Immunohistological study in cases of HELLP syndrome (hemolysis, elevated liver enzymes and low platelets) and acute fatty liver of pregnancy

Investigating hemolysis, elevated liver enzymes and low platelet count in preeclampsia: A case-control study in Ghana

Background and Aims

Preeclampsia poses a heightened risk for women, particularly in the development of hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome, leading to adverse outcomes for both mothers and newborns. The incidence of HELLP syndrome tends to be notably higher among women with preeclampsia compared with those with normotensive pregnancies. However, there is a dearth of research on the frequency of HELLP syndrome within the context of preeclampsia specifically in Ghana. Furthermore, the potential predictive value of serum erythrocyte adenylate kinase (EAK), a marker of hemolysis, in anticipating the onset of preeclampsia remains largely unexplored.

Methods

Conducted between May 2020 and April 2022, this research employed a case-control methodology at the War Memorial and Upper East Regional Hospitals. A total of 291 pregnant women participated, comprising 111 diagnosed with preeclampsia and 180 control subjects, aged between 18 and 43 years. Venous blood samples were collected and subjected to analysis for platelet count, aspartate aminotransferase (AST), alanine aminotransferase (ALT), lactate dehydrogenase (LDH), and EAK, utilizing automated analyzers, alongside the ELISA technique. Diagnosis of HELLP syndrome was established using the Mississippi triple-class definition.

Results

The median serum ALT level (with interquartile range) was significantly elevated in the preeclampsia group compared with controls [20.0 (13.7-27.0) vs. 13.0 (9.4-18.6); p < 0.001]. Moreover, the frequency of Mississippi class 3 HELLP syndrome was notably higher among preeclampsia cases (2/111; 1.8%) compared with controls (1/180; 0.6%). Serum ALT emerged as the superior predictor of preeclampsia, outperforming LDH (with an area under the curve of 0.73 compared with 0.58). The sensitivity and specificity of ALT were measured at 47.8% and 87.2%, respectively.

Conclusion

Although the occurrence of HELLP syndrome in preeclampsia cases appears relatively low, it may escalate as the prevalence of preeclampsia is anticipated to rise in low and middle-income nations.

HELLP Syndrome—Holistic Insight into Pathophysiology

HELLP syndrome, also known as the syndrome of hemolysis, elevated liver enzymes, and low platelets, represents a severe pregnancy complication typically associated with hypertension. It is associated with increased risks of adverse complications for both mother and fetus. HELLP occurs in 0.2–0.8% of pregnancies, and, in 70–80% of cases, it coexists with preeclampsia (PE). Both of these conditions show a familial tendency. A woman with a history of HELLP pregnancy is at high risk for developing this entity in subsequent pregnancies. We cannot nominate a single worldwide genetic cause for the increased risk of HELLP. Combinations of multiple gene variants, each with a moderate risk, with concurrent maternal and environmental factors are thought to be the etiological mechanisms. This review highlights the significant role of understanding the underlying pathophysiological mechanism of HELLP syndrome. A better knowledge of the disease’s course supports early detection, an accurate diagnosis, and proper management of this life-threatening condition.

Innate and Adaptive Immune Responses in HELLP Syndrome

Innate and adaptive immune involvement in hemolysis, elevated liver enzymes and low platelet (HELLP) syndrome is an understudied field, although it is of high clinical importance. This syndrome implies a risk of serious morbidity and mortality to both the mother and the fetus during pregnancy. It was proposed that HELLP syndrome occurs in a circulatory inflammatory milieu, that might in turn participate in a complex interplay between the secreted inflammatory immunomodulators and immune cell surface receptors. Meanwhile, reported immune cell attenuation during HELLP may consequently lead to a prolonged immunoactivation and tissue damage. In this regard, learning more about the immune components of this syndrome should widen the understanding of the HELLP pathophysiology and eventually enable development of novel immune-based therapeutics. This review aims to summarize and discuss the recent and previous findings of the innate and adaptive immune responses during HELLP in order to update the current knowledge of the immune involvement in HELLP pathogenesis.

Acute fatty liver of pregnancy and concomitant medical conditions: A review of cases at a quaternary obstetric hospital

Acute fatty liver of pregnancy is a rare complication of pregnancy that may result in fulminant hepatic failure. We present a review of all patients presenting to a quaternary obstetric hospital over a 15-year period, with particular regard to biochemical changes, results of gene testing, and pre-existing conditions. Seventeen patients with acute fatty liver of pregnancy were identified. Six patients were documented to have pre-existing gastrointestinal disease; five with inflammatory bowel disease, and one with influenza A hepatitis. Antithrombin III levels were low in this study, consistent with previously published data. There were no recurrences of acute fatty liver of pregnancy in nine subsequent pregnancies to seven mothers. The authors are not aware of any literature addressing pre-existing medical conditions which may predispose to acute fatty liver of pregnancy.

Soluble endoglin, transforming growth factor-Beta 1 and soluble tumor necrosis factor alpha receptors in different clinical manifestations of preeclampsia

Background

Despite intensive research, the etiopathogenesis of preeclampsia (PE) remains uncertain. Inflammatory and angiogenic factors are thought to play considerable roles in this disease. The objective of this study was to investigate the association between soluble endoglin (sEng), transforming growth factor beta-1 (TGF-β1) and tumor necrosis factor alpha soluble receptors (sTNF-Rs) and the clinical manifestations of PE.

Methods

Plasma levels of sEng, TGF-β1 and sTNF-Rs were determined by ELISA in 23 non-pregnant, 21 normotensive pregnant and 43 PE women. PE women were stratified into subgroups according to the severity [mild (n = 12) and severe (n = 31)] and onset-time of the disease [early (n = 19) and late (n = 24)].

Results

Pregnancy was associated with higher levels of sEng, sTNF-R1 and sTNF-R2 than the non-pregnant state. Moreover, PE women had higher levels of sEng and sTNF-R1 than normotensive pregnant women. No difference was found in TGF-β1 levels, comparing the three study groups. Late PE had higher levels of sTNF-R1 and sTNF-R2 than early PE. No significant differences were found in sEng and TGF-β1 comparing early and late PE. sEng levels were higher in severe PE than in mild PE and no difference was found for TGF-β1, sTNF-R1 and sTNF-R2 levels. There was a positive correlation among sEng, TNF-R1 and sTNF-2 levels. Logistic regression analysis revealed that primiparity and sEng levels are independently associated with the development of PE. Furthermore, sEng levels are independently associated with the disease severity.

Conclusions

These results suggest that pregnancy is a condition associated with higher levels of anti-angiogenic and pro-inflammatory factors than the non-pregnant state and that PE is associated with an imbalance of these factors in the maternal circulation.

Expression of inflammatory cytokines in placentas from pregnancies complicated with preeclampsia and HELLP syndrome

OBJECTIVE

To investigate the expression of tumor necrosis factor-alpha (TNF-α), interleukin-6 (IL-6) and interleukin-10 (IL-10) in villous trophoblast, syncytial knots and decidua placentas from pregnancies complicated with preeclampsia (PE), Hemolysis, Elevated Liver enzymes and Low Platelet count (HELLP) syndrome and gestational age-matched controls.

METHODS

Study group included 35 placentas from pregnancies complicated with PE and 35 placentas from pregnancies with HELLP syndrome. Control group included 35 placentas from idiopathic preterm labor. Placentas were matched according to the gestational age. Expression of TNF-α, IL-6 and IL-10 was determined by immunohistochemistry and semi-quantitative HSCORE method in villous trophoblast, syncytial knots and decidua. Non-parametric statistics were used for analyses.

RESULTS

There was no difference in the expression of TNF-α, IL-6 and IL-10 in all the studied placental segments between PE, HELLP and gestational age-matched control group. TNF-α (F = 32, 41, p < 0.001), IL-6 (F = 58, 53, p < 0.001) and IL-10 (F = 17, 62, p < 0.001) expression was significantly different in different placental cell types, the highest expression of cytokines was in decidua.

CONCLUSION

There was no difference in cytokine expression in villous trophoblast, syncytial knots and decidua among the studied placental groups. The expression of cytokines was highest in decidua in all the studied placental groups.

Pathogenesis of the syndrome of hemolysis, elevated liver enzymes, and low platelet count (HELLP): a review

HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome is serious for the mother and the offspring. HELLP occurs in 0.2-0.8% of pregnancies and in 70-80% of cases it coexists with preeclampsia (PE). This review concerns the pathogenetic mechanisms of HELLP syndrome with an emphasis on differences between HELLP and early onset PE. The syndromes show a familial tendency. A previous HELLP pregnancy is associated with an increased risk of HELLP as well as PE in subsequent pregnancies, indicating related etiologies. No single world-wide genetic cause for excessive risk of HELLP or PE has been identified. Combinations of multiple gene variants, each with a moderate risk, with contributing effects of maternal and environmental factors, are probable etiological mechanisms. Immunological maladaptation is the most probable trigger of the insult to the invading trophoblast. This insult occurs early in the first trimester, as indicated by marker molecules in maternal blood. The levels of fetal messenger RNAs in maternal blood at gestational weeks 15-20 are significantly more abnormal in HELLP than in PE, suggesting that the insult is more extensive in HELLP. High levels of HLA-DR in maternal blood in women with HELLP may suggest a similarity to the rejection reaction. In third trimester placentas, gene derangement is more extensive in HELLP. Anti-angiogenic factors released into maternal blood induce the maternal syndromes. Maternal blood levels of anti-angiogenic sFlt1 are similar, but endoglin and Fas Ligand levels are possibly higher in HELLP than in PE. These factors trigger the vascular endothelium, resulting in an enhanced inflammatory response which is stronger in HELLP. Activated coagulation and complement, with high levels of activated leucocytes, inflammatory cytokines, TNF-α, and active von Willebrand factor, induce thrombotic microangiopathy with platelet-fibrin thrombi in microvessels. The angiopathy results in consumption of circulating platelets, causes hemolysis in affected microvessels and reduces portal blood flow in the liver. Placental Fas Ligand damages hepatocytes, resulting in periportal necrosis. In about one half of women with HELLP, activation of coagulation factors and platelets precipitates disseminated intravascular coagulation, which in a minority becomes uncompensated and contributes to life-threatening multiorgan failure.

Characteristics of ascites in patients with pregnancy-specific liver diseases

BACKGROUND & AIMS

The characteristics of ascites in patients with pregnancy-specific liver disease (PsLD), which comprise acute fatty liver of pregnancy, hemolysis, increased levels of liver enzymes, low platelet syndrome, and preeclampsia-associated liver dysfunction, are unknown. We evaluated the cellular and biochemical characteristics, and model for end-stage liver disease scores, in patients with PsLD.

METHODS

We evaluated 46 consecutive patients with PsLD for the presence of ascites. We assessed cellular and biochemical characteristics of the ascites fluid from these patients.

RESULTS

Ascites was observed in 35 of 46 patients with PsLD (76%). In 25 patients tested (71.4%), the ascites fluid had low levels of albumin (<0.2 g/dL) and protein (<1 g/dL) and high serum ascites albumin gradients, indicating portal hypertension. Spontaneous bacterial peritonitis was observed in 48% of patients tested and was not associated with mortality. Patients with ascites had significantly low serum levels of protein and albumin (P < .001). Model for end-stage liver disease scores did not differ between patients with or without ascites (32 vs 27; P = .1).

CONCLUSIONS

Ascites occur in 76% of women with PsLD, is transient, and has characteristics of portal hypertension, based on high serum ascites albumin gradients. Almost half of patients with PsLD develop spontaneous bacterial peritonitis, which does not affect survival.

Comparative analysis of the maternal and umbilical interleukin-8 levels in normal pregnancies and in pregnancies complicated by preeclampsia with intrauterine normal growth and intrauterine growth retardation

OBJECTIVES

The aim of this study was to determine the maternal and umbilical cord serum levels of interleukin-8 (IL-8) in pregnancies complicated by preeclampsia with intrauterine normal growth and intrauterine growth retardation (IUGR), and in normotensive pregnancies.

PATIENTS AND METHODS

The study was carried out on 15 patients with singleton pregnancies complicated by preeclampsia with appropriate for gestational age weight infants and 12 pregnant patients with preeclampsia complicated by IUGR. The control group consisted of 10 healthy normotensive delivering patients with singleton uncomplicated pregnancies. Maternal and umbilical serum IL-8 concentrations were estimated using the ELISA method.

RESULTS

There were no statistically significant differences in patient profiles between the groups. Systolic and diastolic blood pressure and mean arterial blood pressure were higher in the study groups in comparison with the control group. Lower birth weight and lower gestational age at birth were observed in the group of patients with preeclampsia complicated by IUGR. Increased maternal and umbilical serum levels of IL-8 were found in both preeclamptic patient groups in comparison with the control group. The umbilical cord blood concentrations of IL-8 in all groups of patients tended to be higher in comparison with the maternal blood.

CONCLUSIONS

It seems that these higher IL-8 concentrations may be associated with apoptosis, inflammation, neutrophil activation, endothelial cell damage and dysfunction, and increased endothelial permeability. They may also participate in an attempt to compensate for the imbalanced apoptosis and vascular resistance. Our findings suggest a possible significant role of IL-8 in the pathogenesis and sequelae of preeclampsia, especially in preeclamptic pregnancies complicated by IUGR.

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.

Postpartum intravenous dexamethasone for severely preeclamptic patients without hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome: a randomized trial

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.

Acute fatty liver of pregnancy after aspirin intake

Acute fatty liver is a rare but fatal complication of pregnancy. Here we describe a patient presenting with stupor and jaundice after aspirin intake at 35 weeks of gestation. Supportive management and delivery resulted in uneventful discharge of the patient and the newborn. Differential diagnosis and management of this condition are discussed.

Liver emergencies during pregnancy

Liver disease is an uncommon complication of pregnancy, although one that must be recognized early because of its potential for grave consequences for mother and child. Because of increased awareness and rapid triage of patients, maternal and fetal outcomes have improved significantly over the last 30 years.

Anemia and the liver. Hepatobiliary manifestations of anemia

Many types of hemolytic anemia may be associated with liver disease. Liver injury can be caused by the adherence of deformed or hemolyzed erythrocyses to hepatic vascular endothelium. Adhesion of large numbers of hemolyzed red blood cells to hepatic macrophages, or occlusion of hepatic sinusoids by fragmented red cells, can also result in injury of the liver. Thrombosis of the hepatic or portal vein is associated with some types of hemolytic anemia, and can cause severe liner injury. These are some examples of hepatic injury that can be caused by hemolytic anemias. This article discusses some aspects of liver disease that is associated with sickle cell anemia, paroxysmal nocturnal hemoglobinuria, glucose-6-phosphate dehydrogenase deficiency, hereditary spherocytosis, and HELLP syndrome.

Acute fatty liver and HELLP syndrome: two distinct pregnancy disorders

OBJECTIVE

to report the experience clinical, biochemical findings, complications and the maternal-perinatal outcome in patients with HELLP syndrome and acute fatty liver of pregnancy (AFLP) during the same period.

MATERIALS AND METHODS

during the period between January 1996 and December 1999, medical records of patients with the discharge diagnosis of AFLP and HELLP syndrome were reviewed for presenting symptoms, laboratory findings, maternal and perinatal complications. Routine laboratory evaluation included serial measurement of liver function tests, complete blood cell count, coagulation profile and renal function tests.

RESULTS

during the study period 10 patients had AFLP and 75 women had HELLP syndrome as the discharge diagnosis. Patients with HELLP syndrome had major parity than AFLP (P<0.006). The most common presenting symptom for patients with AFLP was malaise noted in all patients, nausea and/or vomiting, abdominal pain and jaundice were very common. Headache, abdominal or epigastric pain and hematuria were the most common symptoms of patients with HELLP syndrome. Women with AFLP had major hypoglycemia, hypocholesterolemia, hypotriglyceridemia, serum transaminase activity and low antithrombin III. Disseminated intravascular coagulation, acute renal insufficiency, ascites, seroma and encephalophaty were more common with AFLP.

CONCLUSIONS

our opinion is that AFLP had clinical presentation, biochemical findings and complications clearly distinguished of HELLP syndrome.

Maternal mortality associated with HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome

OBJECTIVE

The aim of this study was to determine factors contributing to deaths among women with HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome.

STUDY DESIGN

Information from multiple sources was scrutinized to distinguish and profile maternal deaths associated with HELLP syndrome.

RESULTS

Information was available regarding 54 maternal deaths. According to HELLP syndrome classification 60.0% had class 1 disease, 35.6% had class 2 disease, and 4.4% had class 3 disease. Events associated with maternal deaths included cerebral hemorrhage (45%), cardiopulmonary arrest (40%), disseminated intravascular coagulopathy (39%), adult respiratory distress syndrome (28%), renal failure (28%), sepsis (23%), hepatic hemorrhage (20%), and hypoxic ischemic encephalopathy (16%). Delay in diagnosis of HELLP syndrome was implicated in 22 of 43 patients' deaths (51.1%).

CONCLUSIONS

It appears that (1) most maternal deaths occurred among women with class 1 HELLP syndrome, (2) delay in diagnosis was associated with mortal consequences, and (3) hemorrhage in the hepatic or central nervous system or vascular insult to the cardiopulmonary or renal system were associated with increased mortality risk.

The spectrum of severe preeclampsia: comparative analysis by HELLP (hemolysis, elevated liver enzyme levels, and low platelet count) syndrome classification

OBJECTIVE

This study was undertaken to explore the spectrum of maternal disease with a triple classification system of HELLP (hemolysis, elevated liver enzyme levels, and low platelet count) syndrome and compare these classes with severe preeclampsia without HELLP syndrome.

STUDY DESIGN

In this retrospective analytic study the pregnancies of 777 patients with class 1, 2, or 3 HELLP syndrome were compared and contrasted with those of 193 women with severe preeclampsia but without HELLP syndrome.

RESULTS

Eclampsia, epigastric pain, nausea and vomiting, significant proteinuria, major maternal morbidity, and stillbirth increased as HELLP syndrome worsened from class 3 to class 1. In contrast, headache and diastolic hypertension were more common among the significantly heavier patients with severe preeclampsia without HELLP syndrome. Approximately half of pregnancies complicated by class 1 HELLP syndrome exhibited significant maternal morbidity, compared with only 11% of those complicated by severe preeclampsia without HELLP syndrome. Although a significant trend was apparent in increasing levels of lactate dehydrogenase, aspartate aminotransferase, and uric acid as HELLP syndrome worsened, there was considerable variation within groups.

CONCLUSION

Laboratory and clinical indices of disease severity in patients with severe preeclampsia or eclampsia generally were highest with class 1 HELLP syndrome and were lowest when HELLP syndrome was absent. Class 3 HELLP syndrome is considered a clinically significant transitional group.

Acute fatty liver of pregnancy

Acute fatty liver of pregnancy is a rare clinical entity unique to pregnancy that occurs during the third trimester. The obstetric team must be familiar with this disease because early diagnosis and prompt delivery have dramatically improved prognosis, which was often fatal for both mother and child. Clinicians must have a high index of suspicion for this condition when a woman has nausea or vomiting, abdominal pain (particularly epigastric), jaundice, polyuria-polydipsia (without diabetes), increased serum transaminase activity or thrombocytopenia in late pregnancy. The disease rarely recurs during a subsequent pregnancy. The cause is unknown, but some cases of acute fatty liver of pregnancy have been associated with a genetic deficiency of fatty acid beta-oxidation. Because of the possibility of this congenital deficiency, infants of affected mothers should undergo close follow-up from birth.