HELLP syndrome: a diagnostic conundrum with severe complications

Cardiovascular complications during delivery hospitalizations in patients with nonalcoholic fatty liver disease in pregnancy

OBJECTIVE

While the association between metabolic dysfunction-associated steatotic liver disease (MASLD) and long-term cardiovascular risks has been studied, the impact of MASLD on cardiovascular events during delivery hospitalizations remains relatively unexplored. This study aims to examine the prevalence of cardiovascular diseases (CVDs) and cardiac arrhythmias in pregnant patients with MASLD and identify potential risk factors.

METHODS

A retrospective analysis of hospital discharge records from the National Inpatient Sample database between 2009 and 2019 was conducted to assess maternal cardiovascular outcomes. Multivariable logistic regression models were employed, and adjusted odds ratios (AOR) were calculated to evaluate the association between MASLD and cardiovascular outcomes during pregnancy.

RESULTS

The study sample included 17 593 pregnancies with MASLD and 41 171 211 pregnancies without this condition. Women with MASLD exhibited an increased risk of congestive heart failure [AOR 3.45, 95% confidence interval (CI) 1.04-11.43], cardiac arrhythmia (AOR 2.60, 95% CI 1.94-3.49), and gestational hypertensive complications (AOR 3.30, 95% CI 2.93-3.72). Pregnancies with MASLD were also associated with a higher rate of pulmonary edema (AOR 3.30, 95% CI 1.60-6.81).

CONCLUSION

MASLD is an independent risk factor for cardiovascular complications during delivery hospitalizations, emphasizing the necessity for prepregnancy screening and targeted prevention strategies to manage CVD risks in expectant patients with MASLD.

Prenatal hypertension as the risk of eclampsia, HELLP syndrome, and critical obstetric hemorrhage

Critical bleeding is a common cause of maternal mortality in obstetric patients. However, the non-obstetric factors underlying critical obstetric bleeding remain uncertain. Therefore, this study aimed to clarify the impact of chronic hypertension on obstetric hemorrhage by evaluating a nationwide administrative database in Japan. Women who gave birth between 2018 and 2022 were enrolled. The primary outcome was critical hemorrhage requiring massive red blood cell (RBC) transfusion during childbirth. In total, 354, 299 eligible women were selected from the database. The maternal mortality rate was >1.0% among those who received a massive RBC transfusion (≥4000 cc), and this amount was used as the cutoff of the outcome. Critical hemorrhage was less frequent with elective Caesarean section (CS) compared with vaginal childbirth or emergent CS (odds ratio [OR], 0.38; 95% confidence interval, 0.30-0.47). Multiple logistic regression analysis adjusting for these obstetric risks revealed that a higher maternal age (adjusted OR [aOR] per 1 year, 1.07 [1.05-1.09]); oral medications with prednisolone (aOR, 2.5 [1.4-4.4]), anti-coagulants (aOR, 10 [5.4-19]), and anti-platelets (aOR, 2.9 [1.3-6.4]); and a prenatal history of hypertension (aOR, 2.5 [1.5-4.4]) and hypoproteinemia (aOR, 5.8 [1.7-20]) are the risks underlying critical obstetric hemorrhage. Prenatal history of hypertension was significantly associated with obstetric disseminated intravascular coagulation (OR, 1.9 [1.5-2.4]); Hemolysis, Elevated Liver enzymes, and Low platelet count (HELLP) syndrome (OR, 3.3 [2.7-4.2]); and eclampsia (OR, 6.1 [4.6-8.1]). In conclusion, a maternal prenatal history of hypertension is associated with the development of HELLP syndrome, eclampsia, and resultant critical hemorrhage. The incidence of HELLP syndrome and eclampsia increased more than fivefold in the presence of prenatal hypertension. However, the likelihood of subsequently developing DIC or experiencing critical bleeding did not change by the presence of prenatal hypertension.

Maternal and fetal outcomes of acute pancreatitis in pregnancy: a population-based study

BACKGROUND

Acute pancreatitis during pregnancy can have negative effects on both the mother and the fetus. The primary aim of this study is to evaluate the trends, maternal and fetal outcomes, and associated comorbidities of acute pancreatitis during pregnancy using data from the USA National Inpatient Sample (NIS) database.

METHODS

This study is a retrospective analysis of hospital discharge records from the NIS database from 2009 to 2019.

RESULTS

Delivery patients with acute pancreatitis faced a higher risk of maternal mortality (AOR 91.02, 95% CI 28.47-291.06), postpartum hemorrhage (AOR 1.59, 95% CI 1.02-2.49), and hypertensive complications (defined as preeclampsia, eclampsia, or HELLP syndrome) (AOR 3.42, 95% CI 2.56-4.56) compared to those without acute pancreatitis. Moreover, we saw an increased incidence of preterm labor (AOR 3.94, 95% CI 3.02-5.12) and fetal death (AOR 3.12, 95% CI 1.76-5.53). Rates of fetal restriction and large fetal size were comparable. Additionally, the acute pancreatitis group showed higher rates of acute kidney injury (4.2% vs. 0.06%; AOR, 31.02, 95% CI 12.50-76.98), severe sepsis (0.8% vs. 0.01%; AOR, 34.49, 95% CI 7.67-155.14), and respiratory failure (2.4% vs. 0.06%; AOR, 20.77, 95% CI (8.55-50.41). There were no significant differences in maternal and perinatal outcomes in biliary pancreatitis after the intervention compared to conservative treatment.

CONCLUSION

Acute pancreatitis during pregnancy can have negative effects on both the mother and fetus. Treatment for biliary pancreatitis does not affect maternal and fetal outcomes. An interdisciplinary approach is essential to ensure optimal outcomes for mothers and their offspring in these cases.

Maternal morbidity and mortality in pregnant/postpartum women with suspected HELLP syndrome identifiable as probable thrombotic thrombocytopenic purpura or atypical hemolytic uremic syndrome by high LDH to AST ratio

OBJECTIVE

To describe findings in 8 women initially diagnosed as presumptive HELLP Syndrome, eventually confirmed as TTP/aHUS as distinguished by elevated calculated LDH:AST ratio > 22:1.

METHODS

All medicolegal files of patients evaluated between 1986 and 2015 with presumptive HELLP syndrome but later determined to have TTP/aHUS had LDH:AST ratios evaluated throughout care.

RESULTS

Fifty-eight pregnant/postpartum women presented with a diagnosis of presumptive HELLP syndrome. In the final analysis, 8 women had TTP/aHUS characterized by severe thrombocytopenia (<20 000/μl) at admission, rare epigastric pain, and the consistent demonstration of a very high calculated total LDH to AST ratio. This calculation greatly exceeded 22:1 with TTP/aHUS (mean = 32:1) versus 2:1 with HELLP and could be consistently demonstrated throughout care. Six of 8 women with TTP/aHUS died.

CONCLUSION

Correctly distinguishing between HELLP syndrome versus an imitator disorder continues to challenge obstetric specialists. This medicolegal data supplements prior findings supporting the concept of the LDH:AST ratio as a useful screening tool for clinicians to differentiate TTP/aHUS apart from HELLP syndrome in order to facilitate earlier hematology consultation, patient referral to tertiary care and emergent hemotherapy for these mothers.

COVID-19 and HELLP: Overlapping Clinical Pictures in Two Gravid Patients

Background  The impact of severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) on pregnancies is currently under investigation. There is a significant overlap between the clinical findings in novel coronavirus disease 2019 (COVID-19) and hemolysis, elevated liver enzymes, and low platelets syndrome (HELLP). Cases  Patients presented at 22 and 29 weeks of gestation with suspected COVID-19 pneumonia. While the patient at 22 weeks of gestation subsequently had an intrauterine fetal demise, the patient at 29 weeks of gestation delivered via an emergency cesarean delivery for nonreassuring fetal status. Both patients also developed transaminitis, thrombocytopenia, and disseminated intravascular coagulation with a proof of hemolysis on peripheral smear. Conclusion  Clinicians are encouraged to consider both of these diagnoses when caring for pregnant women during the COVID-19 pandemic to assure that both maternal and fetal concerns are addressed and treated appropriately.