Hepatic fibrinogen deposits in pre-eclampsia. Immunofluorescent evidence

Perturbations in kinetics of the thrombin generation assay identify women at risk of preeclampsia in the first trimester and provide the rationale for a preventive approach

BACKGROUND

Activation of the coagulation system and increased thrombin generation have been implicated in the pathophysiology of preeclampsia, and this rationale supports the administration of low-molecular-weight heparin to prevent this syndrome in patients at risk. Yet, randomized trials of this prophylactic measure have yielded contradictory results. A possible explanation is that only a subset of patients with preeclampsia have excessive thrombin generation and would benefit from the administration of low-molecular-weight heparin. Therefore, the key questions are whether and when patients who subsequently develop preeclampsia present evidence of abnormal thrombin generation.

OBJECTIVE

This study aimed to determine (1) the kinetics of thrombin generation throughout gestation in women with a normal pregnancy and in those with early and late preeclampsia, and (2) the diagnostic performance of in vivo thrombin generation parameters to predict the development of preeclampsia.

STUDY DESIGN

This retrospective, nested case-control study was based on a prospective longitudinal cohort of singleton gestations. Cases comprised women who developed preeclampsia (n=49), and controls consisted of patients with a normal pregnancy (n=45). Preeclampsia was classified into early-onset (n=24) and late-onset (n=25). Longitudinal changes in the parameters of the thrombin generation assay (lag time, time to peak thrombin concentration, peak thrombin concentration, endogenous thrombin generation, and velocity index) throughout gestation were compared between the study groups, and normal pregnancy percentiles were derived from the control group. We tested whether a single parameter or a combination of parameters, derived from the kinetics of thrombin generation, could identify patients who subsequently developed preeclampsia. Time-related parameters <10th percentile were considered short, and concentration-related parameters >90th percentile were considered high.

RESULTS

(1) Patients who developed preeclampsia (early- and late-onset) had abnormal thrombin generation kinetics as early as 8 to 16 weeks of pregnancy; (2) patients with a combination of a short lag time and high peak thrombin concentration at 8 to 16 weeks of pregnancy had an odds ratio of 43.87 for the subsequent development of preeclampsia (area under the curve, 0.79; sensitivity, 56.8%; specificity, 92.7%; positive likelihood ratio, 7.76); (3) at 16 to 22 weeks of gestation, patients with a combination of a short lag time and a high velocity index had an odds ratio of 16 for the subsequent development of preeclampsia (area under the curve, 0.78; sensitivity, 62.2%; specificity, 92.5%; positive likelihood ratio, 8.29).

CONCLUSION

During early pregnancy, the thrombin generation assay can identify the subset of patients at a greater risk for the development of preeclampsia owing to accelerated and enhanced production of thrombin. This observation provides a rationale for testing the efficacy of low-molecular-weight heparin in this subset of patients. We propose that future research on the efficacy of low-molecular-weight heparin and other interventions targeting the coagulation system to prevent preeclampsia should be focused on patients with abnormal kinetics of thrombin generation.

Preeclampsia and eclampsia: the conceptual evolution of a syndrome

Preeclampsia, one of the most enigmatic complications of pregnancy, is considered a pregnancy-specific disorder caused by the placenta and cured only by delivery. This article traces the condition from its origins-once thought to be a disease of the central nervous system, recognized by the occurrence of seizures (ie, eclampsia)-to the present time when preeclampsia is conceptualized primarily as a vascular disorder. We review the epidemiologic data that led to the recommendation to use diastolic hypertension and proteinuria as diagnostic criteria, as their combined presence was associated with an increased risk of fetal death and the birth of small-for-gestational-age neonates. However, preeclampsia is a multisystemic disorder with protean manifestations, and the condition can be present even in the absence of hypertension and proteinuria. Toxins gaining access to the maternal circulation have been proposed to mediate the clinical manifestations-hence, the term "toxemia of pregnancy," which was used for several decades. The search for putative toxins has challenged investigators for more than a century, and a growing body of evidence suggests that products of an ischemic or a stressed placenta are responsible for the vascular changes that characterize this syndrome. The discovery that the placenta can produce antiangiogenic factors, which regulate endothelial cell function and induce intravascular inflammation, has been a major step forward in the understanding of preeclampsia. We view the release of antiangiogenic factors by the placenta as an adaptive response to improve uterine perfusion by modulating endothelial function and maternal cardiovascular performance. However, this homeostatic response can become maladaptive and lead to damage of target organs during pregnancy or the postpartum period. Early-onset preeclampsia has many features in common with atherosclerosis, whereas late-onset preeclampsia seems to result from a mismatch of fetal demands and maternal supply, that is, a metabolic crisis. Preeclampsia, as it is understood today, is essentially vascular dysfunction unmasked or caused by pregnancy. A subset of patients diagnosed with preeclampsia are at greater risk of the subsequent development of hypertension, ischemic heart disease, heart failure, vascular dementia, and end-stage renal disease. However, these adverse events may be the result of a preexisting vascular pathologic process; it is not known if the occurrence of preeclampsia increases the baseline risk. Therefore, the understanding, prediction, prevention, and treatment of preeclampsia are healthcare priorities.

Pathological AT1R-B2R Protein Aggregation and Preeclampsia

Preeclampsia is one of the most frequent and severe complications of pregnancy. Symptoms of preeclampsia usually occur after 20 weeks of pregnancy and include hypertension and kidney dysfunction with proteinuria. Up to now, delivery of the infant has been the most effective and life-saving treatment to alleviate symptoms of preeclampsia because a causative treatment does not exist, which could prolong a pregnancy complicated with preeclampsia. Preeclampsia is a complex medical condition, which is attributed to a variety of different risk factors and causes. Risk factors account for insufficient placentation and impaired vasculogenesis and finally culminate in this life-threatening condition of pregnancy. Despite progress, many pathomechanisms and causes of preeclampsia are still incompletely understood. In recent years, it was found that excessive protein complex formation between G-protein-coupled receptors is a common sign of preeclampsia. Specifically, the aberrant heteromerization of two vasoactive G-protein-coupled receptors (GPCRs), the angiotensin II AT1 receptor and the bradykinin B2 receptor, is a causative factor of preeclampsia symptoms. Based on this knowledge, inhibition of abnormal GPCR protein complex formation is an experimental treatment approach of preeclampsia. This review summarizes the impact of pathological GPCR protein aggregation on symptoms of preeclampsia and delineates potential new therapeutic targets.

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.

Preeclampsia Induced Liver Dysfunction Complicated by Disseminated Intravascular Coagulopathy and Placental Abruption: A Case Report and Review of the Literature

A 33-year-old primigravida at 32-week gestation was admitted to labor and delivery complaining of severe right upper quadrant pain and worsening coagulopathy. We report the anesthetic and obstetrical management of a complex case of a parturient with a mixed picture of hemolysis, elevated liver enzymes and low platelets who was delivered under general anesthesia further complicated by Disseminated Intravascular Coagulopathy (DIC) and placental abruption.

The importance of comorbidities in ischemic stroke: Impact of hypertension on the cerebral circulation

Comorbidities are a hallmark of stroke that both increase the incidence of stroke and worsen outcome. Hypertension is prevalent in the stroke population and the most important modifiable risk factor for stroke. Hypertensive disorders promote stroke through increased shear stress, endothelial dysfunction, and large artery stiffness that transmits pulsatile flow to the cerebral microcirculation. Hypertension also promotes cerebral small vessel disease through several mechanisms, including hypoperfusion, diminished autoregulatory capacity and localized increase in blood-brain barrier permeability. Preeclampsia, a hypertensive disorder of pregnancy, also increases the risk of stroke 4-5-fold compared to normal pregnancy that predisposes women to early-onset cognitive impairment. In this review, we highlight how comorbidities and concomitant disorders are not only risk factors for ischemic stroke, but alter the response to acute ischemia. We focus on hypertension as a comorbidity and its effects on the cerebral circulation that alters the pathophysiology of ischemic stroke and should be considered in guiding future therapeutic strategies.

Hepatic rupture from haematomas in patients with pre-eclampsia/eclampsia: a case series

Hepatic rupture from haematomas is a rare complication of severe preeclampsia/eclampsia especially when complicated with the haemolysis, elevated liver enzymes and low platelet count (HELLP) syndrome. It is associated with poor maternal and foetal outcomes as demonstrated by three cases we describe. The first case had eclampsia at 31 weeks gestation with features of abruptio placentae and at caesarean section we found haemoperitoneum of 1.5 litres, a 10cm liver rupture and a still birth. She subsequently died in ICU within 24 hours of surgery; the second case had eclampsia at 35 weeks and ended up as a table death during emergency caesarean section. She had 4 litres of haemoperitoneum, hepatic rupture, placental abruption and a stillbirth; the third case had pre-eclampsia at 33 weeks with markedly elevated liver enzymes. She had one litre haemoperitoneum, right lobe hepatic rupture and a stillbirth. She recovered after conservative management. Severe pre-eclampsia/eclampsia associated hepatic rupture calls for rapid and aggressive intervention with prompt multidisciplinary management to avert adverse outcomes.

Causes and Complications of Fulminant Hepatic Failure

Fulminant hepatic failure can be caused by a number of viral, metabolic, toxic, and vascular factors. Identification of the cause can lead to specific intervention in some conditions. Care of the patient with fulminant hepatic failure resulting from diverse causes requires intensive monitoring to prevent death from a variety of complications. Cerebral edema, gastrointestinal hemorrhage, sepsis, coagulopathy, and hypoglycemia are potentially catastrophic complications that must be anticipated and preempted whenever possible. Liver transplantation has emerged as a reasonable therapeutic option; survival rates in small series are approximately 50%.

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.

Liver diseases in pregnancy: Diseases unique to pregnancy

Pregnancy is a special clinical state with several normal physiological changes that influence body organs including the liver. Liver disease can cause significant morbidity and mortality in both pregnant women and their infants. This review summarizes liver diseases that are unique to pregnancy. We discuss clinical conditions that are seen only in pregnant women and involve the liver; from Hyperemesis Gravidarum that happens in 1 out of 200 pregnancies and Intrahepatic Cholestasis of Pregnancy (0.5%-1.5% prevalence), to the more frequent condition of preeclampsia (10% prevalence) and its severe form; hemolysis, elevated liver enzymes, and a low platelet count syndrome (12% of pregnancies with preeclampsia), to the rare entity of Acute Fatty Liver of Pregnancy (incidence of 1 per 7270 to 13000 deliveries). Although pathogeneses behind the development of these aliments are not fully understood, theories have been proposed. Some propose the special physiological changes that accompany pregnancy as a precipitant. Others suggest a constellation of factors including both the mother and her fetus that come together to trigger those unique conditions. Reaching a timely and accurate diagnosis of such conditions can be challenging. The timing of the condition in relation toward which trimester it starts at is a key. Accurate diagnosis can be made using specific clinical findings and blood tests. Some entities have well-defined criteria that help not only in making the diagnosis, but also in classifying the disease according to its severity. Management of these conditions range from simple medical remedies to measures such as immediate termination of the pregnancy. In specific conditions, it is prudent to have expert obstetric and medical specialists teaming up to help improve the outcomes.

Subcapsular Liver Hematoma in HELLP Syndrome: Case Report

Subcapsular liver hematoma, as a rare complication of HELLP syndrome, must be managed in a tertiary center for prompt recognition and treatment with close monitoring of hemodynamic and coagulation parameters, treatment of underlying disorders, and assessment by the imaging techniques. These patients underwent different therapeutic options varying from conservative therapy to operative management, including liver transplantation. As a choice of treatment, patients with HELLP syndrome can be followed up conservatively in stable hemodynamic conditions. In this report, we presented a 32-year-old woman with subcapsular liver hematoma secondary to HELLP syndrome managed conservatively.

Gastrointestinal complications of pre-eclampsia

Gastrointestinal complications of pre-eclampsia can occur and have the risk of being life-threatening for the mother and fetus. Hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome has been recognized as a complication of pre-eclampsia for decades. Pregnancies complicated by this syndrome require a well-formulated management plan, including assessing and stabilizing the maternal condition as well as evaluating fetal well-being. Patients with HELLP syndrome should receive anti-seizure prophylaxis with magnesium sulfate, treatment for severe hypertension, and correction of coagulopathy, if present. The potential benefits of expectant management of HELLP syndrome in those remote from term and the use of corticosteroids to improve maternal outcome remain experimental. Computed tomography or ultrasound of the abdomen should be performed if a subcapsular hematoma of the liver is suspected. If a ruptured hematoma is confirmed, massive transfusions and laparotomy are indicated. Ischemia associated with pre-eclampsia cannot only damage the liver but also the pancreas and gallbladder.

New developments in pre-eclampsia

It is quite clear that pre-eclampsia is not simply pregnancy-induced hypertension; rather, it is a multisystem disease with pathophysiological changes secondary to reduced organ perfusion. This reduction can be explained by vasospasm secondary to increased sensitivity of the vasculature to usual circulating pressors, and vascular occlusion secondary to activation of the coagulation cascade. Although pre-eclampsia becomes clinically evident late in pregnancy, pathological and pathophysiological changes antedate the clinical syndrome by weeks to months. The syndrome occurs only in pregnancy and is cured by the removal of fetoplacental tissues.

Based on these findings, we have proposed that the inciting pathophysiological change of preeclampsia is reduced trophoblastic perfusion, which produces an agent that perturbs endothelial cells. The altered endothelial functions associated with this insult increase sensitivity to pressors, activate the coagulation cascade and produce the clinical and pathological findings of preeclampsia. Although we feel this hypothesis could explain pre-eclampsia, it is possible that its major value will be to stimulate others to approach this disorder by considering all facets of its pathophysiology rather than merely its hypertensive component.

The appreciation of pre-eclampsia as a disease present from early pregnancy and the potential role of vasodilator prostaglandins have already stimulated therapeutic trials of aspirin in women at very high risk with encouraging results. At present, information is insufficient to determine the risk/benefit ratio of this therapy in lower risk patients, and aspirin therapy should not be used in these women. Another potential modification of therapy, the substitution of phenytoin for magnesium sulphate, does not seem warranted on the basis of either currently available data or on theoretical grounds.

Fruitful directions for research in the near future will be the explanation of the abnormal trophoblastic invasion of pre-eclampsia and the determination of how reduced perfusion translates into a multisystem disease. In addition, aspirin therapy or other potential prophylactic therapies would be greatly aided by the development of new tests with reasonable positive predictive values, in order to identify preeclampsia prior to clinically evident disease.

Hepatic disorders severely affected by pregnancy: medical and obstetric management

Hepatic disorders severely affected by pregnancy include choledochal cysts that can be compressed by the gravid uterus and potentially rupture; hepatic adenomas that exhibit accelerated growth because of hyperestrogenemia during pregnancy; acute intermittent porphyria that is exacerbated by increased female sex hormones during pregnancy; splenic artery aneurysms that can rupture during pregnancy because of compression by the gravid uterus; Budd-Chiari syndrome that is promoted by hyperestrogenemia; and hepatitis E and herpes simplex hepatitis that are particularly severe during pregnancy. Hepatic disorders unique to pregnancy include intrahepatic cholestasis of pregnancy; acute fatty liver of pregnancy; preeclampsia and eclampsia; and hemolysis, elevated liver function tests, and low platelet count (HELLP) syndrome. Most disorders uniquely related to pregnancy are treated by prompt fetal delivery as soon as the fetus is sufficiently mature.

Preeclampsia: a danger growing in disguise

Preeclampsia occurs in 3-14% of pregnancies and is defined by maternal hypertension with proteinurea, generally associated with edema, coagulation abnormalities, and disseminated intravascular coagulation. The conditions can lead to eclampsia, characterized by hyperreflexia and convulsions. Several organs are afflicted by the condition, most importantly the liver and kidneys. The direct cause of preeclampsia is unknown, but the initial events are linked to abnormalities of placentation. This implies abnormalities in trophoblast invasion and in physiological alterations of placental vessels required for adequate perfusion of the placenta, which leads to ischemia. The mechanisms that link the ischemic placenta to endothelial lesions and to stimulation of vasoconstrictors and inhibition of vasodilators are still subject of speculation. The only treatment of preeclampsia is delivery. Lowering of blood pressure and prevention of eclampsia with magnesium sulfate is indicated in severe preeclampsia. Despite numerous studies attempting to elucidate the exact etiopathogenesis of this complex multifactorial disease, prediction or prevention methods of preeclampsia are not available.

Thrombin activatable fibrinolysis inhibitor (TAFI): A role in pre-eclampsia?

Pre-eclampsia (P-Ec) is a complex multisystem disorder of unknown aetiology reported to occur in about 6% to 8% of all pregnancies throughout the world. This disease is associated with fibrin deposition and occlusive lesions in placental vessels. Pro-thrombin activatable fibrinolysis inhibitor (pro-TAFI) is a relatively recently described glycoprotein that can be converted into its active form (TAFIa) by thrombin, thrombin-thrombomodulin and plasmin. TAFIa potentially inhibits fibrinolysis by removing C-terminal lysine and arginine residues from fibrin. These residues are required for adsorption of tissue-type plasminogen activator (t-PA) and plasminogen to fibrin. Therefore, TAFIa decreases plasmin formation and protects the fibrin clot against lysis. An increased of pro-TAFI/TAFIa levels has been reported in some clinical conditions associated with thrombotic tendency, as type II diabetes mellitus, deep vein thrombosis and symptomatic artery disease. Few studies have investigated pro-TAFI/TAFIa in normal or complicated pregnancy but contrasting results were reported. Understanding the role of pro-TAFI/TAFIa in the pathogenesis of P-Ec can hold great promise for improving P-Ec management. In this context, a large-scale study evaluating plasma TAFI antigen and activity, its synthesis and metabolism in pre-eclamptic women is required. Recently new selective TAFIa inhibitors have been developed. The design of a new therapy to treat and/or prevent P-Ec, based on successful use of TAFIa inhibitors, may have significant clinical ramifications.

Preeclampsia: the Death of Goliath

In this review, a novel and unifying pathophysiologic mechanism of preeclampsia is presented whereby a minimal excess of placental immune complex production versus removal causes a proinflammatory autoamplification cascade of trophoblast apoptosis/necrosis and oxidative stress, culminating in clinical preeclampsia. This concept immediately leads to a plethora of new and robust therapeutic strategies.

Hepatic disease and pregnancy: An overview of diagnosis and management

OBJECTIVES

To provide a review of the current literature on hepatic disease in pregnancy, outlining the incidence, pathophysiology, diagnosis, and management of major diseases in this category.

DESIGN

A thorough review of expert analysis, case reports, and randomized clinical trials was used to assess current methods of managing the major diseases related to hepatic dysfunction in pregnancy. A review of bibliographies was also utilized.

RESULTS

Hepatic disease complicates nearly 3% of all pregnancies and is a significant cause of morbidity during the gravid state. However, several diseases, including HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets), acute fatty liver of pregnancy, acute cholestasis of pregnancy, ruptured liver hematoma, and preeclampsia, can be managed with successful outcomes for both the mother and fetus if diagnosed in early stages. Astute clinical judgment and laboratory evaluation of the patient is vital in the appropriate diagnosis of hepatic disease in pregnancy.

CONCLUSIONS

Early intervention and appropriate diagnosis can substantially reduce the morbidity and mortality associated with hepatic derangements of pregnancy.

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

Pregnancies complicated by hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome require a well-formulated management plan. The development of this syndrome after 34 weeks' gestation or with documentation of maternal or fetal compromise is an indication for delivery. Acute fatty liver of pregnancy, hemolytic uremic syndrome, and thrombotic thrombocytopenic purpura may present with signs, symptoms, and laboratory abnormalities that may be confused with HELLP syndrome. Thorough investigation is warranted because of the differences in proper management among these various complications of pregnancy. Expectant management in patients with HELLP syndrome remote from term and the use of corticosteroids to improve postpartum maternal outcome remain experimental.

Subcapsular liver hematoma in HELLP syndrome: Evaluation of diagnostic and therapeutic options--a unicenter study

OBJECTIVE

Subcapsular liver hematoma formation has been reported in less than 2% of pregnancies complicated by HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome. The purpose of this study was to identify the main diagnostic and therapeutic options for management of these patients.

STUDY DESIGN

In this 10-year retrospective review, we performed a computer-directed search of all cases of confirmed HELLP syndrome with hepatic hematoma treated in the surgical department of our tertiary care referral medical center.

RESULTS

Five patients with subcapsular liver hematoma in HELLP syndrome could be identified. All patients received transabdominal ultrasound, computed tomography, or magnetic resonance imaging. Conservative treatment was successful in three patients. Emergency surgical intervention was necessary in two patients, including one liver transplantation.

CONCLUSION

The case series shows the full diagnostic spectrum with transabdominal ultrasound, computed tomography, and magnetic resonance imaging, as well as the different therapeutic options varying from conservative therapy to operative management, including liver transplantation.

Pregnancy and liver disease

Liver disease has an impact on women's health during pregnancy because of the complex interactions between the physiologic changes induced by pregnancy and the pathophysiologic changes of liver disease. In particular, liver diseases that predominantly afflict females, such as primary biliary cirrhosis and autoimmune hepatitis, pose a special problem for conception and management of pregnancy. Pregnancy, moreover, specifically is associated with several potentially life-threatening liver diseases. This article reviews comprehensively the impact of liver diseases on pregnancy and of pregnancy on liver function and liver disease.

Abdominal pain during pregnancy

Numerous medical, surgical, psychiatric, gynecologic, and obstetric disorders can cause abdominal pain during pregnancy. The patient history, physical examination, laboratory data, and radiologic findings usually provide the diagnosis. The pregnant woman has physiologic alterations that affect the clinical presentation, including atypical normative laboratory values. Abdominal ultrasound is generally the recommended radiologic imaging modality; roentgenograms are generally contraindicated during pregnancy because of radiation teratogenicity. Concerns about the fetus limit the pharmacotherapy. Maternal and fetal survival have recently increased in many life-threatening conditions, such as ectopic pregnancy, appendicitis, and eclampsia, because of improved diagnostic technology, better maternal and fetal monitoring, improved laparoscopic technology, and earlier therapy.

Imaging of subcapsular hepatic and renal hematomas in pregnancy complicated by preeclampsia and the HELLP syndrome

The purpose of this report is to provide an illustrative case of spontaneous hepatic and renal hematomas that occurred during a pregnancy complicated by preeclampsia and the HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome. The sonographic and computed tomographic findings included intrahepatic, subcapsular hepatic, and extracapsular perihepatic hematomas in addition to a large subcapsular renal hematoma. Since hepatic and renal hematomas that occur in association with preeclampsia and the HELLP syndrome are rare but potentially life-threatening complications, prompt laboratory and radiologic evaluations are essential and may reduce the associated morbidity and mortality.

Hepatobiliary diseases in women

Most diseases of the hepatic and biliary systems affect both women and men. There are several disorders, however, that affect women differently than they affect men. Gallstones, primary biliary cirrhosis (PBC), and autoimmune liver disease occur more often in women. The impact of alcohol on the liver is worse in women. Chronic liver disease from any cause can affect fertility. In addition, oral contraceptive use and pregnancy can have specific effects on the liver.

The procoagulant activity of red blood cells from patients with severe preeclampsia

OBJECTIVE

Our purpose was to determine whether red blood cells from patients with severe preeclampsia may exhibit increased membrane exposure of procoagulant phospholipids (i.e., phosphatidylserine), which may initiate intravascular clotting and platelet activation.

STUDY DESIGN

The study group comprised 28 women: 9 with severe preeclampsia in the third trimester of pregnancy, 10 normotensive with uncomplicated pregnancies, and 9 age-matched, nonpregnant, healthy women. The exposure of phosphatidylserine on the outer membrane phospholipid layer was analyzed with use of isolated, washed red blood cells that were added as a source of phospholipids to a "prothrombinase" coagulation complex.

RESULTS

The resultant thrombin formed was measured by an amidolytic assay. Thrombin generation significantly increased on the addition of red blood cells from women with preeclampsia (741 +/- 132 mU/ml/min) compared with red blood cells from normotensive pregnant (422 +/- 228 mU/ml/min) and nonpregnant women (316 +/- 268 mU/ml/min, p = 0.0008).

CONCLUSION

This study indicates that in patients with preeclampsia the red blood cells exhibit a significant procoagulant surface that may trigger thrombin formation, thereby playing a role in the hypercoagulable state.

The factor V Leiden mutation may predispose women to severe preeclampsia

OBJECTIVE

A recent study showed that resistance to activated protein C may underlie some cases of severe preeclampsia. A common missense mutation in the factor V gene, the Leiden mutation, is the most frequent genetic cause of resistance to activated protein C. Our objective was to determine whether this mutation is more prevalent in patients with severe preeclampsia than in normotensive controls.

STUDY DESIGN

Deoxyribonucleic acid was extracted from whole blood of 158 gravid women meeting criteria of The American College of Obstetricians and Gynecologists for severe preeclampsia and 403 normotensive gravid women. The polymerase chain reaction was used to amplify exon 10 of the factor V gene, followed by allele-specific restriction with Mnl 1 for mutation detection. Results were analyzed with a chi(2) contingency table.

RESULTS

No patients were homozygous for the Leiden mutation. Fourteen of 158 women with severe preeclampsia (8.9%) were heterozygous for the Leiden mutation compared with 17 of 403 normotensive gravid controls (4.2%). The difference in frequency between women with severe preeclampsia and normotensive controls was statistically significant, chi(2) 4.686, p = 0.03.

CONCLUSIONS

Our data suggest that carriers of the factor V Leiden mutation are at increased risk for severe preeclampsia. Deoxyribonucleic acid analysis for the factor V Leiden mutation could serve as one component of a genetic screening profile for preeclampsia and other adverse pregnancy outcomes. Women who carry this mutation are at increased risk for deep venous thrombosis. Carriers of this common thrombophilic mutation may be identified so that adequate counseling regarding future contraceptive usage and effective thromboembolic prophylaxis during pregnancy and surgical procedures may be offered.

Plasma exchange in a patient with postpartum HELLP syndrome

The case of a patient with HELLP syndrome, who was unresponsive to supportive management but successfully treated with plasma exchange, is presented. The significance of plasma exchange in the treatment of HELLP syndrome is discussed.

Hepatic imaging in HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count)

OBJECTIVES

Our objective was to describe the hepatic imaging findings in selected patients with HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count) and to correlate these findings with the severity of concurrent clinical and laboratory abnormalities.

STUDY DESIGN

Patients with laboratory criteria for HELLP syndrome with complaints of severe right upper quadrant abdominal pain in association with either shoulder pain, neck pain, or relapsing hypotension underwent imaging of the liver. Clinical and laboratory parameters were then correlated with the hepatic imaging findings.

RESULTS

Thirty-four patients were evaluated in this study. Computed tomographic scanning of the liver was used for 33 patients. Additional imaging evaluations included magnetic resonance imaging for 4 patients and ultrasonographic evaluation of the liver for 5 patients. In 15 cases (45%) the computed tomographic results were abnormal. The most frequent abnormal hepatic imaging findings were subcapsular hematoma (n = 13) and intraparenchymal hemorrhage (n = 6). There was no statistically significant correlation between the presence of an abnormal hepatic imaging finding and the severity of liver function test abnormalities. However, the severity of thrombocytopenia did correlate with hepatic imaging findings (p = 0.04). In particular, an abnormal hepatic imaging finding was noted for 10 of 13 patients (77%) with a platelet count of < or = 20 x 10(9)/L (p = 0.012).

CONCLUSIONS

Abnormalities in liver function test results do not accurately reflect the presence of abnormal hepatic imaging findings in HELLP syndrome. Patients with HELLP syndrome having complaints of right upper quadrant pain and neck pain, shoulder pain, or relapsing hypotension should undergo imaging of the liver.

Pregnancy-Associated Hemolysis, Elevated Liver Functions, Low Platelets (HELLP) Syndrome: An Obstetric Disease in the Intensive Care Unit

We reviewed the experience with hemolysis, elevated liver functions, low platelets (HELLP) syndrome at the University of New Mexico Hospital over the past 10 years to delineate the epidemiology and the clinical course of the disease. A retrospective chart review of a large, university-based, largely indigent, pregnant population was undertaken with attention to diagnostic features of the syndrome and maternal and infant outcomes of affected pregnancies. Comparisons were made with other large reported clinical series. Preeclampsia complicated 5.6% of deliveries in this study, and the HELLP syndrome occurred in 116 patients (0.3% of all deliveries). Epigastric pain, nausea, vomiting, and malaise usually heralded the syndrome. Signs and symptoms of preeclampsia (e.g., hypertension, proteinuria, and edema) were most often not striking at the time of presentation. The mean platelet count at diagnosis was 60 ± 25 × 103. Initial signs of hemolysis were usually minimal, although the hematocrit decreased a mean of 11.5 ± 5 vol% over the course of the disease. Moderate elevations of hepatic enzyme levels, specifically lactic dehydrogenase, were common; hyperbilirubinemia was usually mild and late. Maternal complications included disseminated intravascular coagulation, eclampsia, pulmonary edema, adult respiratory distress syndrome, and hepatic hematoma. Eight stillbirths and 7 neonatal deaths occurred (perinatal mortality, 126/1,000). HELLP syndrome is a relatively infrequent but serious development in the evolution of preeclampsia/eclampsia. Variations in onset and severity of hemolysis, hepatic dysfunction, and thrombocytopenia are common. Maternal complications and the perinatal mortality rate are high. Pregnant patients with right upper quadrant or epigastric pain and thrombocytopenia, even in the absence of significant hypertension and proteinuria, are most likely to have HELLP syndrome, rather than some other medical condition. Awareness of the variable presentations of this syndrome permit the prompt recognition and management necessary to optimize maternal and neonatal outcomes.

Complexity and complicity in eclampsia: barriers or bridges?

The aetiology of pre-eclampsia-eclampsia remains largely unclarified, despite over 100 years of systematic study. The assumption that the triggering event is linear and amenable to reductionist techniques has characterized these efforts. The main purpose of this paper is to show that complexity and complicity characterize most pathophysiological processes in pre-eclampsia-eclampsia, a situation suggesting that similar mechanisms must exist at the origin of the disease. The unique configuration of the intervillous space and the intensity of energy transference through the fetomaternal interface offer many dysfunctional possibilities, even in clinically normal pregnancies. The most characteristic seem to be: the shedding and deportation of trophoblast, the fragmentation of villi, the escape of fetal blood, and events associated with trophoblast damage, degeneration and death. The pathogenic potential of these natural processes seems to depend on the association with amplifiers and permissive factors, which vary from person to person and from time to time. Thus, considering the convergence of multiple factors and the presence of nonlinearity in some of their interactions as a plausible working hypothesis, further exploration on this subject should adhere to the rules of this different reality. To find the best possible method of inquiry and to recognize its limitations will be the surest way to avoid failure.

Lupus anticoagulant and HELLP syndrome complicated by placental abruption, hepatic, dermal and adrenal infarction

Pregnancy complicated by the HELLP syndrome and antiphospholipid antibodies has not previously been documented. The patient suffered a significant placental abruption, hepatic, adrenal and cutaneous infarctions, and ongoing adrenal insufficiency. Attention is drawn to the serious clinical potential of this association.

The laboratory evaluation of hypertensive gravidas

A number of laboratory tests are available for the evaluation of the hypertensive gravida. These tests can be used to either predict and/or prognosticate between preeclampsia and other hypertensive disorders of pregnancy. These laboratory tests were evaluated based on published experience with special attention to its ability to facilitate identification of the patient with preeclampsia apart from other hypertensive disorders that co-exist with and occur as a complication of pregnancy. Hypocalciuria and increased cellular plasma fibronectin seem to be good tests to differentiate preeclampsia from chronic hypertension. The management of preeclampsia with its increased risk of perinatal morbidity and mortality renders this differentiation clinically very important. Hyperuricemia, proteinuria, increased serum beta-thromboglobulin concentration, abnormal red blood cell morphology with increased hemoglobin/hematocrit, and increased serum iron individually and collectively reflect the severity of preeclampsia. Platelets and total serum lactate dehydrogenase are the best tests to reflect the severity of HELLP syndrome. Circulating hCG and serum thromboglobulin seem to be the most promising future predictors for preeclampsia.

Acute fatty liver of pregnancy: an experience in the diagnosis and management of fourteen cases

OBJECTIVE

Our purpose was to investigate the diagnostic problems and maternal-perinatal outcome in cases of acute fatty liver of pregnancy.

STUDY DESIGN

Fourteen cases with acute fatty liver of pregnancy managed during the past 8-years were studied with emphasis on presenting symptoms, admitting diagnosis, laboratory findings, clinical course, maternal complications, and neonatal outcome.

RESULTS

The mean gestational age at onset was 34.5 weeks (range 28 to 39). Only seven patients had acute fatty liver of pregnancy as a definite or suspected diagnosis on admission. Computed tomography of the liver was performed on 10 patients, with only two positive results. There were no maternal deaths; however, maternal morbidity was frequent: four patients had hepatic encephalopathy, three pulmonary edema, three ascites, four respiratory arrest, two diabetes insipidus, and 10 had transfusion of blood or blood products to correct either disseminated intravascular coagulation or excessive bleeding. Coagulation abnormalities were common: hypofibrinogenemia (< 300 mg/dl) in 13 patients (93%), prolonged prothrombin time in 12 (86%), and prolonged partial thromboplastin time in 11 (79%). The corrected perinatal mortality was 6.6%.

CONCLUSION

Acute fatty liver of pregnancy should be suspected in all patients with symptoms of preeclampsia in the presence of hypoglycemia, low fibrinogen, and prolonged prothrombin time, particularly in the absence of severe abruptio placentae. Computed tomography of the liver has a high false-negative rate in patients with acute fatty liver of pregnancy. In spite of the literature's dismal prognosis, our findings indicate that maternal and perinatal outcomes appear favorable in well-managed patients.

Enhancement of hepatic artery resistance to blood flow in preeclampsia in presence or absence of HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets)

OBJECTIVE

Our purpose was to test the hypothesis that the HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome is the result of excessive vasoconstriction of the hepatic arterial circulation.

STUDY DESIGN

Doppler ultrasonography was used to measure the pulsatility index of the common hepatic artery in 14 women with preeclampsia, 15 with preeclampsia complicated by HELLP syndrome, and 8 with HELLP syndrome but without proteinuria. Gestational age ranged from 24 to 38 weeks. The study group was compared with a reference group (n = 42).

RESULTS

Both in preeclampsia and in the HELLP syndrome the hepatic artery pulsatility index values were significantly increased compared with the reference group. However, no significant differences were found between the preeclamptic group, the HELLP group with proteinuria, and those with HELLP without proteinuria.

CONCLUSIONS

These findings indicate that hepatic artery resistance to blood flow is increased in preeclampsia in the presence or absence of the HELLP syndrome. The results also demonstrate that vasoconstriction of the hepatic arteries is not more pronounced in the HELLP syndrome than in other manifestations of preeclampsia. Therefore factors other than vasoconstriction are likely to be responsible for the development of the HELLP syndrome.