Results of the pregnancies with HELLP syndrome

Targeting Neutrophil Extracellular Trap Formation: Exploring Promising Pharmacological Strategies for the Treatment of Preeclampsia

Neutrophils, which constitute the most abundant leukocytes in human blood, emerge as crucial players in the induction of endothelial cell death and the modulation of endothelial cell responses under both physiological and pathological conditions. The hallmark of preeclampsia is endothelial dysfunction induced by systemic inflammation, in which neutrophils, particularly through the formation of neutrophil extracellular traps (NETs), play a pivotal role in the development and perpetuation of endothelial dysfunction and the hypertensive state. Considering the potential of numerous pharmaceutical agents to attenuate NET formation (NETosis) in preeclampsia, a comprehensive assessment of the extensively studied candidates becomes imperative. This review aims to identify mechanisms associated with the induction and negative regulation of NETs in the context of preeclampsia. We discuss potential drugs to modulate NETosis, such as NF-κβ inhibitors, vitamin D, and aspirin, and their association with mutagenicity and genotoxicity. Strong evidence supports the notion that molecules involved in the activation of NETs could serve as promising targets for the treatment of preeclampsia.

The role of haptoglobin in the diagnosis of preeclampsia and HELLP syndrome and in predicting neonatal outcomes

OBJECTIVE

The study aimed to determine whether maternal serum haptoglobin values could have an effect on predicting diagnosis and neonatal outcomes in preeclampsia and HELLP syndrome.

MATERIALS AND METHODS

Hundred sixteen pregnant women who met the inclusion criteria were included in the study. To evaluate whether serum haptoglobin level in maternal blood could be used in early diagnosis of preeclampsia and HELLP syndrome, 49 pregnant women diagnosed with preeclampsia and 13 pregnant women diagnosed with HELLP syndrome were included in the study group, and 54 healthy pregnant women in the control group. The groups were compared regarding maternal serum haptoglobin level, platelet count, ALT, AST, LDH, and uric acid levels. Moreover, the age, obstetric histories, and newborn outcomes of all pregnant women were recorded and compared between groups.

RESULTS

The mean haptoglobin values were 0.29 ± 0.23 g/L in the HELLP syndrome group, 1.01 ± 0.52 g/L in the preeclampsia group, and 1.16 ± 0.37 g/L in the control group. The mean haptoglobin result was lower in the HELLP syndrome group compared to the preeclampsia and control groups (p < 0.001). While the differences between HELLP syndrome and the control and preeclampsia groups were statistically significant, no significant difference was determined between the preeclampsia and control groups. There was a significant positive correlation between haptoglobin value with the week of delivery, umbilical cord pH value, and the first and fifth-minute Apgar scores (p < 0.05).

CONCLUSION

It was concluded that haptoglobin values could be used together with other biochemical parameters to diagnose HELLP syndrome and predict newborn outcomes.

Can SIRI or other inflammatory indices predict HELLP syndrome in the first trimester?

OBJECTIVE

To investigate the use of systemic immune-response index (SIRI) and other inflammatory indices for the prediction of HELLP syndrome STUDY DESIGN: The presented retrospective case-control study was conducted with twenty-eight pregnant women diagnosed with HELLP syndrome and 100 low-risk pregnant women. The possible predictive indices for HELLP syndrome were determined as NLR (neutrophil/lymphocyte), MLR (monocyte/lymphocyte), HbLR (hemoglobin/lymphocyte), SII (neutrophil×platelet/lymphocyte), and SIRI (neutrophil×monocyte/lymphocyte). The indices were evaluated in the first trimester and at the admission time for delivery for all participants. The statistical analyses were carried out using SPSS 23. Descriptive statistics were presented as the mean and standard deviation (SD), as they conform to a normal distribution. To compare the parameters between the groups, the Student-t test was used. Categorical variables were presented as numbers and percentages. The chi-square test was used to compare categorical variables between groups. The paired sample t-test was used to compare correlated samples. Statistical significance was defined as a two-tailed P value of 0.05.

RESULTS

In the first trimester; WBC, neutrophil, and monocyte counts were statistically higher in the HELLP syndrome group. However, no significant difference was observed between the groups for the concerned indices. The hemoglobin, WBC, neutrophil, monocyte counts, NLR, SIRI and MLR were significantly higher in the HELLP group at the delivery time. Platelet count was decreased and ALT/AST counts and adverse outcomes were found to be significantly higher at delivery time admission in the HELLP syndrome group.

CONCLUSION

To the best of our knowledge, this was the first study investigating SIRI with the other indices for the prediction of HELLP syndrome in accordance with its inflammatory etiology. The underlying inflammatory process was observed at the delivery time. However, none of the investigated indices was found effective in the first trimester in the prediction. Simple and non-invasive prediction indices might be valuable tools for the prediction and management of HELLP syndrome. Further and larger studies are needed for this purpose.

Preeclampsia pathophysiology and adverse outcomes during pregnancy and postpartum

Background

Preeclampsia is a disease with far-reaching consequences that extend beyond the immediate postpartum period and have a significant impact later in life. Preeclampsia exerts an effect on most organ systems in the body. These sequelae are mediated in part by the incompletely elucidated pathophysiology of preeclampsia and the associated vascular changes.

Content

Current research focuses on unraveling the pathophysiology of preeclampsia with the goal of implementing accurate screening and treatment modalities based on disease development and progression. Preeclampsia causes significant short- and long-term maternal morbidity and mortality, not only in the cardiovascular system but also in other organ systems throughout the body. This impact persists beyond pregnancy and the immediate postpartum period.

Summary

The goal of this review is to discuss the current understanding of the pathophysiology of preeclampsia as it relates to the adverse health consequences in patients impacted by this disease, along with a brief discussion of ways to improve overall outcomes.

Do Case Reports and Case Series Generate Clinical Discoveries About Preeclampsia? A Systematic Review

Background

Preeclampsia is a leading cause of maternal and perinatal mortality and morbidity. The management of preeclampsia has not changed much in more than two decades, and its aetiology is still not fully understood. Case reports and case series have traditionally been used to communicate new knowledge about existing conditions. Whether this is true for preeclampsia is not known.

Objective

To determine whether recent case reports or case series have generated new knowledge and clinical discoveries about preeclampsia.

Methods

A detailed search strategy was developed in consultation with a medical librarian. Two bibliographic databases were searched through Ovid: Embase and MEDLINE. We selected case reports or case series published between 2015 and 2020, comprising pregnant persons diagnosed with hypertensive disorders of pregnancy, including preeclampsia. Two reviewers independently screened all publications. One reviewer extracted data from included studies, while another conducted a quality check of extracted data. We developed a codebook to guide our data extraction and outcomes assessment. The quality of each report was determined based on Joanna Briggs Institute (JBI) critical appraisal checklist for case reports and case series.

Results

We included 104 case reports and three case series, together comprising 118 pregnancies. A severe presentation or complication of preeclampsia was reported in 81% of pregnancies, and 84% had a positive maternal outcome, free of death or persistent complications. Only 8% of the case reports were deemed to be of high quality, and 53.8% of moderate quality; none of the case series were of high quality. A total of 26 of the 107 publications (24.3%) included a novel clinical discovery as a central theme.

Conclusion

Over two-thirds of recent case reports and case series about preeclampsia do not appear to present new knowledge or discoveries about preeclampsia, and most are of low quality.

Hepatitis E and Pregnancy: An Unholy Alliance Unmasked from Kashmir, India

The adverse relationship between viral hepatitis and pregnancy in developing countries had been interpreted as a reflection of retrospectively biased hospital-based data collection by the West. However, the discovery of hepatitis E virus (HEV) as the etiological agent of an epidemic of non-A, non-B hepatitis in Kashmir, and the documenting of the increased incidence and severity of hepatitis E in pregnancy via a house-to-house survey, unmasked this unholy alliance. In the Hepeviridae family, HEV-genotype (gt)1 from genus Orthohepevirus A has a unique open reading frame (ORF)4-encoded protein which enhances viral polymerase activity and viral replication. The epidemics caused by HEV-gt1, but not any other Orthohepevirus A genotype, show an adverse relationship with pregnancy in humans. The pathogenesis of the association is complex and at present not well understood. Possibly multiple factors play a role in causing severe liver disease in the pregnant women including infection and damage to the maternal-fetal interface by HEV-gt1; vertical transmission of HEV to fetus causing severe fetal/neonatal hepatitis; and combined viral and hormone related immune dysfunction of diverse nature in the pregnant women, promoting viral replication. Management is multidisciplinary and needs a close watch for the development and management of acute liver failure. (ALF). Preliminary data suggest beneficial maternal outcomes by early termination of pregnancy in patients with lower grades of encephalopathy.

Manejo de la ruptura hepática espontánea en el síndrome de HELLP

Introducción. El síndrome de HELLP es una variante grave de la preeclampsia, con una baja incidencia, entre el 0,5-0,9 % de todos los embarazos. La ruptura hepática espontánea en el embarazo es infrecuente, presenta una alta mortalidad, y se ha relacionado con hemangiomas hepáticos, coriocarcinoma y síndrome de HELLP. Caso clínico. Mujer de 29 años con embarazo de 34,3 semanas, con actividad uterina progresiva, sufrimiento fetal agudo y hallazgos compatibles con síndrome de HELLP. Se practicó cesárea de urgencia encontrando hemoperitoneo y ruptura hepática del lóbulo derecho, por lo que se realizó empaquetamiento abdominal y posterior reintervención quirúrgica. Discusión. La ruptura hepática espontánea en el embarazo es una entidad infrecuente y potencialmente mortal. Es esencial un alto nivel de sospecha para realizar el diagnóstico y la rápida intervención. Requiere un manejo multidisciplinario para un resultado exitoso. Se han descrito múltiples tratamientos que dependen de las manifestaciones clínicas y extensión de la lesión, pero es claro que la laparotomía primaria y el taponamiento constituyen la mejor elección ante el hallazgo intraoperatorio

Effect of HELLP syndrome on acute kidney injury in pregnancy and pregnancy outcomes: a systematic review and meta-analysis

Background

HELLP syndrome may increase adverse pregnancy outcomes, though the incidence of it is not high. At present, the impact of HELLP syndrome on P-AKI (acute kidney injury during pregnancy) and maternal and infant outcomes is controversial. Thus, we conducted a meta-analysis to find out more about the relationship between HELLP syndrome and P-AKI and pregnancy outcomes.

Methods

We systematically searched PubMed, Embassy and Cochrane Databases for cohort studies and RCT to assess the effect of HELLP syndrome on P-AKI and maternal and infant outcomes. Study-specific risk estimates were combined by using fixed-effect or random-effect models.

Results

This meta-analysis included 11 cohort studies with a total of 6333 Participants, including 355 cases of pregnant women with HELLP syndrome and 5979 cases that without. HELLP syndrome was associated with relatively higher risk of P-AKI (OR4.87 95% CI 3.31 ~ 7.17, P<0.001), fetal mortality (OR1.56 95% CI 1.45 ~ 2.11, P<0.001) and Maternal death (OR3.70 95% CI 1.72 ~ 7.99, P<0.001).

Conclusions

HELLP syndrome is associated with relatively higher risk of P-AKI, fetal mortality and maternal death.

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

Background:

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

Objectives:

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

Case Reports:

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

Conclusion:

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

Physiological changes of pregnancy and the Swansea criteria in diagnosing acute fatty liver of pregnancy

The Swansea criteria are used to assess the likelihood of acute fatty liver of pregnancy. There are significant physiological changes in normal pregnancy in several of the pathology parameters used in the Swansea criteria. This may impact the sensitivity and specificity of the Swansea criteria. Five of the 11 case series reporting laboratory values in acute fatty liver of pregnancy used values divergent from the Swansea criteria. When using the Swansea criteria for diagnosis of acute fatty liver of pregnancy, using pregnancy-specific and/or laboratory-specific reference intervals is recommended. Simpler diagnostic criteria using parameters of hepatocellular damage and hepatic synthetic dysfunction may be an alternative to the Swansea criteria, and further studies investigating the sensitivity and specificity of these parameters would be useful.

Review article: Investigations and the pregnant woman in the emergency department - part 1: Laboratory investigations

Accurate assessment of the pregnant patient in the ED depends on knowledge of physiological changes in pregnancy, and how these changes may impact on pathology tests, appearance on point-of-care ultrasound and electrocardiography. In addition the emergency physician needs to be cognisant of disorders that are unique to or more common in pregnancy. Part 1 of this review addresses potential deviations in laboratory investigation reference intervals resulting from physiological alterations in pregnancy, and the important causes of abnormal laboratory results in pregnancy. Part 2 will address the role of point-of-care ultrasound in pregnancy, physiological changes that may affect interpretation of point-of-care ultrasound, physiological changes in electrocardiography, and the safety of radiological procedures in the pregnant patient.

Acute Kidney Injury in Pregnancy-specific Disorders

The incidence of acute kidney injury in pregnancy (P-AKI) has declined significantly over the last three decades in developing countries. However, it is still associated with significant fetomaternal mortality and morbidity. The diagnosis of P-AKI is based on the serum creatinine increase. The usual formulas for estimating glomerular filtration rate (GFR) are not validated in this population. The incidence of P-AKI with respect to total AKI cases has decreased in the last three decades from 25% in 1980s to 9% in 2000s at our centre. During the first trimester of gestation, AKI develops most often due to septic abortion or hyperemesis gravidarum. Septic abortion related AKI with respect to total AKI decreased from 9% to 5% in our study. Prevention of unwanted pregnancy and avoidance of septic abortion are keys to eliminate abortion associated AKI in early pregnancy. However, we have not seen AKI on account of hyperemesis gravidarum over a period of 33 years at our center. In the third trimester, the differential diagnosis of AKI in association with pregnancy specific conditions namely preeclampsia/HELLP syndrome, acute fatty liver of pregnancy and thrombotic microangiopathies of pregnancy (P-TMA) is more challenging, because these 3 conditions share several clinical features of thrombotic microangiopathy which makes the diagnosis very difficult on clinical grounds. It is imperative to distinguish these conditions to make appropriate therapeutic decisions. Typically, AFLP and HELLP syndrome improve after delivery of the fetus, whereas plasma exchange is the first-line treatment for pregnancy associated thrombotic microangioathies (P-TMA). We observed that preclampsia/eclampsia is the most common cause of AKI in late third trimester and postpartum periods followed by puerperal sepsis and postpartum hemorrhage. Pregnancy-associated thrombotic microangiopathies (aHUS/TTP) and AFLP are rare causes of AKI during pregnancy in developing countries.

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

Introduction

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

Case Report

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

Conclusion

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

Two Cases of Severe Preeclampsia Were Diagnosed with HELLP Postpartum after Caesarian Section

HELLP occurs in 0.5%-0.9% of all pregnancies. About 30% of the cases happen within 48 hours after delivery. Women with postpartum HELLP syndrome have significantly higher incidences of complications. Because of the absence of classical signs of preeclampsia, it can confuse physicians and lead to delay in diagnosis. Therefore, it is associated with serious maternal morbidity. We present two cases of acute postpartum HELLP syndrome after caesarean section following severe preeclampsia. Our cases were successfully managed with the timely diagnosis and therapy.

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

BACKGROUND AND OBJECTIVE

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

CASE REPORT

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

CONCLUSIONS

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

Acute renal failure in pregnancy: Tertiary centre experience from north Indian population

Background:

Obstetrical acute renal failure ARF is now a rare entity in the developed countries but still a common occurrence in developing countries. Delay in the diagnosis and late referral is associated with increased mortality. This study aimed to evaluate the contributing factors responsible for pregnancy-related acute kidney failure, its relation with mortality and morbidity and outcome measures in these patients.

Materials and Methods:

Total 520 patients of ARF of various aetiology were admitted, out of these 60 (11.5%) patients were pregnancy-related acute renal failure.

Results:

ARF Acute renal failure occurred in 32 (53.3%) cases in early part of their pregnancy, whereas in 28 (46.7%) cases in later of the pregnancy. Thirty-two (53.3%) patients had not received any antenatal visit, and had home delivery, 20 (33.4%) patients had delivered in hospitals but without antenatal care and eight (13.3%) patients received antenatal care and delivered in the hospitals. Anuria was observed in 23 (38.3%) cases, remaining 37 (61.7%) cases presented with oliguria. Septicemia was present in 25 (41.7%), hypertensive disorder of pregnancy in 20 (33.3%), haemorrhage in eight (13.3%), abortion in 5 (8.3%), haemolysis elevated liver enzymes low platelets counts (HELLP) syndrome in one (1.67%) and disseminated intravascular coagulation in one (1.67%). (61.7%) patients were not dialyzed, 33 (55%) recovered normal renal function with conservative treatment. Complete recovery was observed in 45 (75%) patients, five (8.4%) patients developed irreversible renal failure. Maternal mortality was nine (15%) and foetal loss was 25 (41.7%).

Conclusion:

Pregnancy-related ARF is usually a consequence of obstetric complications; it carries very high morbidity and mortality.

Postpartum HELLP syndrome--the case of lost battle

Unexpected rapid maternal death after delivery due to HELLP syndrome is rarely encountered and may become the subject of forensic expertise. Unexpectedness, suddenness, and fulminant course of this syndrome as well as absence of classical signs of pre-eclampsia can confuse physicians and lead to diagnostic delay. A definitive post-mortem diagnosis of HELLP syndrome in questionable cases of maternal death should be based on accepted laboratory criteria and characteristic histopathological alterations. We present a case of acute postpartum HELLP syndrome complicated by disseminated intravascular coagulation and acute renal failure which caused rapid maternal death only 20 hours after a caesarean section following an uncomplicated pregnancy.

Diagnosis and management of maternal thrombocytopenia in pregnancy

Thrombocytopenia is a common finding in pregnancy, occurring in approximately 7-10% of pregnancies. It may be a diagnostic and management problem, and has many causes, some of which are specific to pregnancy. Although most cases of thrombocytopenia in pregnancy are mild, and have no adverse outcome for either mother or baby, occasionally a low platelet count may be part of a more complex disorder with significant morbidity and may be life-threatening. Overall, about 75% of cases are due to gestational thrombocytopenia, 15-20% secondary to hypertensive disorders; 3-4% due to an immune process, and the remaining 1-2% made up of rare constitutional thrombocytopenias, infections and malignancies. In this review, a diagnostic approach to investigating thrombocytopenia in pregnancy is presented, together with antenatal, anaesthetic and peri-natal management issues for mother and baby, followed by a detailed discussion on the specific causes of thrombocytopenia and the management options in each case.

Do clinical and laboratory parameters effect maternal and fetal outcomes in pregnancies complicated with hemolysis, elevated liver enzymes, and low platelet count syndrome?

OBJECTIVE

The aim of the study was to investigate whether the clinical features and laboratory parameters affect maternal and fetal outcomes in pregnancies complicated with HELLP syndrome.

MATERIAL AND METHODS

The medical records of pregnant patients complicated with HELLP syndrome were analyzed retrospectively between June 01, 2003 and June 01, 2010. The demographic data, medical history, admission symptoms, clinical and laboratory findings and recovery time were evaluated. The adverse maternal outcomes including eclampsia, placental abruption, disseminated intravascular coagulation, postpartum hemorrhage, pulmonary complications, cerebral edema and visual loss were recorded. Fetal growth restriction, necessity for neonatal intensive care unit admission and perinatal mortality were recorded as an adverse fetal outcome.

RESULTS

The incidence of HELLP syndrome was 0.52%. The mean age of the patients was 28.93±7.90 (range 17-45). HELLP syndrome was diagnosed on average in the 33.68±4.41(th) (ranged 24-40) week of gestation. Eighteen cases (40.9%) were nullipara and twenty-six cases (59.1%) multipara. The most common complications were eclampsia (40.9%) and abruption placenta (15.9%). Pregnancy was terminated within 48 hours in all patients. The rate of cesarean section was 90.9%. Perinatal mortality rate in HELLP syndrome was 31.8%. There was no maternal mortality.

CONCLUSION

Neither clinical characteristics nor laboratory parameters was found effective for prediction of adverse maternal and fetal outcomes.

The HELLP syndrome: clinical issues and management. A Review

BACKGROUND

The HELLP syndrome is a serious complication in pregnancy characterized by haemolysis, elevated liver enzymes and low platelet count occurring in 0.5 to 0.9% of all pregnancies and in 10-20% of cases with severe preeclampsia. The present review highlights occurrence, diagnosis, complications, surveillance, corticosteroid treatment, mode of delivery and risk of recurrence.

METHODS

Clinical reports and reviews published between 2000 and 2008 were screened using Pub Med and Cochrane databases.

RESULTS AND CONCLUSION

About 70% of the cases develop before delivery, the majority between the 27th and 37th gestational weeks; the remainder within 48 hours after delivery. The HELLP syndrome may be complete or incomplete. In the Tennessee Classification System diagnostic criteria for HELLP are haemolysis with increased LDH (> 600 U/L), AST (>or= 70 U/L), and platelets < 100 x 10(9)/L. The Mississippi Triple-class HELLP System further classifies the disorder by the nadir platelet counts. The syndrome is a progressive condition and serious complications are frequent. Conservative treatment (>or= 48 hours) is controversial but may be considered in selected cases < 34 weeks' gestation. Delivery is indicated if the HELLP syndrome occurs after the 34th gestational week or the foetal and/or maternal conditions deteriorate. Vaginal delivery is preferable. If the cervix is unfavourable, it is reasonable to induce cervical ripening and then labour. In gestational ages between 24 and 34 weeks most authors prefer a single course of corticosteroid therapy for foetal lung maturation, either 2 doses of 12 mg betamethasone 24 hours apart or 6 mg or dexamethasone 12 hours apart before delivery. Standard corticosteroid treatment is, however, of uncertain clinical value in the maternal HELLP syndrome. High-dose treatment and repeated doses should be avoided for fear of long-term adverse effects on the foetal brain. Before 34 weeks' gestation, delivery should be performed if the maternal condition worsens or signs of intrauterine foetal distress occur. Blood pressure should be kept below 155/105 mmHg. Close surveillance of the mother should be continued for at least 48 hours after delivery.

Factor H, membrane cofactor protein, and factor I mutations in patients with hemolysis, elevated liver enzymes, and low platelet count syndrome

The HELLP syndrome, defined by the existence of hemolysis, elevated liver enzymes, and low platelet count, is a serious complication of pregnancy-related hypertensive disorders and shares several clinical and biologic features with thrombotic microangiopathy (TMA). Several recent studies have clearly shown that an abnormal control of the complement alternative pathway is a major risk for the occurrence of a peculiar type of TMA involving mainly the kidney. The aim of this study was to screen for complement abnormalities in 11 patients with HELLP syndrome and renal involvement. We identified 4 patients with a mutation in one of the genes coding for proteins involved in the regulation of the alternative pathway of complement. Our results suggest that an abnormal control of the complement alternative pathway is a risk factor for the occurrence of HELLP syndrome.

Perinatal outcome with HELLP/partial HELLP complicating hypertensive disorders of pregnancy. An Indian rural experience

A total of 615 women with hypertensive disorders during pregnancy were the study subjects. Of these, 145 (23.58%) women had HELLP or partial HELLP (only one or two of the three components H,EL, LP). Overall, eight (1.3%), i.e. five out of 399 primigravida (1.2%) and three of the 216 multigravida (1.3%), had complete HELLP and the remaining 137 (22.2%) had partial HELLP. Of the 399 primigravida with hypertensive disorders, 107 (26.5%) had partial HELLP, statistically significantly more (p<0.002) than the 30 out of the 216 (13.8%) multigravida. In 210 (44.6%) out of 470 women with hypertension without HELLP/partial HELLP, labour was induced and the perinatal mortality rate (PMR) was 138.9 (58.06 in term and 363.63 in pre-term cases), and in the other 260 women in whom labour was not induced, PMR was 96.15 (in term cases 74.07 and in pre-term 120). Among the women with HELLP/partial HELLP (145), out of the 64 women in whom labour was induced, the PMR was 359.37 (235.29 in term and 500 in pre-term) and of those in whom labour was not induced (81), PMR was 209.87 (106 in term cases and 352.94 in pre-term). All the eight women with the full HELLP syndrome had labour induced, the PMR in these cases was 500. Overall, in women with HELLP/partial HELLP, the PMR was 275.8 and in the remainder with hypertensive disorders without HELLP/partial HELLP, it was 114.89.

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

Antepartum or postpartum HELLP syndrome constitutes an obstetric emergency that requires expert knowledge and management skills. The insidious and variable nature of disease presentation and progression challenges the clinician and complicates consensus on universally accepted diagnostic and classification criteria. A critical review of published research about this variant form of severe preeclampsia, focused primarily on what is known about the pathogenesis of this disorder as it relates to patient experience with corticosteroids for its management, leads to the conclusion that there is maternal-fetal benefit realized when potent glucocorticoids are aggressively used for its treatment. Although acknowledging the need for definitive multicenter trials to better define the limits of benefit and the presence of any maternal or fetal risk, and given an understanding of the nature of the disorder with its potential to cause considerable maternal morbidity and mortality, we recommend for the present that aggressively used potent glucocorticoids constitute the cornerstone of management for patients considered to have HELLP syndrome.

The diagnosis of acute renal failure in intensive care: mongrel or pedigree?

Acute renal failure is common in the intensive care unit; it is well recognised that patients who develop acute renal failure have a high mortality rate. While there have been improvements in the management of acute renal failure, the mortality remains high. Acute renal failure is easily diagnosed biochemically and clinically but it is not a single disease entity. It is a syndrome that affects a very heterogeneous population. Studies of acute renal failure and of the impact of renal replacement therapy in intensive care are usually inconclusive, which may be the natural consequence of studying a syndrome. This article focuses on the more uncertain features of acute renal failure, the problems of investigating acute renal failure as a disease and the difficulties of applying the results of a study of a heterogeneous population to the management of individuals.

Maternal and fetal outcomes in HELLP syndrome complicated with acute renal failure

OBJECTIVE

This study reviews maternal and fetal outcomes in HELLP syndrome complicated with acute renal failure (ARF), and compares clinical and laboratory findings of the cases of HELLP syndrome that did not develop ARF.

MATERIALS AND METHODS

All pregnant women with hypertensive disorders admitted or referred to the maternal and fetal unit were recorded into a perinatal database between January 15, 2002 and September 15, 2003. During the study period, out of 615 cases of hypertensive pregnancy, we followed and delivered 347 cases of severe preeclampsia, of them 132 cases were diagnosed as HELLP syndrome. ARF was defined as creatinine level > or =1.2 mg/dL and/or oliguria <400 mL/24 hr. The cases were divided into three groups on the basis of the highest creatinine level recorded during hospitalization: creatinine <1.2 mg/dL, creatinine > or =1.2 to 2.0 mg/dL, and creatinine > or =2.0 mg/dL. Statistical comparisons were performed by Student t test, X2 analysis, and Fisher's Exact test as appropriate. The value of P < .05 was considered significant.

RESULTS

ARF developed in 8.9% (n:31) of severe preeclampsia (n:347); of them, 15 (4.3%) cases were nonoliguric, and all had mildly elevated creatinine levels between 1.2 and 1.9 mg/dL. Moderately elevated creatinine levels were 2 to 3.9 mg/dL in 10 cases, and severely elevated creatinine levels were 4 to 8.4 mg/dL in 6 cases, for a total of 16 (4.6%) cases; creatinine levels were > or =2.0 mg/dL (range: 2.0-8.4 mg/dL). HELLP syndrome was the most frequent cause of ARF, 64.5% (n:20/31), and was observed in 15% (n:20) of 132 cases of HELLP syndrome. Fourteen (88%) of 16 cases that had oliguria and creatinine levels > or =2 mg/dL were detected in HELLP syndrome (n:14/132; 10.6%). Major maternal complications in HELLP syndrome with ARF and creatinine level > or =2 mg/dL in the study group were abruptio placentae (42.8%; n:6/14), incisional hematoma (21%; n:3/14), pulmonary edema (14%; n:2/14), cesarean hysterectomy (7%; n: 1/14), and dialysis (50%; n:7/14). There was no maternal mortality. All patients complicated with ARF were discharged without renal impairment. Perinatal mortality was 26.1% in the cases of HELLP syndrome with ARF-creatinine > or =1.2 mg/dL and further increased to 37.5% when creatinine levels were above 2.0 mg/dL, compared with 11.8% in the cases having creatinine <2.0 mg/dL, and the difference was statistically significant (p:.007).

CONCLUSIONS

The most contributing factors leading to ARF in HELLP syndrome were abruptio placentae and HELLP syndrome complicated with ARF, particularly, oliguric ARF has relatively higher maternal complications and perinatal mortality.