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Kumasawa K, Kubota K, Takahashi Y, Nakayama T, Iriyama T, Nagamatsu T, Osuga Y, Fujii T. Abdominal compartment syndrome complicated by preeclampsia and partial HELLP syndrome in a 45-year-old woman: A case report. Clin Case Rep 2020; 8:1251-1254. [PMID: 32695369 PMCID: PMC7364097 DOI: 10.1002/ccr3.2904] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 05/10/2019] [Accepted: 05/20/2019] [Indexed: 01/07/2023] Open
Abstract
HELLP syndrome is sometimes followed by massive bleeding, leading to DIC. In cases of intra-abdominal compartment syndrome due to massive intra-abdominal bleeding after cesarean section, if preeclampsia and partial HELLP syndrome persist, hematoma removal helps in the recovery from preeclampsia and partial HELLP syndrome.
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Affiliation(s)
- Keiichi Kumasawa
- Department of Obstetrics and GynecologyFaculty of MedicineThe University of TokyoTokyoJapan
| | - Kaori Kubota
- Department of Obstetrics and GynecologyFaculty of MedicineThe University of TokyoTokyoJapan
| | - Yuko Takahashi
- Department of Obstetrics and GynecologyFaculty of MedicineThe University of TokyoTokyoJapan
| | - Toshio Nakayama
- Department of Obstetrics and GynecologyFaculty of MedicineThe University of TokyoTokyoJapan
| | - Takayuki Iriyama
- Department of Obstetrics and GynecologyFaculty of MedicineThe University of TokyoTokyoJapan
| | - Takeshi Nagamatsu
- Department of Obstetrics and GynecologyFaculty of MedicineThe University of TokyoTokyoJapan
| | - Yutaka Osuga
- Department of Obstetrics and GynecologyFaculty of MedicineThe University of TokyoTokyoJapan
| | - Tomoyuki Fujii
- Department of Obstetrics and GynecologyFaculty of MedicineThe University of TokyoTokyoJapan
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Acute kidney injury associated with preeclampsia or hemolysis, elevated liver enzymes, and low platelets syndrome. Pregnancy Hypertens 2020; 19:94-99. [PMID: 31927326 DOI: 10.1016/j.preghy.2019.11.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 11/02/2019] [Accepted: 11/25/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To determine the prevalence of acute kidney injury (AKI), placental abruption and postpartum hemorrhage in patients with preeclampsia or HELLP syndrome. STUDY DESIGN A retrospective study of patients with preeclampsia or HELLP syndrome treated at the University of Mississippi Medical Center from January 2000 through December 2010. MAIN OUTCOME MEASURES Relationships among the obstetric complications of placental abruption, postpartum hemorrhage, and AKI (serum creatinine >107 µmol/L) of women with preeclampsia or HELLP syndrome. Additional analysis was undertaken to explore if there was a correlation between postpartum hemorrhage/placental abruption and the severity of HELLP syndrome according to the Mississippi classification system. RESULTS Data from 1276 women over 11 years were included in the analysis. 67 of 466 patients (14.4%) with HELLP syndrome and 38 of 810 preeclampsia patients (4.7%) met criteria for AKI. Women with either placental abruption or postpartum hemorrhage had statistically significant increased odds of also having AKI (p < 0.01). Women with HELLP and AKI were also more likely to experience either placental abruption or postpartum hemorrhage. Women with Class 1 HELLP with placental abruption or postpartum hemorrhage were also more likely to have AKI than women with preeclampsia. CONCLUSION HELLP syndrome, AKI and placental abruption or postpartum hemorrhage appear to be interrelated. AKI occurs more frequently in women with HELLP syndrome with or without associated postpartum hemorrhage and placental abruption.
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Diagnosis of HELLP Syndrome: A 10-Year Survey in a Perinatology Centre. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16010109. [PMID: 30609811 PMCID: PMC6339138 DOI: 10.3390/ijerph16010109] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 12/27/2018] [Accepted: 12/28/2018] [Indexed: 11/16/2022]
Abstract
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.
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Añez-Aguayo MY, Vigil-De Gracia P. Dexamethasone in HELLP syndrome: experience in Bolivia. J Matern Fetal Neonatal Med 2018; 33:1-4. [PMID: 29804488 DOI: 10.1080/14767058.2018.1482272] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Objective: To demonstrate the utility of dexamethasone, used according to the criteria of the attending physician, in patients with HELLP syndrome.Methods: This cross-sectional study was conducted in patients with HELLP syndrome and was based on the daily, real-life management of HELLP syndrome. Patients who received dexamethasone had it administered immediately after giving birth at a dosage of 8 mg every 8 hours for 72 hours, for a total of 72 mg. The analysis was conducted between patients who received corticosteroids and those who did not, with complete or partial HELLP.Results: There were 97 women who suffered complications from HELLP syndrome, there were 43 (44.3%) received dexamethasone. The groups were comparable except for the initial platelet count because this was the criterion used to divide the groups. In addition, the group without corticosteroids comprised more patients with partial HELLP. The platelet count shows that on the third day was similar in both groups, following a difference of more than 40,000 at the beginning of the study. The average platelet increase was 27,448 in the group without corticosteroids and 88,408 in the corticosteroid group; p = .001.Conclusions: This study demonstrates that the administration of postpartum dexamethasone at a dosage of 8 mg every 8 hours for 72 hours in HELLP syndrome is associated with a significant increase in platelet count.
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Affiliation(s)
- María Yuly Añez-Aguayo
- Department of Gynecology and Obstetrics, Japanese University Municipal Hospital of Santa Cruz, Santa Cruz, Bolivia
| | - Paulino Vigil-De Gracia
- Department of Gynecology and Obstetrics, Obstetric Pathology, Hospital Complex of the Social Security Fund, National System of Researchers, SENACYT, Panama, Panama
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Hizkiyahu R, Rabinovich A, Thachil J, Sheiner E, Shaked G, Sebbag G, Maymon E, Erez O. Modified ISTH pregnancy-specific DIC score in parturients with liver rupture: population-based case series. J Matern Fetal Neonatal Med 2018; 32:2517-2523. [DOI: 10.1080/14767058.2018.1439469] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Ranit Hizkiyahu
- Department of Obstetrics and Gynecology “B”, Soroka University Medical Center, Ben-Gurion University of the Negev, Be’er Sheva, Israel
| | - Anat Rabinovich
- Thrombosis and Hemostasis Unit, Hematology Institute, Soroka University Medical Center, Be’er Sheva, Israel
| | - Jecko Thachil
- Department of Hematology, Manchester Royal Infirmary, Manchester, UK
| | - Eyal Sheiner
- Department of Obstetrics and Gynecology “B”, Soroka University Medical Center, Ben-Gurion University of the Negev, Be’er Sheva, Israel
| | - Gad Shaked
- Department of General Surgery and Trauma Unit, Soroka University Medical Center, Ben-Gurion University of the Negev, Be’er Sheva, Israel
| | - Gilbert Sebbag
- Department of General Surgery and Trauma Unit, Soroka University Medical Center, Ben-Gurion University of the Negev, Be’er Sheva, Israel
| | - Eli Maymon
- Department of Obstetrics and Gynecology “B”, Soroka University Medical Center, Ben-Gurion University of the Negev, Be’er Sheva, Israel
| | - Offer Erez
- Maternity Department “D” and Obstetrical Day Care Unit, Department of Obstetrics and Gynecology, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Be’er Sheva, Israel
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High-Dose Methylprednisolone to Prevent Platelet Decline in Preeclampsia: A Randomized Controlled Trial. Obstet Gynecol 2017; 128:153-8. [PMID: 27275791 DOI: 10.1097/aog.0000000000001470] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate whether early administration of high-dose methylprednisolone limits the fall of platelets in preeclampsia. METHODS A randomized trial of 180 mg methylprednisolone or placebo administered in divided doses over 36 hours was conducted in women admitted for preeclampsia and platelet counts below 150×10/L in four French academic centers. Patients were not included when platelet counts were below 50×10/L or when immediate delivery was required. The primary study outcome was the proportion of patients with platelet counts above 100×10/L 36 hours after the first dose of study medication. The total sample size needed to detect a 23% difference in the rate of this outcome between groups with a one-tailed α of 0.05 and 90% power was 94 patients. RESULTS Thirty-six patients were randomly assigned to receive methylprednisolone and 34 placebo between October 2007 and May 2011. Platelet counts above 100×10/L at 36 hours after the first dose of study medication were recorded in 30 (83%) in the active group and 29 (85%) in the placebo group (relative risk 0.98, 95% confidence interval 0.80-1.20; P=.82). The only adverse potentially study-related event was hyperglycemia in one woman allocated to methylprednisolone. CONCLUSION In women with preeclampsia and platelet counts under 150×10/L, methylprednisolone was not effective in maintaining platelet counts above 100×10/L. CLINICAL TRIAL REGISTRATION EU Clinical Trials Register, http://clinicaltrialsregister.eu, EudraCT 2006-004881-15-FR.
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Yang L, Ren C, Mao M, Cui S. 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. Medicine (Baltimore) 2016; 95:e3203. [PMID: 27043683 PMCID: PMC4998544 DOI: 10.1097/md.0000000000003203] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
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.
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Affiliation(s)
- Li Yang
- From the Department of Gynecology & Obstetrics (LY, CR, SC), The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan; and West Zone (MM), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
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Mao M, Chen C. Corticosteroid Therapy for Management of Hemolysis, Elevated Liver Enzymes, and Low Platelet Count (HELLP) Syndrome: A Meta-Analysis. Med Sci Monit 2015; 21:3777-83. [PMID: 26633822 PMCID: PMC4672720 DOI: 10.12659/msm.895220] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Background Hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is a severe condition of pregnancy that is associated with significant morbidity and mortality. Corticoteroid (CORT) therapy is common in the management of HELLP syndrome. This study evaluates the efficacy of CORT therapy to patients with HELLP Syndrome. Material/Methods A literature search was carried out in multiple electronic databases. Meta-analyses of means difference and odds ratio were carried under the random-effects model. Results Fifteen studies (675 CORT treated and 787 control HELLP patients) were included. CORT treatment significantly improved platelet count (mean difference between CORT treated and controls in changes from baseline, MD: 38.08 [15.71, 60.45]×109; p=0.0009), lactic dehydrogenase (LDH) levels (MD: −440 [−760, −120] IU/L; p=0.007), and alanine aminotransferase (ALT) levels (MD: −143.34 [−278.69, −7.99] IU/L; p=0.04) but the decrease in aspartate aminotransferase (AST) levels was not statistically significant (MD: −48.50 [−114.32, 17.32] IU/L; p=0.15). Corticosteroid treatment was also associated with significantly less blood transfusion rate (odds ratio, OR: 0.42 [0.24, 0.76]; p=0.004) and hospital/ICU stay (MD: −1.79 [−3.54, −0.05] days; p=0.04). Maternal mortality (OR: 1.27 [0.45, 3.60]; p=0.65), birth weight (MD: 0.09 [−0.11, 0.28]; p=0.38) and the prevalence of morbid conditions (OR: 0.79 [0.58, 1.08]; p=0.14) did not differ significantly between both groups. Conclusions Corticosteroid administration to HELLP patients improves platelet count, and the serum levels of LDH and ALT, and reduces hospital/ICU stay and blood transfusion rate, but is not significantly associated with better maternal mortality and overall morbidity.
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Affiliation(s)
- Minhong Mao
- West Zone, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China (mainland)
| | - Chen Chen
- West Zone, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China (mainland)
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Stepan H, Kuse-Föhl S, Klockenbusch W, Rath W, Schauf B, Walther T, Schlembach D. Diagnosis and Treatment of Hypertensive Pregnancy Disorders. Guideline of DGGG (S1-Level, AWMF Registry No. 015/018, December 2013). Geburtshilfe Frauenheilkd 2015; 75:900-914. [PMID: 28435172 PMCID: PMC5396549 DOI: 10.1055/s-0035-1557924] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Purpose: Official guideline published and coordinated by the German Society of Gynecology and Obstetrics (DGGG). Hypertensive pregnancy disorders contribute significantly to perinatal as well as maternal morbidity and mortality worldwide. Also in Germany these diseases are a major course for hospitalization during pregnancy, iatrogenic preterm birth and long-term cardiovascular morbidity. Methods: This S1-guideline is the work of an interdisciplinary group of experts from a range of different professions who were commissioned by DGGG to carry out a systematic literature search of positioning injuries. Members of the participating scientific societies develop a consensus in an informal procedure. Afterwards the directorate of the scientific society approves the consensus. Recommendations: This guideline summarizes the state-of-art for classification, risk stratification, diagnostic, treatment of hypertensive pregnancy disorders.
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Affiliation(s)
- H. Stepan
- Abteilung für Geburtsmedizin, Universitätsklinikum Leipzig,
Leipzig
| | - S. Kuse-Föhl
- Abteilung für Geburtsmedizin, Universitätsklinikum Leipzig,
Leipzig
| | - W. Klockenbusch
- Universitätsklinikum Münster, Klinik und Poliklinik für Frauenheilkunde und
Geburtshilfe, Abt. für Geburtshilfe, Münster
| | - W. Rath
- Frauenklinik für Gynäkologie und Geburtshilfe, Universitätsklinikum RWTH
Aachen, Aachen
| | - B. Schauf
- Frauenklinik Sozialstiftung Bamberg, Bamberg
| | - T. Walther
- Department of Pharmacology and Therapeutics, University College Cork, Cork,
Ireland
| | - D. Schlembach
- Klinik für Geburtsmedizin, Vivantes Klinikum Neukölln, Berlin
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Aydin S, Ersan F, Ark C, Arıoğlu Aydın Ç. Partial HELLP syndrome: Maternal, perinatal, subsequent pregnancy and long-term maternal outcomes. J Obstet Gynaecol Res 2014; 40:932-40. [DOI: 10.1111/jog.12295] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2013] [Accepted: 09/06/2013] [Indexed: 11/28/2022]
Affiliation(s)
- Serdar Aydin
- Obstetrics and Gynaecology; Istanbul Kanuni Sultan Suleyman Research and Teaching Hospital; İstanbul Turkey
| | - Fırat Ersan
- Obstetrics and Gynaecology; Istanbul Kanuni Sultan Suleyman Research and Teaching Hospital; İstanbul Turkey
| | - Cemal Ark
- Obstetrics and Gynaecology; Istanbul Kanuni Sultan Suleyman Research and Teaching Hospital; İstanbul Turkey
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Darby M, Martin JN, Mitchell SQ, Owens MY, Wallace K. Using case reports to determine when liver bleeding occurs during disease progression in HELLP syndrome. Int J Gynaecol Obstet 2013; 123:7-9. [DOI: 10.1016/j.ijgo.2013.06.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Revised: 03/26/2013] [Accepted: 06/21/2013] [Indexed: 11/28/2022]
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Aloizos S, Seretis C, Liakos N, Aravosita P, Mystakelli C, Kanna E, Gourgiotis S. HELLP syndrome: Understanding and management of a pregnancy-specific disease. J OBSTET GYNAECOL 2013; 33:331-7. [DOI: 10.3109/01443615.2013.775231] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Milestones in the quest for best management of patients with HELLP syndrome (microangiopathic hemolytic anemia, hepatic dysfunction, thrombocytopenia). Int J Gynaecol Obstet 2013; 121:202-7. [DOI: 10.1016/j.ijgo.2013.02.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Pourrat O, Pierre F. Utilité de la corticothérapie dans le syndrome HELLP : mythe ou réalité ? Rev Med Interne 2012; 33:297-9. [DOI: 10.1016/j.revmed.2011.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2011] [Accepted: 11/03/2011] [Indexed: 10/14/2022]
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Jank A, Schaarschmidt W, Stepan H. Effect of steroids on angiogenic factors in pregnant women with HELLP syndrome. J Perinat Med 2011; 39:611-3. [PMID: 21801093 DOI: 10.1515/jpm.2011.068] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Honiden S, Abdel-Razeq SS, Siegel MD. The management of the critically ill obstetric patient. J Intensive Care Med 2011; 28:93-106. [PMID: 21841145 DOI: 10.1177/0885066611411408] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Hypertensive disorders, postpartum hemorrhage, and sepsis are the most common indications for intensive care unit admission among obstetric patients. In general, ICU mortality is low, and better than would be predicted using available mortality prediction tools. Provision of care to this special population requires an intimate understanding of physiologic changes that occur during pregnancy. Clinicians must be aware of the way various diagnostic and treatment choices can affect the mother and fetus. Most clinically necessary radiographic tests can be safely performed and fall under the maternal radiation exposure limit of less than 0.05 Gray (Gy). Careful attention must be paid to acid-base status, oxygenation, and ventilation when faced with respiratory failure necessitating intubation. Cesarean delivery can be justified after 4 minutes of cardiac arrest and may improve fetal and maternal outcomes. The treatment of obstetric patients in the ICU introduces complexities and challenges that may be unfamiliar to many critical care physicians; teamwork and communication with obstetricians is crucial.
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Affiliation(s)
- Shyoko Honiden
- Department of Medicine, Section of Pulmonary and Critical Care Medicine, Yale University School of Medicine, New Haven, CT 06520, USA.
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Abstract
The HELLP syndrome is a serious complication of pregnancy characterized by hemolysis (H), elevated liver (EL) enzymes, and low platelet (LP) count that occurs in 0.2-0.6% of all pregnancies and in 10-20% of cases with severe preeclampsia and frequently leads to adverse maternal and perinatal outcome. The exact pathobiology of HELLP syndrome has not been clearly defined. As it is considered a form or a complication of severe preeclampsia, it likely has its origin in aberrant placental development and function resulting in ischemia-producing oxidative stress. However, there is still a debate on whether HELLP must be considered a severe form of preeclampsia or a separate disease entity. It can be described as a placenta-induced disease, as is preeclampsia itself, but with a more acute and predominant inflammatory process typically targeting the liver and with a greater activation of the coagulation system. This occurs during a disordered immunologic process and may be due to a genetic predisposition. In this review, we discuss the main biochemical characteristics of HELLP syndrome, particularly focusing on molecular aspects of placental involvement and maternal systemic responses.
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Martin JN, Owens MY, Keiser SD, Parrish MR, Tam Tam KB, Brewer JM, Cushman JL, May WL. Standardized Mississippi Protocol Treatment of 190 Patients with HELLP Syndrome: Slowing Disease Progression and Preventing New Major Maternal Morbidity. Hypertens Pregnancy 2011; 31:79-90. [DOI: 10.3109/10641955.2010.525277] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Ikezoe T, Ikenoue N, Uchikawa N, Kojima S, Fukaya T, Yokoyama A. Use of recombinant human soluble thrombomodulin in the management of HELLP syndrome complicated by DIC. Thromb Res 2010; 126:e238-40. [DOI: 10.1016/j.thromres.2010.05.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2010] [Revised: 04/26/2010] [Accepted: 05/04/2010] [Indexed: 10/19/2022]
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Are maternal and fetal parameters related to perinatal mortality in HELLP syndrome? Arch Gynecol Obstet 2010; 283:1227-32. [PMID: 20526778 DOI: 10.1007/s00404-010-1534-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2010] [Accepted: 05/25/2010] [Indexed: 10/19/2022]
Abstract
PURPOSE We designed this retrospective study to evaluate the association between maternal and fetal parameters and perinatal mortality in hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. METHODS In this retrospective study, 152 pregnancies complicated with HELLP syndrome were evaluated. Risk factors recorded were maternal age, gravidity, gestational age (weeks), systolic and diastolic blood pressure, platelet count, alanine aminotransferase (ALT), aspartate aminotransferase (AST), lactate dehydrogenase (LDH), fetal weight, and Apgar scores. The association of these factors with perinatal mortality was determined. Statistical analyses were performed using the Chi-square (χ (2)) test with Yates' correction, the Student's t test, logarithmic transformation, and the logistic regression method. RESULTS Ninety-two (60.52%) patients had mild preeclampsia, 46 (22.2%) had eclampsia, and 14 (15.2%) had severe preeclampsia. The fetal mortality rate was higher in eclamptic and severe preeclamptic patients (P = 0.029). No correlation was found between maternal age, laboratory values (platelet count, ALT, AST, and LDH), or systolic and diastolic blood pressure and fetal morbidity. According to the logistic regression model, fetuses with prematurity, low birth weight, and low Apgar scores (Apgar score 1 ≤ 3 and Apgar score 5 ≤ 5) were found to be at significant risk for perinatal mortality (P < 0.001). The odds ratios (95% CI) were 3.0 (2-5), 3.42 (1.82-6.41), 0.62 (0.44-0.86) and 4.66 (2.04-10.63), respectively. CONCLUSIONS Maternal laboratory and clinical parameters were not associated with fetal mortality. Fetal prematurity, low birth weight, and low Apgar scores were significantly associated with fetal mortality. The HELLP syndrome and severe preeclampsia may be life threatening to the mother; therefore, the accepted treatment is expeditious delivery. Our study indicates that prevention of prematurity must be the main priority for the fetus in pregnancies complicated by the HELLP syndrome. This can be efficaciously achieved using glucocorticoid therapy for lung maturity and ensuring that delivery is at an experienced hospital with a multidisciplinary approach including a neonatal intensive care unit.
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Lin CK, Chang WH, Pan HH, Chen CH. Postpartum HELLP Syndrome With Unusually High Levels of Liver Enzymes. Taiwan J Obstet Gynecol 2009; 48:308-10. [PMID: 19797028 DOI: 10.1016/s1028-4559(09)60312-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Schwartz N, Rochelson B, Jacob J. Failure of selective termination and dexamethasone rescue therapy to arrest HELLP syndrome in a midtrimester triplet gestation with one triploid fetus. J Matern Fetal Neonatal Med 2009; 17:313-4. [PMID: 16147843 DOI: 10.1080/14767050500123905] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
We present a case of a patient with a triplet pregnancy at 22 weeks with one triploid fetus (69XXX) who developed severe preeclampsia that did not reverse with dexamethasone rescue therapy and selective termination. With multiple gestations on the rise and the early diagnosis of abnormal pregnancies being accomplished through ultrasound, serum markers, and invasive procedures, the question remains if there is a point in gestation before which selective termination of an abnormal fetus would allow the pregnancy to continue without preeclampsia developing or progressing. Appropriate counseling as to the maternal risk in cases of trisomy 13 or triploidy is essential as early in pregnancy as possible.
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Affiliation(s)
- Nadav Schwartz
- Department of Obstetrics and Gynecology, North Shore University Hospital, Manhasset, New York 11030, USA
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Ferguson S, Allen VM, Craig C, Allen AC, Dodds L. Timing of indicated delivery after antenatal steroids in preterm pregnancies with severe hypertension. Hypertens Pregnancy 2009; 28:63-75. [PMID: 19165671 DOI: 10.1080/10641950802366237] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To evaluate the effect of the time interval between administering antenatal steroids needed to accelerate fetal lung maturity and indicated delivery in preterm pregnancies complicated by severe hypertension, as determined by maternal and perinatal outcomes. METHODS The Nova Scotia Atlee Perinatal Database was used to identify a population-based cohort of women with severe hypertension who delivered an infant between 1989 and 2002. Women were included if they received antenatal steroids and required delivery between 26 and 34 weeks gestation. Multivariate logistic regression analyses were conducted to evaluate the effect of time interval on maternal and perinatal mortality, maternal hemorrhagic and hypertension-associated morbidity, and perinatal respiratory, infectious, and prematurity-associated morbidity, while controlling for confounding variables. RESULTS 172 pregnancies satisfied inclusion and exclusion criteria. Betamethasone was the most commonly used corticosteroid to accelerate fetal lung maturity (95%). Among infants delivered at 26 to 34 weeks, adjusted analyses showed a reduction in risk of depression at birth (RR, 0.54; 95% CI, 0.24 to 0.97) and need for surfactant (RR, 0.50; 95% CI, 0.25 to 0.95) when the time interval from steroid administration to delivery was >48 hours compared with <or= 48 hours. Adjusted analyses in a subgroup of women with cesarean delivery (81% of deliveries) demonstrated no differences in rates maternal or neonatal morbidity. CONCLUSIONS The rates of most adverse maternal and neonatal outcomes in preterm pregnancies with severe hypertension delivered at 26 to 34 weeks are not affected by timing from steroid administration to delivery. These data support the decision for delivery based mainly on obstetrical indications.
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Affiliation(s)
- Shaun Ferguson
- Department of Obstetrics and Gynaecology, Dalhousie University, Halifax, Nova Scotia, Canada
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Haram K, Svendsen E, Abildgaard U. The HELLP syndrome: clinical issues and management. A Review. BMC Pregnancy Childbirth 2009; 9:8. [PMID: 19245695 PMCID: PMC2654858 DOI: 10.1186/1471-2393-9-8] [Citation(s) in RCA: 296] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2008] [Accepted: 02/26/2009] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The HELLP syndrome is a serious complication in pregnancy characterized by haemolysis, elevated liver enzymes and low platelet count occurring in 0.5 to 0.9% of all pregnancies and in 10-20% of cases with severe preeclampsia. The present review highlights occurrence, diagnosis, complications, surveillance, corticosteroid treatment, mode of delivery and risk of recurrence. METHODS Clinical reports and reviews published between 2000 and 2008 were screened using Pub Med and Cochrane databases. RESULTS AND CONCLUSION About 70% of the cases develop before delivery, the majority between the 27th and 37th gestational weeks; the remainder within 48 hours after delivery. The HELLP syndrome may be complete or incomplete. In the Tennessee Classification System diagnostic criteria for HELLP are haemolysis with increased LDH (> 600 U/L), AST (>or= 70 U/L), and platelets < 100 x 10(9)/L. The Mississippi Triple-class HELLP System further classifies the disorder by the nadir platelet counts. The syndrome is a progressive condition and serious complications are frequent. Conservative treatment (>or= 48 hours) is controversial but may be considered in selected cases < 34 weeks' gestation. Delivery is indicated if the HELLP syndrome occurs after the 34th gestational week or the foetal and/or maternal conditions deteriorate. Vaginal delivery is preferable. If the cervix is unfavourable, it is reasonable to induce cervical ripening and then labour. In gestational ages between 24 and 34 weeks most authors prefer a single course of corticosteroid therapy for foetal lung maturation, either 2 doses of 12 mg betamethasone 24 hours apart or 6 mg or dexamethasone 12 hours apart before delivery. Standard corticosteroid treatment is, however, of uncertain clinical value in the maternal HELLP syndrome. High-dose treatment and repeated doses should be avoided for fear of long-term adverse effects on the foetal brain. Before 34 weeks' gestation, delivery should be performed if the maternal condition worsens or signs of intrauterine foetal distress occur. Blood pressure should be kept below 155/105 mmHg. Close surveillance of the mother should be continued for at least 48 hours after delivery.
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Affiliation(s)
- Kjell Haram
- Department of Obstetrics and Gynaecology, Haukeland University Hospital, Bergen, Norway.
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Medications in pregnancy and lactation: Part 2. Drugs with minimal or unknown human teratogenic effect. Obstet Gynecol 2009; 113:417-32. [PMID: 19155916 DOI: 10.1097/aog.0b013e31818d686c] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This is the second of a two-part series on the use of medication during pregnancy and lactation. Pregnancy risk factors together with an increased incidence of chronic diseases and the rise in mean maternal age predict an increase in medication use during gestation. However, as highlighted in the first installment of this series, relatively few medications have specifically been tested for safety and efficacy during pregnancy, and, therefore, responses to those inquiries can be uninformed and inaccurate. Whereas the first installment provided new insight into the nature of medications with known human teratogenic effects, this part concentrates on drugs with minimal or no known human teratogenic effect. It is important that clinicians become familiar with all of the aspects of the drugs they prescribe, in addition to the controversies surrounding them, through consultation with maternal-fetal medicine specialists and through references and Web sites providing up-to-date information in an effort to promote safer prescribing practices.
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Ozer A, Kanat-Pektas M, Ozer S, Tapisiz OL, Zulfikaroglu EE, Danisman N. The effects of betamethasone treatment on clinical and laboratory features of pregnant women with HELLP syndrome. Arch Gynecol Obstet 2008; 280:65-70. [PMID: 19089438 DOI: 10.1007/s00404-008-0865-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2008] [Accepted: 11/24/2008] [Indexed: 11/27/2022]
Abstract
AIM The present study aims to investigate the effects of betamethasone treatment on clinical outcome and laboratory data of pregnant women diagnosed with HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome. METHODS A prospective, randomized and placebo-controlled clinical trial was undertaken in a total of 60 pregnant women with HELLP syndrome who were treated at the perinatology department of the study center between January 2005 and February 2008. Betamethasone treatment (intramuscular injection of 12 mg in every 24 h) was given to 30 subjects while remaining 30 subjects received placebo. The treatment and control groups were compared in the aspects of clinical outcome and laboratory data. RESULTS The alterations in platelet counts, alanine aminotransferase, aspartate aminotransferase and lactate dehydrogenase levels of women treated with betamethasone were statistically similar to those of the placebo group. Although there was a significant decrease in diastolic blood pressure values of control group (P = 0.04), alterations in systolic blood pressure values were statistically indifferent in both study groups. Hematological and metabolic complications occurred significantly less in women treated with betamethasone (P < 0.05). Interestingly, the percentage of women who received platelet transfusion was significantly higher in the control group (P < 0.005). No case of maternal mortality occurred. CONCLUSIONS The betamethasone treatment has ended up with insignificant alterations in clinical outcomes and laboratory data of women with HELLP syndrome except beneficial effects on metabolic complications and need for platelet transfusion. Further investigation is required to assess the efficiency of betamethasone in management of HELLP syndrome.
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Affiliation(s)
- Alev Ozer
- Department of Perinatology, Dr. Zekai Tahir Burak Women Health Research and Education Hospital, Ankara, Turkey
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Beucher G, Simonet T, Dreyfus M. Prise en charge du HELLP syndrome. ACTA ACUST UNITED AC 2008; 36:1175-90. [DOI: 10.1016/j.gyobfe.2008.08.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2008] [Accepted: 08/09/2008] [Indexed: 11/26/2022]
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Holzgreve W, Hahn S, Zhong XY, Lapaire O, Hösli I, Tercanli S, Mindy P. Genetic communication between fetus and mother: short- and long-term consequences. Am J Obstet Gynecol 2007; 196:372-81. [PMID: 17403426 DOI: 10.1016/j.ajog.2006.12.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2006] [Accepted: 12/12/2006] [Indexed: 01/26/2023]
Affiliation(s)
- Wolfgang Holzgreve
- Department of Obstetrics and Gynecology, University of Basel, Basel, Switzerland.
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Abstract
The obstetric patient poses exceptional challenges in the intensive care unit. Knowledge of the physiologic changes of pregnancy and specific pregnancy-related disorders is necessary for optimal management. Intensive care unit diagnoses may include preeclampsia, including the HELLP syndrome, pulmonary embolic disease, amniotic fluid embolism, status asthmaticus, respiratory infection, the acute respiratory distress syndrome, and sepsis. The management of mechanical ventilation is based on principles of avoiding lung injury, and hypercapnia may be tolerated even during the pregnancy. When the clinician is faced with the extraordinary instance of cardiopulmonary arrest, perimortem cesarean delivery must be considered to improve the potential for maternal and fetal survival.
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Affiliation(s)
- Janet M Shapiro
- Medical Intensive Care Unit, St. Luke's Hospital, Columbia University, New York, New York 10025, USA.
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31
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Elovitz MA. Anti-inflammatory interventions in pregnancy: now and the future. Semin Fetal Neonatal Med 2006; 11:327-32. [PMID: 16828353 DOI: 10.1016/j.siny.2006.03.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2006] [Indexed: 10/24/2022]
Abstract
A growing body of evidence implicates inflammatory pathways in adverse reproductive outcomes. This expanding evidence suggests that anti-inflammatory interventions may hold promise in reducing the maternal and neonatal morbidities and mortalities associated with these obstetrical complications. Preterm birth, preeclampsia, pregnancy loss and adverse neonatal outcomes have all been associated with the activation of inflammatory pathways during pregnancy. Because of the number of observational human studies, as well as animal models of preterm birth, the mechanisms by which inflammation may promote preterm parturition and adverse effects on the fetus are beginning to be elucidated. Although the future use of anti-inflammatory interventions in this context holds significant promise, much research is still warranted. Only when the pathogenesis of obstetrical complications is more fully understood can meaningful therapeutic interventions become a realistic goal.
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Affiliation(s)
- Michal A Elovitz
- Department of Obstetrics and Gynecology, University of Pennsylvania School of Medicine, 421 Curie Boulevard, 1353 BRB 2/3, Philadelphia, PA 19104-6142, USA.
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van Runnard Heimel PJ, Huisjes AJM, Franx A, Koopman C, Bots ML, Bruinse HW. A randomised placebo-controlled trial of prolonged prednisolone administration to patients with HELLP syndrome remote from term. Eur J Obstet Gynecol Reprod Biol 2006; 128:187-93. [PMID: 16412552 DOI: 10.1016/j.ejogrb.2005.11.041] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2005] [Revised: 11/26/2005] [Accepted: 11/29/2005] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To evaluate the effect of prolonged administration of high-dose prednisolone on early onset HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome during expectant management. STUDY DESIGN A randomized, double-blind trial was performed in 31 pregnant women with HELLP syndrome with an onset before 30 weeks gestation. Patients received either 50mg prednisolone or placebo intravenously twice a day. Primary outcome measures were the entry-to-delivery interval and the number of recurrent HELLP exacerbations in the antepartum period. RESULTS Serious maternal morbidity was considerable, in particular in the placebo group where even on maternal occurred as a consequence of liver rupture. The mean entry-delivery interval did not differ between the prednisolone group (6.9 days) and the placebo group (8.0 days). However, patients in the prednisolone group had a significant lower risk of a recurrent HELLP exacerbation after the initial crisis had subsided, as compared to patients in the placebo group (HR 0.3, with 95% CI 0.3-0.9). Platelet count recovered faster in the prednisolone group as compared to the placebo group (mean 1.7 days versus 6.2 days, P<0.01). CONCLUSIONS HELLP syndrome remote from term causes high risk for serious maternal morbidity and mortality. When expectant management is pursued in selected patients with a HELLP syndrome remote from term, prolonged administration of prednisolone reduces the risk of recurrent HELLP syndrome exacerbations.
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Basama FMS, Granger K. Case report: post partum class 1 HELLP syndrome. Arch Gynecol Obstet 2006; 275:187-9. [PMID: 16819612 DOI: 10.1007/s00404-006-0199-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2006] [Accepted: 05/24/2006] [Indexed: 10/24/2022]
Abstract
The objective of this case report is to highlight the lack of screening tests that is capable of predicting HELLP syndrome before its occurrence. The patient developed severe pre-eclamptic toxaemia at 34+ weeks gestation. The foetus was growth retarded. The patient received anti-hypertensive therapy and was delivered by an emergency caesarean section. The patient developed post partum HELLP syndrome that required supportive treatment and renal haemodialysis; nevertheless, the patient fully recovered.
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Affiliation(s)
- F M S Basama
- Royal Lancaster Infirmary Hospital, Ashton Road, Lancaster, Lancashire, UK.
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34
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Abstract
A perfect baby is the expectation of all parents, and a perfect outcome is the mission of obstetrics. Every obstetrician dreads to hear that there is an unexpected maternal mortality and/or severe fetal injury at the hospital. The role of a perceived public expectation of perfection in obstetric medicine reflects a belief that bad outcomes in obstetrics should not be tolerated and that every maternal-fetal injury merits financial compensation and punishment. What has brought these troubling times to obstetric medicine? The drivers behind malpractice crises are the four leading interest groups in the medical-legal debate: pregnant patients and their environment (husband, parents, relatives, friends, legislators, and the media), health-care providers, insurance companies, and trial attorneys. Litigation in obstetrics is the result of a complex of events when malpractice (presumed or real) impacts on the attitude of pregnant women and their environment. In such complexity, information is mandatory but may often be misinterpreted. If messages are not tailored to the receiver's capacity, communicating well with the pregnant patient becomes crucial. Therefore, to reduce medical-legal issues in obstetrics, increasing attention and an applicable standard of obstetric care to avoid negligence and medical errors should go along with better communication with pregnant women. Communication should be clear, targeted, effective, flexible, and empathic to share a common language and decisions. This review briefly presents and discusses some of the most frequently encountered medical-legal claim cases in obstetric practice. In-depth review of pregnancy-related deaths and major morbidities can help determine strategies needed to continue making pregnancy safer.
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Affiliation(s)
- Min Min Chou
- Department of Obstetrics and Gynecology, Taichung Veterans General Hospital, Chung Shan Medical University, Taichung, Taiwan.
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Collinet P, Delemer-Lefebvre M, Dharancy S, Lucot JP, Subtil D, Puech F. Le HELLP syndrome : diagnostic et prise en charge thérapeutique. ACTA ACUST UNITED AC 2006; 34:94-100. [PMID: 16483824 DOI: 10.1016/j.gyobfe.2006.01.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2005] [Accepted: 01/13/2006] [Indexed: 11/18/2022]
Abstract
Management of HELLP syndrome is still controversial. In order to improve maternal and foetal prognosis, 2 approaches are usually considered: immediate termination of pregnancy (risk of foetal complications related to prematurity) or conservative treatment (maternal risk of complications related to hematologic disorders). Choice of treatment needs to be taken after evaluation of the maternal and fetal risk/benefit ratio.
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Affiliation(s)
- P Collinet
- Clinique de Gynécologie, Obstétrique et Néonatalogie, Hôpital Jeanne-de-Flandre, CHRU de Lille, 2, avenue Oscar-Lambret, 59037 Lille cedex, France.
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36
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Sibai BM, Barton JR. Dexamethasone to improve maternal outcome in women with hemolysis, elevated liver enzymes, and low platelets syndrome. Am J Obstet Gynecol 2005; 193:1587-90. [PMID: 16260196 DOI: 10.1016/j.ajog.2005.08.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Rhen T, Cidlowski JA. Estrogens and glucocorticoids have opposing effects on the amount and latent activity of complement proteins in the rat uterus. Biol Reprod 2005; 74:265-74. [PMID: 16221988 DOI: 10.1095/biolreprod.105.045336] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
The mammalian uterus faces unique immunological challenges. It must nurture and protect the semiallogenic fetus from attack by the maternal immune system while guarding against infection by pathogens that compromise fetal and maternal health. Complement has recently been implicated in the etiology of pregnancy loss, but its regulation by steroid hormones and its role in host defense in the uterus are not clearly defined. Here we use biochemical, functional, and physiological assays to elucidate the regulation of complement proteins in the rat uterus. We demonstrate that estrogens (17 beta-estradiol) and glucocorticoids (dexamethasone) have major, but opposing, effects on the amount and latent activity of complement effectors in the uterus. Treatment with 17 beta-estradiol induced vasodilation and an increase in vascular permeability, which resulted in extravasation of plasma and complement into the uterus, rather than de novo complement biosynthesis. In vitro assays revealed that 17 beta-estradiol induced a potent bactericidal activity in uterine luminal fluid and that the antibacterial component was complement. These proinflammatory and immunomodulatory effects were evident within 4 h of treatment and were blocked by coadministration of dexamethasone. We also found that estrogen effects on the vasculature were mediated in part by activation of the contact system and bradykinin B1 receptors. These results indicate that complement plays a central role in innate immunity in the female reproductive tract and suggest that estrogens or glucocorticoids might be used therapeutically to enhance or inhibit complement-dependent processes in the uterus.
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Affiliation(s)
- Turk Rhen
- Laboratory of Signal Transduction, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, North Carolina 27709, USA.
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Affiliation(s)
- John M O'Brien
- Perinatal Diagnostic Center, Central Baptist Hospital, Lexington, Kentucky 40503, USA.
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Barrilleaux PS, Martin JN, Klauser CK, Bufkin L, May WL. Postpartum intravenous dexamethasone for severely preeclamptic patients without hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome: a randomized trial. Obstet Gynecol 2005; 105:843-8. [PMID: 15802415 DOI: 10.1097/01.aog.0000154887.57440.d1] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We compared maternal outcomes for patients with severe preeclampsia who were managed postpartum with or without adjunctive intravenous dexamethasone. METHODS This study was a randomized, blinded placebo-controlled clinical trial comparing the use of dexamethasone postpartum (10 mg-10 mg-5 mg-5 mg intravenously every 12 hours) with a saline control in patients with severe preeclampsia. The Student t and chi(2) tests were used for data analysis, with P < .05 considered significant. RESULTS Data from 157 patients (77 patients receiving dexamethasone, 80 patients receiving placebo) who were treated during 2000-2003 were analyzed. Demographics, diagnostic criteria, baseline laboratory values, and postpartum outcomes were similar between groups. Although dexamethasone-treated patients had fewer returns (6.5% compared with 11.3%) to the labor/delivery/recovery unit for uncontrolled hypertension than control patients, no significant differences were found in blood pressure, antihypertensive requirements, laboratory values, length of hospitalization, interval urine output at 48 hours postpartum, or major maternal morbidity. Two control patients developed hemolysis, elevated liver enzymes, low platelets syndrome. CONCLUSION Adjunctive use of intravenous dexamethasone for postpartum patients with severe preeclampsia does not reduce disease severity or duration. LEVEL OF EVIDENCE I.
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Affiliation(s)
- P Scott Barrilleaux
- Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, Mississippi 39216-4505, USA
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O'Brien JM, Poynter L, Barton JR. Transfusion for hemolysis, elevated liver function tests, and low platelet count in pregnancy. Int J Gynaecol Obstet 2005; 89:291-2. [PMID: 15919403 DOI: 10.1016/j.ijgo.2005.02.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2004] [Accepted: 02/28/2005] [Indexed: 10/25/2022]
Affiliation(s)
- J M O'Brien
- Perinatal Diagnostic Center, Central Baptist Hospital, 1740 Nicholasville Road, Lexington, KY 40503, USA.
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Tsen LC. What’s new and novel in obstetric anesthesia? Contributions from the 2003 scientific literature. Int J Obstet Anesth 2005; 14:126-46. [PMID: 15795148 DOI: 10.1016/j.ijoa.2004.12.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2004] [Accepted: 12/24/2004] [Indexed: 10/25/2022]
Abstract
THE PREGNANT PATIENT: Age; maternal disease; prophylactic antibiotics; gastroesophageal reflux; obesity; starvation; genotyping; coagulopathy; infection; substance abuse; altered drug responses in pregnancy; physiological changes of pregnancy. THE FETUS: Fetal monitoring; intrauterine surgery. THE NEWBORN: Breastfeeding; maternal infection, fever, and neonatal sepsis evaluation. OBSTETRIC COMPLICATIONS: Embolic phenomena; hemorrhage; preeclampsia; preterm delivery. OBSTETRIC MANAGEMENT: External cephalic version and cervical cerclage; elective cesarean delivery; fetal malpresentation; vaginal birth after cesarean delivery; termination of pregnancy. OBSTETRIC ANESTHESIA: Analgesia for labor and delivery; anesthesia for cesarean delivery; anesthesia for short obstetric operations; complications of anesthesia. MISCELLANEOUS: Consent; ethics; history; labor support; websites/books/leaflets/journal announcements.
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Affiliation(s)
- L C Tsen
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston MA 02115, USA.
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van Runnard Heimel PJ, Franx A, Schobben AFAM, Huisjes AJM, Derks JB, Bruinse HW. Corticosteroids, pregnancy, and HELLP syndrome: a review. Obstet Gynecol Surv 2005; 60:57-70; quiz 73-4. [PMID: 15618920 DOI: 10.1097/01.ogx.0000150346.42901.07] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Corticosteroids are potent antiinflammatory and immunosuppressive drugs, which are used in the treatment of a wide range of medical disorders. During pregnancy, several corticosteroids are administered for maternal as well as fetal reasons. Prednisone and prednisolone show limited transplacental passage and are thus used for treatment of maternal disease. Dexamethasone and betamethasone, drugs that can easily cross the placenta, are more suitable for fetal indications. During the last decade, administration of corticosteroids was introduced in the treatment of hemolysis, elevated liver enzymes, and low platelets (HELLP syndrome), a severe form of preeclampsia unique to human pregnancy. Several randomized, controlled trials as well as other prospective and retrospective studies have been performed to investigate this beneficial effect of corticosteroids on biochemical measures and clinical signs. This review discusses the characteristics of corticosteroids in humans and details the use of corticosteroids during pregnancy. A review of literature on the effect of corticosteroids on HELLP syndrome is given and possible mechanisms of action are discussed.
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Affiliation(s)
- P J van Runnard Heimel
- Department of Perinatology and Gynecology, University Medical Center, Utrecht, The Netherlands.
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Abstract
UNLABELLED Preeclampsia/eclampsia has been recognized for centuries and continues to plague both the patient and the obstetrician. A severe variant, the syndrome of hemolysis, elevated liver enzymes, and low platelets (HELLP), has been recognized for 50 years. Although much new data has been elucidated about the condition, only several observations have withstood the test of time. These are the uniqueness of the disease to humans, the progressive nature of the disease, and the fact that delivery is the sole therapy. TARGET AUDIENCE Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES After completion of this article, the reader should be able to outline the history of HELLP syndrome and describe the pathophysiology of HELLP syndrome, to summarize the clinical presentation and differential diagnosis of HELLP syndrome, and to list the various management options.
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Affiliation(s)
- Jason K Baxter
- Department of Obstetrics and Gynecology, Fellow, Division of Maternal-Fetal Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
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Martin JN, Thigpen BD, Moore RC, Rose CH, Cushman J, May W. Stroke and severe preeclampsia and eclampsia: a paradigm shift focusing on systolic blood pressure. Obstet Gynecol 2005; 105:246-54. [PMID: 15684147 DOI: 10.1097/01.aog.0000151116.84113.56] [Citation(s) in RCA: 337] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To identify important clinical correlates of stroke in patients with preeclampsia and eclampsia. METHODS The case histories of 28 patients who sustained a stroke in association with severe preeclampsia and eclampsia were scrutinized with particular attention to blood pressures. RESULTS Stroke occurred antepartum in 12 patients, postpartum in 16. Stroke was classified as hemorrhagic-arterial in 25 of 27 patients (92.6%) and thrombotic-arterial in 2 others. Multiple sites were involved in 37% without distinct pattern. In the 24 patients being treated immediately before stroke, systolic pressure was 160 mm Hg or greater in 23 (95.8%) and more than 155 mm Hg in 100%. In contrast, only 3 of 24 patients (12.5%) exhibited prestroke diastolic pressures of 110 mm Hg or greater, only 5 of 28 reached 105 mm Hg, and only 6 (25%) exceeded a mean arterial pressure of 130 mm Hg before stroke. Only 3 patients received prestroke antihypertensives. Twelve patients sustained a stroke while receiving magnesium sulfate infusion; 8 had eclampsia. Although all blood pressure means after stroke were significantly higher than prestroke, only 5 patients exhibited more than 110 mm Hg diastolic pressures. In 18 of 28 patients, hemolysis, elevated liver enzymes, low platelets syndrome did not significantly alter blood pressures compared with non-hemolysis, elevated liver enzymes, low platelets. Mean systolic and diastolic changes from pregnancy baseline to prestroke values were 64.4 and 30.6 mm Hg, respectively. Maternal mortality was 53.6%; only 3 patients escaped permanent significant morbidity. CONCLUSION In contrast to severe systolic hypertension, severe diastolic hypertension does not develop before stroke in most patients with severe preeclampsia and eclampsia. A paradigm shift is needed toward considering antihypertensive therapy for severely preeclamptic and eclamptic patients when systolic blood pressure reaches or exceeds 155-160 mm Hg. LEVEL OF EVIDENCE III.
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Affiliation(s)
- James N Martin
- Department of Obstetrics and Gynecology, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216-4505, USA.
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Makris A, Thornton CE, Xu B, Hennessy A. Garlic increases IL-10 and inhibits TNFalpha and IL-6 production in endotoxin-stimulated human placental explants. Placenta 2005; 26:828-34. [PMID: 16226132 DOI: 10.1016/j.placenta.2004.10.019] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2004] [Revised: 09/26/2004] [Accepted: 10/27/2004] [Indexed: 11/17/2022]
Abstract
Preeclampsia is a multisystem disorder manifest by hypertension after 20 weeks' gestation associated with end organ damage, usually proteinuria. The placenta is thought to be pivotal in the pathogenesis of the disease. Both the placenta and the maternal systemic response are characterised by heightened inflammation. Garlic has been shown to have anti-inflammatory and pro-apoptotic properties amongst others. It was hypothesised that treating placental explants with garlic may inhibit the production of inflammatory cytokines (interleukin-6 (IL-6) and tumour necrosis factor (TNFalpha)) and stimulate the production of anti-inflammatory cytokines (interleukin-10 (IL-10)) by the placental explants. Garlic, we hypothesised, would also stimulate apoptosis in the explants as measured by soluble TNF-related apoptosis-inducing ligand/Apo-2L (sTRAIL) production. Normal placental explants (n=5) and explants from women who had preeclampsia (n=4) were cultured in the presence of various garlic concentrations (10-1000 microg/mL). The lowest garlic concentration (10 microg/mL) increased the normal explant production of IL-10 by 29.2% (12.2, 57.5%; p<0.01) while inhibiting the production of IL-6 by 23.5% (8.9, 32.5%; p<0.01) (normal explants) and TNFalpha by 19.4% (4.5, 35.3%; p<0.05) (preeclamptic explants). Garlic resulted in an increase in IL-10 production at lower doses (normal explants only) and inhibition of the production of IL-10 at higher doses (normal and preeclamptic explants). Garlic also resulted in a dose-dependent reduction of IL-6 and TNFalpha. Initially there was no change in sTRAIL production; however, at the highest garlic concentrations there was a significant increase in production. We thus conclude that garlic may have an immunomodulatory effect on normal and preeclamptic placentas.
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Affiliation(s)
- A Makris
- Vascular Immunology Research Laboratory, Heart Research Institute, 145 Missenden Road, Camperdown, Australia.
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Rose CH, Thigpen BD, Bofill JA, Cushman J, May WL, Martin JN. Obstetric implications of antepartum corticosteroid therapy for HELLP syndrome. Obstet Gynecol 2004; 104:1011-4. [PMID: 15516393 DOI: 10.1097/01.aog.0000143262.85124.e8] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE We reviewed the impact of intravenous high-dose corticosteroid administration for preterm hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome on vaginal delivery rate and degree of clinically significant thrombocytopenia. METHODS Retrospective analysis of 1991-2000 HELLP syndrome (platelets < 100,000/uL, lactate dehydrogenase > 600 IU/L, aspartate aminotransferase and/or alanine aminotransferase > 70 IU/L) data focusing on labor inductions for gestations of less than 34 weeks and increase in platelet count sufficient to permit regional anesthetic techniques. RESULTS Antepartum high-dose corticosteroid use increased from 32% (1991-1995) to 67% (1996-2000) for 350 patients studied (n = 199, < 34 weeks; n = 151, > 34 weeks). Corresponding vaginal delivery rates were 32% for gestations of less than 30 weeks, 61% at 30-31 weeks, and 62% at 32-33 weeks. Similarly, 27% of patients with a platelet count of less than 75,000/uL and 52% with a platelet count of less than 100,000/uL who received high-dose corticosteroids during the study interval subsequently achieved a 100,000/uL threshold in time to perform regional anesthesia for delivery. CONCLUSION Administration of intravenous high-dose corticosteroids for preterm HELLP syndrome increases probability of successful labor induction and candidacy for regional anesthesia. LEVEL OF EVIDENCE II-3.
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Affiliation(s)
- Carl H Rose
- Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, Mississippi 39216-4505, USA.
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Barton JR, Sibai BM. Diagnosis and management of hemolysis, elevated liver enzymes, and low platelets syndrome. Clin Perinatol 2004; 31:807-33, vii. [PMID: 15519429 DOI: 10.1016/j.clp.2004.06.008] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- John R Barton
- Central Baptist Hospital, Perinatal Diagnostic Center, 1740 Nicholasville Road, Lexington, KY 40503-1499, USA.
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Henry CS, Biedermann SA, Campbell MF, Guntupalli JS. Spectrum of hypertensive emergencies in pregnancy. Crit Care Clin 2004; 20:697-712, ix. [PMID: 15388197 DOI: 10.1016/j.ccc.2004.05.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Hypertension in pregnancy represents a spectrum of clinical entities, including pregnancy-induced hypertension (PIH), preeclampsia, eclampsia, and hemolysis, elevated liver enzyme levels, low platelet count syndrome. Although hypertension is a common denominator in this group of disorders, the pathogenesis, clinical features, and clinical course of these disorders is variable and somewhat distinct. Therapy must be tailored to the clinical entity and the patient. The incidence and prevalence of preeclampsia and eclampsia is decreasing worldwide. This decrease partly may be caused by the improved treatment of PIH and improved obstetrical services.
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Affiliation(s)
- Charles S Henry
- Division of Renal Diseases and Hypertension, Department of Internal Medicine, University of Texas Medical School, 6431 Fannin, MSB 4.126, Houston, TX 77030, USA
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Clenney TL, Viera AJ. Corticosteroids for HELLP (haemolysis, elevated liver enzymes, low platelets) syndrome. BMJ 2004; 329:270-2. [PMID: 15284151 PMCID: PMC498027 DOI: 10.1136/bmj.329.7460.270] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/13/2004] [Indexed: 11/04/2022]
Affiliation(s)
- Timothy L Clenney
- Uniformed Services University of Health Sciences, F Edward Hébert School of Medicine, Bethesda, MD, USA.
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