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Kasem AF, Alqenawy HB, Elgendi MA, Ali RR, Ahmed RH, Sorour MN, Hegab KM, El-Skaan RG, El Helw RH, Elsewefy MS, Abdelrazek MM, Elrefaey YM, Albahaie MY, Salama MH, Nabhan AF. Corticosteroids for improving patient-relevant outcomes in HELLP syndrome: a systematic review and meta-analysis. BMC Pregnancy Childbirth 2024; 24:487. [PMID: 39026148 PMCID: PMC11264471 DOI: 10.1186/s12884-024-06665-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 06/28/2024] [Indexed: 07/20/2024] Open
Abstract
BACKGROUND We conducted this updated systematic review to assess the effects of corticosteroids vs. placebo or no treatment for improving patient-relevant outcomes in hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome. METHODS CENTRAL, MEDLINE/PubMed, Web of Science, and Scopus, from the date of inception of the databases to February 3, 2024 were searched. Reference lists of included studies and systematic reviews were thoroughly searched. We included RCTs that enrolled women with HELLP syndrome, whether antepartum or postpartum, to receive any corticosteroid versus placebo or no treatment. No language or publication date restrictions were made. We used a dual independent approach for screening titles and abstracts, full text screening, and data extraction. Risk of bias was assessed in the included studies using Cochrane's RoB 2 tool. Pairwise meta-analyses were conducted, where two or more studies met methodological criteria for inclusion. GRADE approach was used to assess certainty of evidence for the pre-specified outcomes. RESULTS Fifteen trials (821 women) compared corticosteroids with placebo or no treatment. The effect of corticosteroids is uncertain for the primary outcome i.e., maternal death (risk ratio [RR] 0.77, 95% confidence interval [CI] 0.25 to 2.38, very low certainty evidence). Out of 6 studies reporting maternal death, 5 were judged overall to have "low risk" of bias. The effect of corticosteroids is also uncertain for other important outcomes including pulmonary edema (RR 0.70, 95% CI 0.23 to 2.09), dialysis (RR 3, 95% CI 0.13 to 70.78), liver morbidity (hematoma, rupture, and failure; RR 0.22, 95% CI 0.03 to 1.83), or perinatal death (0.64, 95% CI 0.21 to 1.97) because of very low certainty evidence. Low certainty evidence suggests that corticosteroids have little or no effect on the need for platelet transfusion (RR 0.98, 95% CI 0.60 to 1.60) and may result in a slight reduction in acute renal failure (RR 0.67, 95% CI 0.40 to 1.12). Subgroup and sensitivity analyses showed results that were similar to the primary synthesis. CONCLUSIONS In women with HELLP syndrome, the effect of corticosteroids vs. placebo or no treatment is uncertain for patient-relevant outcomes including maternal death, maternal morbidity, and perinatal death. These uncertainties regarding this critical question should be addressed by adequately powered rigorous trials. SYSTEMATIC REVIEW REGISTRATION Center for Open Science, osf.io/yzku5.
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Affiliation(s)
- Asmaa F Kasem
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Ramses Street, Cairo, 11591, Egypt
| | - Hamdy B Alqenawy
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Ramses Street, Cairo, 11591, Egypt.
| | - Marwa A Elgendi
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Ramses Street, Cairo, 11591, Egypt
| | - Radwa R Ali
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Ramses Street, Cairo, 11591, Egypt
| | - Rania Hm Ahmed
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Ramses Street, Cairo, 11591, Egypt
| | - Mohammad N Sorour
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Ramses Street, Cairo, 11591, Egypt
| | - Khadiga Mh Hegab
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Ramses Street, Cairo, 11591, Egypt
| | - Rania G El-Skaan
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Ramses Street, Cairo, 11591, Egypt
| | - Rowyna H El Helw
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Ramses Street, Cairo, 11591, Egypt
| | - Mohamed S Elsewefy
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Ramses Street, Cairo, 11591, Egypt
| | - Maya M Abdelrazek
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Ramses Street, Cairo, 11591, Egypt
| | - Yasser M Elrefaey
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Ramses Street, Cairo, 11591, Egypt
| | - Mohamed Yg Albahaie
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Ramses Street, Cairo, 11591, Egypt
| | - Mohamed H Salama
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Ramses Street, Cairo, 11591, Egypt
| | - Ashraf F Nabhan
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Ramses Street, Cairo, 11591, Egypt
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Sun WJ, Hu J, Zhang Q, Shan JM. Administration of corticosteroid therapy for HELLP syndrome in pregnant women: evidences from seven randomized controlled trials. Hypertens Pregnancy 2023; 42:2276726. [PMID: 37937841 DOI: 10.1080/10641955.2023.2276726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 10/20/2023] [Indexed: 11/09/2023]
Abstract
BACKGROUND HELLP syndrome, featuring hemolysis, elevated liver enzymes, and thrombocytopenia, is life-threatening disease of pregnancy that triggers comorbidities in both pregnant women and the fetus/newborn. This study provides an updated systematic review and meta-analysis of relevant studies to assess the therapeutic efficacy of corticosteroids in maternal and neonatal outcomes. METHODS Randomized control trials (RCTs) regarding the use of corticosteroids in the HELLP population from three electronic databases, including Ovid MEDLINE, Ovid EMBASE, andCochrane Central Register of Controlled Trials, were searched from database inception to 23 March 202323 March 2023. RESULTS A total of 485 patients treated with corticosteroids from 7 RCTs were included. Compared to placebo, corticosteroids therapy failed to significantly improve the maternal outcomes regard to maternal morbidity (RR = 1.36, 95%CI [0.45, 4.10]), eclampsia (RR = 1.16, 95%CI [0.76, 1.77]), acute renal failure (RR = 0.71, 95%CI [0.41, 1.22]), pulmonary edema (RR = 0.34, 95%CI [0.10, 1.15]) and oliguria (RR = 1.08, 95%CI [0.75, 1.54]). In addition, pooled data showed that it wasn't significant differences between corticosteroids therapy and placebo regarding neonatal outcomes. CONCLUSIONS This study compared the efficacy of corticosteroids in patients with HELLP syndrome, revealing that corticosteroids did not provide any significant benefit in clinical outcomes for pregnant women and newborns with HELLP. The conclusions of this study must be verified by a larger sample of high-quality RCTs.
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Affiliation(s)
- Wei-Jing Sun
- Department of Obstetrics and Gynecology, Yancheng Third People's Hospital, The Yancheng School of Clinical Medicine of Nanjing Medical University, Yancheng, Jiangsu, China
| | - Jing Hu
- Department of Obstetrics and Gynecology, Yancheng Third People's Hospital, The Yancheng School of Clinical Medicine of Nanjing Medical University, Yancheng, Jiangsu, China
| | - Qing Zhang
- Medical College, Jiangsu Vocational College of Medicine, Yancheng, Jiangsu, China
| | - Jin-Mei Shan
- Department of Obstetrics and Gynecology, Yancheng Third People's Hospital, The Yancheng School of Clinical Medicine of Nanjing Medical University, Yancheng, Jiangsu, China
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Cairns AE, Pealing L, Duffy JMN, Roberts N, Tucker KL, Leeson P, MacKillop LH, McManus RJ. Postpartum management of hypertensive disorders of pregnancy: a systematic review. BMJ Open 2017; 7:e018696. [PMID: 29187414 PMCID: PMC5719299 DOI: 10.1136/bmjopen-2017-018696] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 10/02/2017] [Accepted: 10/06/2017] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES Hypertensive disorders of pregnancy (HDP) affect one in ten pregnancies and often persist postpartum when complications can occur. We aimed to determine the effectiveness and safety of pharmacological interventions, other interventions and different care models for postpartum hypertension management. DESIGN A systematic review was undertaken. Nine electronic databases, including Medline, were searched from inception to 16 March 2017. After duplicate removal, 4561 records were screened. Two authors independently selected studies, extracted study characteristics and data, and assessed methodological quality. SETTING Randomised controlled trials, case-control studies and cohort studies from any country and healthcare setting. PARTICIPANTS Postnatal women with HDP. INTERVENTIONS Therapeutic intervention for management of hypertension, compared with another intervention, placebo or no intervention. PRIMARY AND SECONDARY OUTCOME MEASURES Outcome data were collected for maternal mortality and severe morbidity; systolic, diastolic and mean arterial blood pressure (BP) control; and safety data. Secondary outcome data collected included the length of postnatal hospital stay and laboratory values. RESULTS 39 studies were included (n=2901). Results were heterogeneous in terms of intervention, comparison and outcome requiring a narrative approach. There were insufficient data to recommend any single pharmacological intervention. 18 studies reported calcium-channel blockers, vasodilators and beta-blockers lowered BP postpartum. 12 of these reported safety data. Limited data existed regarding management in the weeks following hospital discharge. Neither loop diuretics (three studies) nor corticosteroids (one study) produced clinical benefit. Uterine curettage significantly reduced BP over the first 48 hours postpartum (range 6-13 mm Hg) compared with standard care (eight studies), with safety data only reported by four of eight studies. CONCLUSION There was insufficient evidence to recommend a particular BP threshold, agent or model of care, but three classes of antihypertensive appeared variably effective. Further comparative research, including robust safety data, is required. Curettage reduced BP, but without adequate reporting of harms, so it cannot currently be recommended.
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Affiliation(s)
- Alexandra E Cairns
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Louise Pealing
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - James M N Duffy
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Nia Roberts
- Knowledge Centre, Bodleian Libraries, University of Oxford, Oxford, UK
| | - Katherine L Tucker
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Paul Leeson
- Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, University of Oxford, Oxford, UK
| | - Lucy H MacKillop
- Nuffield Department of Obstetrics and Gynaecology, University of Oxford, Oxford, UK
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Magann EF, Haram K, Ounpraseuth S, Mortensen JH, Spencer HJ, Morrison JC. Use of antenatal corticosteroids in special circumstances: a comprehensive review. Acta Obstet Gynecol Scand 2017; 96:395-409. [DOI: 10.1111/aogs.13104] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 01/20/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Everett F. Magann
- Department of Obstetrics and Gynecology; Department of Biostatistics; University of Arkansas for the Medical Sciences; Little Rock AR USA
| | - Kjell Haram
- Haukeland University Hospital; Department of Public and Primary Care; University of Bergen; Bergen Norway
| | - Songthip Ounpraseuth
- Department of Obstetrics and Gynecology; Department of Biostatistics; University of Arkansas for the Medical Sciences; Little Rock AR USA
| | - Jan H. Mortensen
- Haukeland University Hospital; Department of Public and Primary Care; University of Bergen; Bergen Norway
| | - Horace J. Spencer
- Haukeland University Hospital; Department of Public and Primary Care; University of Bergen; Bergen Norway
| | - John C. Morrison
- Department of Obstetrics and Gynecology; University of Mississippi Medical Center; Jackson MS USA
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El-Agwany AS, Abdelsadek AA. A rare case of normotensive HELLP syndrome complicated with massive ascites: Spontaneous resolution. EGYPTIAN JOURNAL OF ANAESTHESIA 2016. [DOI: 10.1016/j.egja.2015.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Lowe SA, Bowyer L, Lust K, McMahon LP, Morton M, North RA, Paech M, Said JM. SOMANZ guidelines for the management of hypertensive disorders of pregnancy 2014. Aust N Z J Obstet Gynaecol 2015; 55:e1-29. [PMID: 26412014 DOI: 10.1111/ajo.12399] [Citation(s) in RCA: 173] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 07/21/2015] [Indexed: 02/06/2023]
Abstract
This guideline is an evidence based, practical clinical approach to the management of Hypertensive Disorders of Pregnancy. Since the previous SOMANZ guideline published in 2008, there has been significant international progress towards harmonisation of definitions in relation to both the diagnosis and management of preeclampsia and gestational hypertension. This reflects increasing knowledge of the pathophysiology of these conditions, as well as their clinical manifestations. In addition, the guideline includes the management of chronic hypertension in pregnancy, an approach to screening, advice regarding prevention of hypertensive disorders of pregnancy, and discussion of recurrence risks and long term risk to maternal health. The literature reviewed included the previous SOMANZ Hypertensive Disorders of Pregnancy guideline from 2008 and its reference list, plus all other published National and International Guidelines on this subject. Medline, Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Registry of Controlled Trials (CCRCT), National Institute for Health and Care Excellence (NICE) Evidence Search, and Database of Abstracts and Reviews of Effects (DARE) were searched for literature published between January 2007 and March, 2014.
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Affiliation(s)
- Sandra A Lowe
- Department of Medicine, Royal Hospital for Women, Sydney, New South Wales, Australia.,School of Women's and Children's Health, UNSW, Sydney, New South Wales, Australia
| | - Lucy Bowyer
- School of Women's and Children's Health, UNSW, Sydney, New South Wales, Australia
| | - Karin Lust
- Department of Obstetric Medicine and Internal Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | | | - Mark Morton
- Women's and Children's Hospital, Adelaide, South Australia, Australia
| | | | - Michael Paech
- Department of Anaesthesia and Pain Medicine, King Edward Memorial Hospital for Women, Perth, Western Australia, Australia
| | - Joanne M Said
- Sunshine Hospital and University of Melbourne, Melbourne, Victoria, Australia
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Nayeri UA, Buhimschi IA, Laky CA, Cross SN, Duzyj CM, Ramma W, Sibai BM, Funai EF, Ahmed A, Buhimschi CS. Antenatal Corticosteroids Impact the Inflammatory Rather Than the Antiangiogenic Profile of Women With Preeclampsia. Hypertension 2014; 63:1285-92. [DOI: 10.1161/hypertensionaha.114.03173] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Unzila A. Nayeri
- From the Department of Obstetrics and Gynecology, Upstate Medical University, Syracuse, NY (U.A.N.); Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH (I.A.B., C.S.B.); Departments of Pediatrics (I.A.B., C.S.B.) and Obstetrics and Gynecology (I.A.B., E.F.F., C.S.B.), The Ohio State University College of Medicine, Columbus; Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University, New Haven, CT (C.A.L., S.N.C., C.M.D., W.R.)
| | - Irina A. Buhimschi
- From the Department of Obstetrics and Gynecology, Upstate Medical University, Syracuse, NY (U.A.N.); Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH (I.A.B., C.S.B.); Departments of Pediatrics (I.A.B., C.S.B.) and Obstetrics and Gynecology (I.A.B., E.F.F., C.S.B.), The Ohio State University College of Medicine, Columbus; Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University, New Haven, CT (C.A.L., S.N.C., C.M.D., W.R.)
| | - Christine A. Laky
- From the Department of Obstetrics and Gynecology, Upstate Medical University, Syracuse, NY (U.A.N.); Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH (I.A.B., C.S.B.); Departments of Pediatrics (I.A.B., C.S.B.) and Obstetrics and Gynecology (I.A.B., E.F.F., C.S.B.), The Ohio State University College of Medicine, Columbus; Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University, New Haven, CT (C.A.L., S.N.C., C.M.D., W.R.)
| | - Sarah N. Cross
- From the Department of Obstetrics and Gynecology, Upstate Medical University, Syracuse, NY (U.A.N.); Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH (I.A.B., C.S.B.); Departments of Pediatrics (I.A.B., C.S.B.) and Obstetrics and Gynecology (I.A.B., E.F.F., C.S.B.), The Ohio State University College of Medicine, Columbus; Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University, New Haven, CT (C.A.L., S.N.C., C.M.D., W.R.)
| | - Christina M. Duzyj
- From the Department of Obstetrics and Gynecology, Upstate Medical University, Syracuse, NY (U.A.N.); Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH (I.A.B., C.S.B.); Departments of Pediatrics (I.A.B., C.S.B.) and Obstetrics and Gynecology (I.A.B., E.F.F., C.S.B.), The Ohio State University College of Medicine, Columbus; Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University, New Haven, CT (C.A.L., S.N.C., C.M.D., W.R.)
| | - Wenda Ramma
- From the Department of Obstetrics and Gynecology, Upstate Medical University, Syracuse, NY (U.A.N.); Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH (I.A.B., C.S.B.); Departments of Pediatrics (I.A.B., C.S.B.) and Obstetrics and Gynecology (I.A.B., E.F.F., C.S.B.), The Ohio State University College of Medicine, Columbus; Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University, New Haven, CT (C.A.L., S.N.C., C.M.D., W.R.)
| | - Baha M. Sibai
- From the Department of Obstetrics and Gynecology, Upstate Medical University, Syracuse, NY (U.A.N.); Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH (I.A.B., C.S.B.); Departments of Pediatrics (I.A.B., C.S.B.) and Obstetrics and Gynecology (I.A.B., E.F.F., C.S.B.), The Ohio State University College of Medicine, Columbus; Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University, New Haven, CT (C.A.L., S.N.C., C.M.D., W.R.)
| | - Edmund F. Funai
- From the Department of Obstetrics and Gynecology, Upstate Medical University, Syracuse, NY (U.A.N.); Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH (I.A.B., C.S.B.); Departments of Pediatrics (I.A.B., C.S.B.) and Obstetrics and Gynecology (I.A.B., E.F.F., C.S.B.), The Ohio State University College of Medicine, Columbus; Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University, New Haven, CT (C.A.L., S.N.C., C.M.D., W.R.)
| | - Asif Ahmed
- From the Department of Obstetrics and Gynecology, Upstate Medical University, Syracuse, NY (U.A.N.); Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH (I.A.B., C.S.B.); Departments of Pediatrics (I.A.B., C.S.B.) and Obstetrics and Gynecology (I.A.B., E.F.F., C.S.B.), The Ohio State University College of Medicine, Columbus; Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University, New Haven, CT (C.A.L., S.N.C., C.M.D., W.R.)
| | - Catalin S. Buhimschi
- From the Department of Obstetrics and Gynecology, Upstate Medical University, Syracuse, NY (U.A.N.); Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH (I.A.B., C.S.B.); Departments of Pediatrics (I.A.B., C.S.B.) and Obstetrics and Gynecology (I.A.B., E.F.F., C.S.B.), The Ohio State University College of Medicine, Columbus; Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University, New Haven, CT (C.A.L., S.N.C., C.M.D., W.R.)
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McCrae KR. Thrombocytopenia in Pregnancy. Platelets 2013. [DOI: 10.1016/b978-0-12-387837-3.00044-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Woudstra DM, Chandra S, Hofmeyr GJ, Dowswell T. Corticosteroids for HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome in pregnancy. Cochrane Database Syst Rev 2010:CD008148. [PMID: 20824872 PMCID: PMC4171033 DOI: 10.1002/14651858.cd008148.pub2] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Pre-eclampsia is a relatively common complication of pregnancy. HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome is a severe manifestation of pre-eclampsia with significant morbidity and mortality for pregnant women and their children. Corticosteroids are commonly used in the treatment of HELLP syndrome in the belief that they improve outcomes. OBJECTIVES To determine the effects of corticosteroids on women with HELLP syndrome and their children. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2010). SELECTION CRITERIA Randomized controlled trials comparing any corticosteroid with placebo, no treatment, or other drug; or comparing one corticosteroid with another corticosteroid or dosage in women with HELLP syndrome. DATA COLLECTION AND ANALYSIS Two review authors assessed trial quality and extracted data independently. MAIN RESULTS Eleven trials (550 women) compared corticosteroids with placebo or no treatment. There was no difference in the risk of maternal death (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.28 to 3.21), maternal death or severe maternal morbidity (RR 0.27, 95% CI 0.03 to 2.12), or perinatal/infant death (RR 0.64, 95% CI 0.21 to 1.97). The only clear effect of treatment on individual outcomes was improved platelet count (standardized mean difference (SMD) 0.67, 95% CI 0.24 to 1.10). The effect on platelet count was strongest for women who commenced treatment antenatally (SMD 0.80, 95% CI 0.25 to 1.35).Two trials (76 women) compared dexamethasone with betamethasone. There was no clear evidence of a difference between groups in respect to perinatal/infant death (RR 0.95, 95% CI 0.15 to 6.17) or severe perinatal/infant morbidity or death (RR 0.64, 95% CI 0.27 to 1.48). Maternal death and severe maternal morbidity were not reported. In respect to platelet count, dexamethasone was superior to betamethasone (MD 6.02, 95% CI 1.71 to 10.33), both when treatment was commenced antenatally (MD 8.10, 95% CI 6.23 to 9.97) and postnatally (MD 3.70, 95% CI 0.96 to 6.44). AUTHORS' CONCLUSIONS There was no clear evidence of any effect of corticosteroids on substantive clinical outcomes. Those receiving steroids showed significantly greater improvement in platelet counts which was greater for those receiving dexamethasone than those receiving betamethasone. There is to date insufficient evidence of benefits in terms of substantive clinical outcomes to support the routine use of steroids for the management of HELLP. The use of corticosteroids may be justified in clinical situations in which increased rate of recovery in platelet count is considered clinically worthwhile.
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Affiliation(s)
- Douglas M Woudstra
- Department of Obstetrics and Gynaecology, University of Alberta, Edmonton, Canada
| | - Sue Chandra
- Department of Obstetrics and Gynaecology, University of Alberta, Edmonton, Canada
| | - G Justus Hofmeyr
- Department of Obstetrics and Gynaecology, East London Hospital Complex, University of the Witwatersrand, University of Fort Hare, Eastern Cape Department of Health, East London, South Africa
| | - Therese Dowswell
- Cochrane Pregnancy and Childbirth Group, School of Reproductive and Developmental Medicine, Division of Perinatal and Reproductive Medicine, The University of Liverpool, Liverpool, UK
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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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Klockenbusch W, Schrepfer F. [Current recommendations for the treatment of preeclampsia]. ACTA ACUST UNITED AC 2007; 47:209-14. [PMID: 17914266 DOI: 10.1159/000107261] [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: 11/19/2022]
Abstract
Low-dose aspirin, but not vitamin C and vitamin E, has small to moderate benefits when used for the prevention of preeclampsia. There is however little to suggest that the course of manifest preeclampsia can be substantially affected by drug treatment. Antihypertensive therapy increases the risk of fetal growth restriction and is only indicated in severe hypertension to reduce the risk of maternal cerebral hemorrhage. Magnesium sulfate is the drug of choice for the prevention and treatment of eclampsia. Volume expansion as well as the use of steroids in preeclamptic patients without HELLP syndrome have failed to show any improvement. Delivery as the only definitive treatment is always beneficial for the mother whereas expectant management is in favor of a premature fetus. Decision-making largely depends on gestational age and severity of the disease.
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Affiliation(s)
- W Klockenbusch
- Klinik und Poliklinik fur Frauenheilkunde und Geburtshilfe, Universitätsklinikum Münster, Münster, Deutschland
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Martin JN, Rose CH, Briery CM. Understanding and managing HELLP syndrome: the integral role of aggressive glucocorticoids for mother and child. Am J Obstet Gynecol 2006; 195:914-34. [PMID: 16631593 DOI: 10.1016/j.ajog.2005.08.044] [Citation(s) in RCA: 178] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2005] [Revised: 07/13/2005] [Accepted: 08/18/2005] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- James N Martin
- Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, MS, USA
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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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