and symptoms were then construed as diagnostic criteria for the poorly understood syndrome of preeclampsia, and this led to a perpetual debate that remains subject to wide disagreement and periodic updates. In this commentary, we will draw attention to the fact that the criteria for preeclampsia should be viewed from the prism of a screening test rather than as diagnostic of a condition in itself. Focusing research on developing better diagnostic and screening methods for what is clinically important, namely maternal and perinatal morbidity and mortality from hypertensive disorders of pregnancy, a long overdue upgrade from what was possible centuries ago, will ultimately lead to better management approaches to what really matters.

Multiple Gestations and Hypertensive Disorders of Pregnancy: What Do We Know?

PURPOSE OF REVIEW

The occurrence of hypertensive disorders of pregnancy (HDP) including gestational hypertension, chronic hypertension, preeclampsia, and eclampsia is proportional to the number of fetuses: singletons 6.5%, twins 12.7%, and triplets 20.0%. Literature on HDP in multifetal gestation is sparse compared with singletons. We aim to summarize the current evidence on HDP, specifically in twins.

RECENT FINDINGS

HDP occurs more frequently, at an earlier gestational age, and can present more severely and atypically in twin pregnancies. HDP in twins carries a higher risk of maternal/fetal morbidity and mortality including renal failure, stroke, cardiac arrest, pulmonary edema, placental abruption, cesarean delivery, fetal growth restriction, and iatrogenic preterm delivery. Low-dose aspirin (60-150 mg) should be initiated in all multifetal pregnancies to reduce the risk of preeclampsia. To improve outcomes and reduce inherent risks associated with multiple gestations, twins should be managed as high-risk pregnancies, and different from singletons.

Hypertensive Disorders: Prevalence, Perinatal Outcomes and Cesarean Section Rates in Pregnant Women Hospitalized for Delivery

OBJECTIVE

 To evaluate the prevalence of hypertensive disorders, perinatal outcomes (preterm infants, low birthweight infants and Apgar score < 7 at the 5th minute and fetal deaths) and the cesarean rates in pregnant women hospitalized for delivery at the Maternidade Hilda Brandão da Santa Casa de Belo Horizonte, Belo Horizonte, state of Minas Gerais, Brazil, from March 1, 2008 to February 28, 2018.

METHODS

 A case-control study was performed, and the groups selected for comparison were those of pregnant women with and without hypertensive disorders. Out of the 36,724 women, 4,464 were diagnosed with hypertensive disorders and 32,260 did not present hypertensive disorders RESULTS:  The prevalence of hypertensive disorders was 12.16%; the perinatal outcomes and cesarean rates between the 2 groups with and without hypertensive disorders were: preterm infants (21.70% versus 9.66%, odds ratio [OR] 2.59, 95% confidence interval [CI], 2.40-2.80, p < 0.001); low birthweight infants (24.48% versus 10.56%; OR 2.75; 95% CI, 2.55-2.96; p < 0.001); Apgar score < 7 at the 5th minute (1.40% versus 1.10%; OR 1.27; 95% CI, 0.97-1.67; p = 0.84); dead fetuses diagnosed prior to delivery (1.90% versus 0.91%; OR 2.12; 95% CI, 1.67-2.70; p < 0.001); cesarean rates (60.22% versus 31.21%; OR 3.34; 95% CI, 3.14-3.55; p < 0.001).

CONCLUSION

 Hypertensive disorders are associated with higher rates of cesarean deliveries and higher risk of preterm infants, low birthweight infants and a higher risk of fetal deaths.

Prenatal Plasma Fibrinogen Level Predicts Postpartum Hemorrhage of Patients With HELLP Syndrome

Hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome is a serious complication of pregnancy. Postpartum hemorrhage indicates poor prognosis of pregnant women with HELLP syndrome. The aim of our study is to investigate the predictive value of coagulation markers for postpartum hemorrhage of pregnant women with HELLP syndrome. In a retrospective cohort study, 106 patients who were diagnosed as pregnant women with HELLP syndrome in Peking University Third Hospital from August 2010 to January 2017 were analyzed. The demographic characters of maternal and fetus, days of hospital stay, postpartum complications, and the laboratory tests of coagulation markers within 3 days before delivery were collected. In addition, 100 healthy pregnant women were collected as a control group. The result showed that the incidence of preeclampsia in pregnant women with postpartum hemorrhage was higher than that in pregnant women without hemorrhage (P = .011). The level of fibrinogen (FIB) in postpartum hemorrhage pregnant women with HELLP syndrome was lower than that in nonpostpartum hemorrhage pregnant women with HELLP syndrome and healthy pregnant women (2.3 [1.68-2.81] vs 3.64 ± 0.95, P = .000; 2.3 [1.68-2.81] vs 4.48 ± 0.62, P = .000). Multivariate analysis showed that decreased FIB levels independently predicted the postpartum hemorrhage of pregnant women with HELLP syndrome (odds ratio = 7.374, 95% confidence interval [CI], 1.551-35.05, P = .012). The receiver operating characteristic curve showed that the area under the curve of FIB level when predicting postpartum hemorrhage is 0.841 (95% CI, 0.708-0.976). When the cutoff value of FIB was 3.04 g/L, the sensitivity was 90.90% and the specificity was75.80%. Therefore, the low level of prenatal FIB is a reliable biomarker to predict postpartum hemorrhage of pregnant women with HELLP syndrome, which make it useful for pregnant women with HELLP syndrome in guiding surveillance therapy and prognosis assessment.

Proteomic identification of Placental Protein 1 (PP1), PP8, and PP22 and characterization of their placental expression in healthy pregnancies and in preeclampsia

INTRODUCTION

Placental Protein 1 (PP1), PP8, and PP22 were isolated from the placenta. Herein, we aimed to identify PP1, PP8, and PP22 proteins and their placental and trophoblastic expression patterns to reveal potential involvement in pregnancy complications.

METHODS

We analyzed PP1, PP8, and PP22 proteins with LC-MS. We compared the placental behaviors of PP1, PP8, and PP22 to the predominantly placenta-expressed PP5/TFPI-2. Placenta-specificity scores were generated from microarray data. Trophoblasts were isolated from healthy placentas and differentiated; total RNA was isolated and subjected to microarray analysis. We assigned the placentas to the following groups: preterm controls, early-onset preeclampsia, early-onset preeclampsia with HELLP syndrome, term controls, and late-onset preeclampsia. After histopathologic examination, placentas were used for tissue microarray construction, immunostaining with anti-PP1, anti-PP5, anti-PP8, or anti-PP22 antibodies, and immunoscoring.

RESULTS

PP1, PP8, and PP22 were identified as 'nicotinate-nucleotide pyrophosphorylase', 'serpin B6', and 'protein disulfide-isomerase', respectively. Genes encoding PP1, PP8, and PP22 are not predominantly placenta-expressed, in contrast with PP5. PP1, PP8, and PP22 mRNA expression levels did not increase during trophoblast differentiation, in contrast with PP5. PP1, PP8, and PP22 immunostaining were detected primarily in trophoblasts, while PP5 expression was restricted to the syncytiotrophoblast. The PP1 immunoscore was higher in late-onset preeclampsia, while the PP5 immunoscore was higher in early-onset preeclampsia.

DISCUSSION

PP1, PP8, and PP22 are expressed primarily in trophoblasts but do not have trophoblast-specific regulation or functions. The distinct dysregulation of PP1 and PP5 expression in either late-onset or early-onset preeclampsia reflects different pathophysiological pathways in these preeclampsia subsets.

Impact of obesity on the prognosis of hypertensive disorders in pregnancy

The prevalence of pathologies due to placental dysfunction superimposed on pregnancy is constantly increasing. The prognosis of the cases complicated by gestational hypertension is usually good, significantly better compared with that of the cases associating preeclampsia. About half of the cases with gestational hypertension will progress to preeclampsia, the risk of decompensation being inversely proportional to the gestational age of the onset of gestational hypertension. The present study, analyzed the cases of pregnancy and postpartum complicated by pathologies related to placental dysfunction, during a period of 5 years. The risk factors analyzed were the presence of infections during pregnancy, diabetes, thrombophilia, pregnancy obtained by in vitro fertilization, abnormal adherence of the placenta, obesity, multiple pregnancy, the presence of an earlier hepatic, endocrine, renal, cardiac or autoimmune pathology, and the existence of an uterine malformation. Obesity appears with a significantly increased incidence in patients with gestational hypertension and middle preeclampsia. Intrauterine growth restriction appears with a significantly increased incidence in patients with mild preeclampsia. Complications such as prematurity, acute fetal distress and abruption of placentae had a significantly increased incidence in patients with severe preeclampsia. Thus, obese patients have a higher risk of moderate preeclampsia, following gestational hypertension and finally severe preeclampsia.

Clinical characteristics and pregnancy outcomes of atypical hemolysis, elevated liver enzymes, and low platelets syndrome: A case series

RATIONALE

Hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome is a serious and rare disease, which is secondary to preeclampsia in most cases. Hypertension is usually considered as a premonitory symptom of HELLP syndrome. In some patients with HELLP syndrome; however, they develop hypertension very late, even after liver enzymes are elevated or platelet count is decreased. This condition is known as atypical HELLP syndrome.

PATIENT CONCERNS

We screened and identified 4 cases of atypical HELLP syndrome in our hospital database from January 2007 to December 2018. All patients had a history of nonspecific symptoms for a few days before hospital admission, such as dizziness, nausea, and vomiting. They developed hypertension after abnormalities were noted in liver enzymes and platelet count.

DIAGNOSES

They were diagnosed with atypical HELLP syndrome.

INTERVENTIONS

These patients received same treatments as those with HELLP syndrome. Two patients took oral antihypertensive treatment to normalize the blood pressure.

OUTCOMES

In our patients, both mothers and neonates had favorable outcomes. In follow-ups, they reported no incidences of high blood pressure after recovery from atypical HELLP syndrome.

LESSONS

These cases provided additional clinical evidences of atypical HELLP syndrome. The incidence of atypical HELLP syndrome is extremely low. Hypertension is not essential for the diagnosis of HELLP syndrome, and can even appear after the onset of laboratory abnormalities. Advanced age, multiple pregnancies, hepatitis B virus infection, and obesity may be potential risk factors for atypical HELLP syndrome. Blood pressure should be monitored closely after delivery.

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.

ACOG Practice Bulletin No. 202: Gestational Hypertension and Preeclampsia

Hypertensive disorders of pregnancy constitute one of the leading causes of maternal and perinatal mortality worldwide. It has been estimated that preeclampsia complicates 2-8% of pregnancies globally (). In Latin America and the Caribbean, hypertensive disorders are responsible for almost 26% of maternal deaths, whereas in Africa and Asia they contribute to 9% of deaths. Although maternal mortality is much lower in high-income countries than in developing countries, 16% of maternal deaths can be attributed to hypertensive disorders (). In the United States, the rate of preeclampsia increased by 25% between 1987 and 2004 (). Moreover, in comparison with women giving birth in 1980, those giving birth in 2003 were at 6.7-fold increased risk of severe preeclampsia (). This complication is costly: one study reported that in 2012 in the United States, the estimated cost of preeclampsia within the first 12 months of delivery was $2.18 billion ($1.03 billion for women and $1.15 billion for infants), which was disproportionately borne by premature births (). This Practice Bulletin will provide guidelines for the diagnosis and management of gestational hypertension and preeclampsia.

Proteomic identification of membrane-associated placental protein 4 (MP4) as perlecan and characterization of its placental expression in normal and pathologic pregnancies

Background

More than 50 human placental proteins were isolated and physico-chemically characterized in the 70–80s by Hans Bohn and co-workers. Many of these proteins turned to have important role in placental functions and diagnostic significance in pregnancy complications. Among these proteins was membrane-associated placental protein 4 (MP4), for which identity or function has not been identified yet. Our aim was to analyze the sequence and placental expression of this protein in normal and complicated pregnancies including miscarriage, preeclampsia and HELLP syndrome.

Methods

Lyophilized MP4 protein and frozen healthy placental tissue were analyzed using HPLC-MS/MS. Placental tissue samples were obtained from women with elective termination of pregnancy (first trimester controls, n = 31), early pregnancy loss (EPL) (n = 13), early preeclampsia without HELLP syndrome (n = 7) and with HELLP syndrome (n = 8), late preeclampsia (n = 8), third trimester early controls (n = 5) and third trimester late controls (n = 9). Tissue microarrays were constructed from paraffin-embedded placentas (n = 81). Slides were immunostained with monoclonal perlecan antibody and evaluated using light microscopy and virtual microscopy. Perlecan was also analyzed for its expression in placentas from normal pregnancies using microarray data.

Results

Mass spectrometry-based proteomics of MP4 resulted in the identification of basement membrane-specific heparan sulfate proteoglycan core protein also known as perlecan. Immunohistochemistry showed cytoplasmic perlecan localization in syncytiotrophoblast and cytotrophoblasts of the villi. Perlecan immunoscore decreased with gestational age in the placenta. Perlecan immunoscores were higher in EPL compared to controls. Perlecan immunoscores were higher in early preeclampsia without and with HELLP syndrome and lower in late preeclampsia than in respective controls. Among patients with preeclampsia, placental perlecan expression positively correlated with maternal vascular malperfusion and negatively correlated with placental weight.

Conclusion

Our findings suggest that an increased placental perlecan expression may be associated with hypoxic ischaemic injury of the placenta in miscarriages and in early preeclampsia with or without HELLP syndrome.

The burden of hypertensive disorders of pregnancy in Africa: A systematic review and meta-analysis

Hypertensive disorders of pregnancy (HDP) are a major contributor to maternal and perinatal morbidity and mortality, especially in resource-limited settings. Little is known about the magnitude of HDP in Africa. We conducted the first systematic review and meta-analysis to summarize available data on the prevalence of HDP in Africa. We did a comprehensive literature search to identify review paper published from January 1, 1996, to September 30, 2017, and searched the reference list of retrieved review paper. We used a random-effects model to estimate the overall and type-specific prevalence of HDP in Africa. We included 82 studies published between 1997 and 2017 reporting data on a pooled sample of 854 304 women during pregnancy or puerperium. Most studies were hospital-based, conducted in urban settings across 24 countries. In this population, the overall prevalence of HDP was 100.4‰ (95% CI: 81.4-121.2). The prevalence was 49.8‰ (95% CI: 32.3-70.7) for gestational hypertension, 14.7‰ (95% CI: 11.6-18.2) for chronic hypertension, 9.2‰ (95% CI: 4.2-16.0) for superimposed preeclampsia, 44.0‰ (95% CI: 36.7-52.0) for preeclampsia, 22.1‰ (95% CI: 14.8-30.8) for severe preeclampsia, 14.7‰ (95% CI: 8.1-23.2) for eclampsia and 2.2‰ (95% CI: 1.2-3.4) for HELLP syndrome. Prevalence of HDP was significantly higher in Central and Western Africa; there was a consistent tendency of increasing HDP prevalence with income at the country level. In conclusion, the burden of HDP in Africa is high, with about one in 10 pregnancies affected. The higher rate of severe forms of HDP that are associated with significant maternal and perinatal mortality is a major concern in the region.

Preeclampsia and HELLP syndrome, the role of the liver

Preeclampsia is a multisystemic disorder which accounts for the high prevalence of maternal and perinatal morbidity and mortality, especially in middle and low-income countries. Currently, the primary intervention is the urgent delivery of the fetus, hence it would be advantageous to identify those who are likely to develop preeclampsia and the maternal and fetal outcomes. However, an array of risk factors makes these challenging. This review explores the potentials of liver biomarkers in predicting the occurrence and outcome of preeclampsia, which could be beneficial in reducing the burden of the disease. Liver dysfunction in preeclampsia results in a severe condition, hence liver function tests are specific predictors of outcome.

Increased placental expression of Placental Protein 5 (PP5) / Tissue Factor Pathway Inhibitor-2 (TFPI-2) in women with preeclampsia and HELLP syndrome: Relevance to impaired trophoblast invasion?

INTRODUCTION

Placental Protein 5 (PP5)/Tissue Factor Pathway Inhibitor-2 (TFPI-2) is an extracellular matrix-associated protein mainly expressed by the syncytiotrophoblast that may regulate trophoblast invasion. Our aim was to study placental PP5/TFPI-2 expression and its relation to placental pathology in various forms of preeclampsia and HELLP syndrome.

METHODS

Placental and maternal blood specimens were collected at the time of delivery from the same women in the following groups: 1) early controls; 2) early preeclampsia; 3) early preeclampsia with HELLP syndrome; 4) late controls; and 5) late preeclampsia. After histopathological examination, placental specimens were immunostained with polyclonal anti-PP5/TFPI-2 antibody on Western blot and tissue microarray immunohistochemistry. Placental PP5/TFPI-2 immunoscores were assessed manually and with a semi-automated method. Maternal sera were immunoassayed for PP5/TFPI-2.

RESULTS

PP5/TFPI-2 was localized to the cytoplasm of syncytiotrophoblast. Manual and semi-automated PP5/TFPI-2 immunoscores were higher in early preeclampsia with or without HELLP syndrome but not in late preeclampsia than in respective controls. In patients with preeclampsia, the correlation of placental PP5/TFPI-2 expression with maternal vascular malperfusion score of the placenta was positive while it was negative with birthweight and placental weight. Maternal serum PP5/TFPI-2 concentration was higher in early preeclampsia and it tended to be higher in early preeclampsia with HELLP syndrome than in early controls.

DISCUSSION

Our findings suggest that an increased placental PP5/TFPI-2 expression may be associated with abnormal placentation in early preeclampsia, with or without HELLP syndrome.

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).

Preeclampsia and risk of developing bronchopulmonary dysplasia in very preterm neonates

OBJECTIVE

Bronchopulmonary dysplasia (BPD) is a severe common complication of preterm birth with considerable short and long-term consequences. As more evidence is emerging that dysregulation of angiogenesis is implicated in the pathogenesis of preeclampsia as well as in fetal lung development, we assessed if preeclampsia is associated with development of BPD in very preterm neonates.

STUDY DESIGN

A retrospective cohort study of 308 infants born between 24⁺⁰ and 31⁺⁶ weeks of gestation in 2011 and 2012. We performed association analysis with univariable and multivariable logistic regression, adjusting for confounders. Models were additionally adjusted for intermediates, to show how an association can be disguised by over adjusting.

MAIN OUTCOME MEASURE

BPD was diagnosed at 36⁺⁰ weeks postmenstrual age and defined as the need for oxygen (FiO2 > 0.21) for at least 12 h per day, for more than 28 days before or at 36⁺⁰ weeks postmenstrual age, and classified as mild, moderate or severe.

RESULTS

After applying our exclusion criteria, we report our primary outcome on 247 mother-neonate pairs. Fifty-nine neonates developed BPD (23.9%) which was moderate to severe in 27 of them (10.9%). Preeclampsia was associated with BPD, adjusted odds ratio, 95% confidence interval: 4.22 (1.63, 10.91). However, after adjusting for additional intermediates no statistical significance remained, adjusted odds ratio, 95% confidence interval: 1.87 (0.49, 7.24).

CONCLUSION

This study shows that early-onset preeclampsia is associated with development of BPD in the very preterm neonate. Part of this association is mediated by fetal growth restriction and mode of delivery.

Maternal and foetal outcomes following natural vaginal versus caesarean section (c-section) delivery in women with bleeding disorders and carriers

BACKGROUND

Bleeding disorders are uncommon but may pose significant bleeding complications during pregnancy, labour and following delivery for both the woman and the foetus. While many bleeding disorders in women tend to improve in pregnancy, thus decreasing the haemorrhagic risk to the mother at the time of delivery, some do not correct or return quite quickly to their pre-pregnancy levels in the postpartum period. Therefore, specific measures to prevent maternal bleeding and foetal complications during childbirth, are required. The safest method of delivery to reduce morbidity and mortality in these women is controversial. This is an update of a previously published review.

OBJECTIVES

To assess the optimal mode of delivery in women with, or carriers of, bleeding disorders.

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Coagulopathies Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the Cochrane Pregnancy and Childbirth Group's Trials Register as well as trials registries and the reference lists of relevant articles and reviews.Date of last search of the Group's Trials Registers: 16 February 2017.

SELECTION CRITERIA

Randomised controlled trials and all types of controlled clinical trials investigating the optimal mode of delivery in women with, or carriers of, any type of bleeding disorder during pregnancy were eligible for the review.

DATA COLLECTION AND ANALYSIS

No trials matching the selection criteria were eligible for inclusion MAIN RESULTS: No results from randomised controlled trials were found.

AUTHORS' CONCLUSIONS

The review did not identify any randomised controlled trials investigating the safest mode of delivery and associated maternal and foetal complications during delivery in women with, or carriers of, a bleeding disorder. In the absence of high quality evidence, clinicians need to use their clinical judgement and lower level evidence (e.g. from observational trials, case studies) to decide upon the optimal mode of delivery to ensure the safety of both mother and foetus.Given the ethical considerations, the rarity of the disorders and the low incidence of both maternal and foetal complications, future randomised controlled trials to find the optimal mode of delivery in this population are unlikely to be carried out. Other high quality controlled studies (such as risk allocation designs, sequential design, and parallel cohort design) are needed to investigate the risks and benefits of natural vaginal and caesarean section in this population or extrapolation from other clinical conditions that incur a haemorrhagic risk to the baby, such as platelet alloimmunisation.

Life-threatening bleeding from gastric dieulafoy's lesion in a pregnant woman with hellp syndrome: a case report and literature review

BACKGROUND

Dieulafoy's lesion (DL) is one of the rare causes of upper gastrointestional bleeding. This disease is characterized by small sub-mucosal arteriole that eroded the stomach mucosa and cause severe upper GI bleeding without obvious ulceration. The most common location is fundus area of stomach and usually affects patients over 50 years of age with multiple comorbidities.

CASE PRESENTATION

We report a case of life-threatening bleeding from DL during late pregnancy 31 weeks. Hemoclips were used twice through upper endoscopy with successful hemostasis. Unfortunately, she developed HELLP syndrome diagnosed 5 days after the GI bleeding was stopped. Her pregnancy had to be terminated with delivery of a premature infant. She recovered from her illness and discharged from hospital uneventfully. There is no current report in literature of DL in pregnant woman subsequently suffered HELLP syndrome.

CONCLUSION

Endoscopic hemoclip application is an effective technique in the treatment of upper GI bleeding from DL. For this patient, laparoscopic surgery or combination therapy before pregnancy may have been a suitable treatment on preventing rebleeding.

Plasma Malondialdehyde (MDA): An Indication of Liver Damage in Women with Pre-Eclamsia

BACKGROUND

One of the features associated with pre-eclampsia is elevated liver transaminases. The reason this happens has not been fully described. However, the hepatocytes are not known to be spared by free radical injury. This study was conducted to examine the relationship between product of free radical injury (malondialdehyde) and transaminases in pre-eclamptic women.

PATIENTS AND METHODS

A total of 98 and 115 pre-eclamptic and apparently normal pregnant women were selected from the booking clinic of Ladoke Akintola University of Technology Teaching Hospital, Osogbo. Non-pregnant women were selected from volunteered members of staff. Malondialdehyde (MDA), aspartate transaminase (AST) and alanine transaminase (ALT) analyses were determined on collected venous blood sample. Statistical analyses of variables were done using SPSS 17 taking level of significance to be p<0.05.

RESULTS

Subjects with plasma AST between 10 and 20U/L had mean plasma MDA of 0.92µmol/l whereas those with plasma levels greater than 41U/L had mean plasma MDA of 4.72µmol/l. Similarly, Subjects with plasma ALT between 10 and 20U/L had mean plasma MDA of 0.86µmol/l, and subjects with plasma ALT greater than 51 U/L had mean plasma MDA of 4.71µmol/l. Positive correlation was observed between AST and ALT(r=0.79; p=0.047), between AST and MDA(r=0.690; p=0.061) as well as between ALT and MDA(r=0.571; p=0.049).

CONCLUSION

The elevated liver enzymes seen in women with pre-eclampsia may be due to free radical injury to the liver. Pre-eclamptic women without free radical injury did not have elevated transaminases.

Prognostic Factors of the Efficacy of High-dose Corticosteroid Therapy in Hemolysis, Elevated Liver Enzymes, and Low Platelet Count Syndrome During Pregnancy: A Meta-analysis

The aim of this study was to identify the factors which can affect the efficacy of corticosteroid (CORT) therapy in the management of hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. Research articles reporting the efficacy of CORT therapy to HELLP syndrome patients were searched in several electronic databases including EMBASE, Google Scholar, Ovid SP, PubMed, and Web of Science. Study selection was based on predefined eligibility criteria. Efficacy was defined by the changes from baseline in HELLP syndrome indicators after CORT therapy. Meta-analyses were carried out with Stata software. Data of 778 CORT-treated HELLP syndrome patients recruited in 22 studies were used in the analyses. Corticosteroid treatment to HELLP syndrome patients was associated with significant changes from baseline in platelet count; serum levels of aspartate aminotransaminase, alanine transaminase, and lactic dehydrogenase (LDH); mean blood pressure; and urinary output. Lower baseline platelet count predicted higher change in platelet count after CORT therapy. Lower baseline platelet count and lower baseline urinary output predicted greater changes in LDH levels after CORT therapy. There was also an inverse relationship between the change from baseline in LDH levels and intensive care duration. Higher CORT doses were associated with greater declines in the aspartate aminotransaminase, alanine transaminase, and LDH levels. Incidence of cesarean delivery was inversely associated with the gestation age. The percentage of nulliparous women had a positive association with the intensive care stay duration. High-dose CORT therapy to HELLP syndrome patients provides benefits in improving disease markers and reducing intensive care duration, especially in cases such as mothers with much lower baseline platelet count and LDH levels.

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.

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.

Management of Spontaneous Hepatic Rupture on Top of HELLP Syndrome: Case Report and Review of the Literature

Introduction

We report the case of a patient with antepartum HELLP syndrome and simultaneous rupture of the right liver lobe. An emergency caesarean section was performed and the liver rupture was managed surgically via perihepatic packing. The mother and her child recovered well and were discharged 19 days after admission.

Case Report

We describe a case report and review the literature. Based on our own experience and the most common clinical presentations of such patients, we were able to establish an algorithm for managing such cases.

Conclusion

An association between liver rupture and HELLP syndrome is rare but was previously described in several case reports. In pregnant women with HELLP syndrome and acute onset abdominal pain, a potential spontaneous hepatic rupture should be taken into consideration.

Advances in understanding and treating liver diseases during pregnancy: A review

Liver disease in pregnancy is rare but pregnancy-related liver diseases may cause threat to fetal and maternal survival. It includes pre-eclampsia; eclampsia; haemolysis, elevated liver enzymes, and low platelets syndrome; acute fatty liver of pregnancy; hyperemesis gravidarum; and intrahepatic cholestasis of pregnancy. Recent basic researches have shown the various etiologies involved in this disease entity. With these advances, rapid diagnosis is essential for severe cases since the decision of immediate delivery is important for maternal and fetal survival. The other therapeutic options have also been shown in recent reports based on the clinical trials and cooperation and information sharing between hepatologist and gynecologist is important for timely therapeutic intervention. Therefore, correct understandings of diseases and differential diagnosis from the pre-existing and co-incidental liver diseases during the pregnancy will help to achieve better prognosis. Therefore, here we review and summarized recent advances in understanding the etiologies, clinical courses and management of liver disease in pregnancy. This information will contribute to physicians for diagnosis of disease and optimum management of patients.

Full-length human placental sFlt-1-e15a isoform induces distinct maternal phenotypes of preeclampsia in mice

OBJECTIVE

Most anti-angiogenic preeclampsia models in rodents utilized the overexpression of a truncated soluble fms-like tyrosine kinase-1 (sFlt-1) not expressed in any species. Other limitations of mouse preeclampsia models included stressful blood pressure measurements and the lack of postpartum monitoring. We aimed to 1) develop a mouse model of preeclampsia by administering the most abundant human placental sFlt-1 isoform (hsFlt-1-e15a) in preeclampsia; 2) determine blood pressures in non-stressed conditions; and 3) develop a survival surgery that enables the collection of fetuses and placentas and postpartum (PP) monitoring.

METHODS

Pregnancy status of CD-1 mice was evaluated with high-frequency ultrasound on gestational days (GD) 6 and 7. Telemetry catheters were implanted in the carotid artery on GD7, and their positions were verified by ultrasound on GD13. Mice were injected through tail-vein with adenoviruses expressing hsFlt-1-e15a (n = 11) or green fluorescent protein (GFP; n = 9) on GD8/GD11. Placentas and pups were delivered by cesarean section on GD18 allowing PP monitoring. Urine samples were collected with cystocentesis on GD6/GD7, GD13, GD18, and PPD8, and albumin/creatinine ratios were determined. GFP and hsFlt-1-e15a expression profiles were determined by qRT-PCR. Aortic ring assays were performed to assess the effect of hsFlt-1-e15a on endothelia.

RESULTS

Ultrasound predicted pregnancy on GD7 in 97% of cases. Cesarean section survival rate was 100%. Mean arterial blood pressure was higher in hsFlt-1-e15a-treated than in GFP-treated mice (∆MAP = 13.2 mmHg, p = 0.00107; GD18). Focal glomerular changes were found in hsFlt-1-e15a -treated mice, which had higher urine albumin/creatinine ratios than controls (109.3 ± 51.7 μg/mg vs. 19.3 ± 5.6 μg/mg, p = 4.4 x 10(-2); GD18). Aortic ring assays showed a 46% lesser microvessel outgrowth in hsFlt-1-e15a-treated than in GFP-treated mice (p = 1.2 x 10(-2)). Placental and fetal weights did not differ between the groups. One mouse with liver disease developed early-onset preeclampsia-like symptoms with intrauterine growth restriction (IUGR).

CONCLUSIONS

A mouse model of late-onset preeclampsia was developed with the overexpression of hsFlt-1-e15a, verifying the in vivo pathologic effects of this primate-specific, predominant placental sFlt-1 isoform. HsFlt-1-e15a induced early-onset preeclampsia-like symptoms associated with IUGR in a mouse with a liver disease. Our findings support that hsFlt-1-e15a is central to the terminal pathway of preeclampsia, and it can induce the full spectrum of symptoms in this obstetrical syndrome.

Maternal and foetal outcomes following natural vaginal versus caesarean section (c-section) delivery in women with bleeding disorders and carriers

BACKGROUND

Bleeding disorders are uncommon but may pose significant bleeding complications during pregnancy, labour and following delivery for both the woman and the foetus. While many bleeding disorders in women tend to improve in pregnancy, thus decreasing the haemorrhagic risk to the mother at the time of delivery, some do not correct or return quite quickly to their pre-pregnancy levels in the postpartum period. Therefore, specific measures to prevent maternal bleeding and foetal complications during childbirth, are required. The safest method of delivery to reduce morbidity and mortality in these women is controversial.

OBJECTIVES

To assess the optimal mode of delivery in women with, or carriers of, bleeding disorders.

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Coagulopathies Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the Cochrane Pregnancy and Childbirth Group's Trials Register as well as trials registries and the reference lists of relevant articles and reviews.Date of last search of the Group's Trials Registers: 13 January 2015.

SELECTION CRITERIA

Randomised controlled trials and all types of controlled clinical trials investigating the optimal mode of delivery in women with, or carriers of, any type of bleeding disorder during pregnancy were eligible for the review.

DATA COLLECTION AND ANALYSIS

No trials matching the selection criteria were eligible for inclusion

MAIN RESULTS

No results from randomized controlled trials were found.

AUTHORS' CONCLUSIONS

The review did not identify any randomised controlled trials investigating the safest mode of delivery and associated maternal and foetal complications during delivery in women with, or carriers of, a bleeding disorder. In the absence of high quality evidence, clinicians need to use their clinical judgement and lower level evidence (e.g. from observational trials, case studies) to decide upon the optimal mode of delivery to ensure the safety of both mother and foetus.Given the ethical considerations, the rarity of the disorders and the low incidence of both maternal and foetal complications, future randomised controlled trials to find the optimal mode of delivery in this population are unlikely to be carried out. Other high quality controlled studies (such as risk allocation designs, sequential design, and parallel cohort design) are needed to investigate the risks and benefits of natural vaginal and caesarean section in this population or extrapolation from other clinical conditions that incur a haemorrhagic risk to the baby, such as platelet alloimmunisation.