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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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Başaran B, Çelebioğlu B, Başaran A, Altınel S, Kutlucan L, Martin JN. Anesthetic practices for patients with preeclampsia or HELLP syndrome: A survey. J Turk Ger Gynecol Assoc 2016; 17:128-33. [PMID: 27651719 DOI: 10.5152/jtgga.2016.16094] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 07/20/2016] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE Substantial controversy exists regarding anesthetic management for patients with preeclampsia or hemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome. Experts, researchers, clinicians, and residents in Turkey were surveyed about their practices. MATERIAL AND METHODS Questionnaires were distributed to attendees at a national conference, and they were filled out immediately. Anonymous 10-item paper surveys were administered to both residents and non-residents. Descriptive statistics were used in the analysis. Agreement among ≥75% of the respondents was considered a majority opinion. Surveys with missing responses were used to analyze the non-response bias. The Chi-square test was used for comparisons. A historical cohort of obstetricians-gynecologists was used for comparison with anesthesiologists. RESULTS Of 339 surveys distributed, 288 were returned (84.9% response rate). Among the returned surveys, the completion rate was 96.1%. The job experience in years among clinicians and residents was 9±5 and 3±1, respectively. General anesthesia was still significantly preferred by 36.1% among patients with preeclampsia with platelet counts of ≥100,000/μL. Compared to obstetricians-gynecologists, anesthesiologists more often preferred general anesthesia. With platelet counts of <50,000/μL or eclampsia, most respondents preferred general anesthesia 94.4% for very low platelets and 89.5% for eclampsia. CONCLUSION A preferential trend toward general anesthesia for patients with preeclampsia or HELLP syndrome exists among anesthesiologists in Turkey, particularly for patients with severe thrombocytopenia and/or eclampsia. There exists a need for well-designed and well-executed prospective clinical trials to provide evidence for the best consensus practice.
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Affiliation(s)
- Betül Başaran
- Department of Anesthesiology, Konya Training and Research Hospital, Konya, Turkey
| | - Bilge Çelebioğlu
- Department of Anesthesiology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Ahmet Başaran
- Department of Obstetrics and Gynecology, Konya Training and Research Hospital, Konya, Turkey
| | - Seher Altınel
- Department of Anesthesiology, Ankara Gazi Mustafa Kemal State Hospital, Ankara, Turkey
| | - Leyla Kutlucan
- Department of Anesthesiology, Konya Training and Research Hospital, Konya, Turkey
| | - James N Martin
- Department of Obstetrics and Gynecology, The University of Mississippi Medical Center, Jackson, USA
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del-Rio-Vellosillo M, Garcia-Medina JJ. Anesthetic considerations in HELLP syndrome. Acta Anaesthesiol Scand 2016; 60:144-57. [PMID: 26446688 DOI: 10.1111/aas.12639] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 05/25/2015] [Accepted: 09/03/2015] [Indexed: 12/27/2022]
Abstract
BACKGROUND HELLP syndrome (hemolysis, elevated liver enzymes, low platelets) is an obstetric complication with heterogonous presentation and multisystemic involvement. It is characterized by microangiopathic hemolytic anemia, elevated liver enzymes by intravascular breakdown of fibrin in hepatic sinusoids and reduction of platelet circulation by its increased consumption. METHODS In terms of these patients' anesthetic management, it is essential to consider some details: (1) effective, safe perioperative management by a multidisciplinary approach, and quick, good communication among clinical specialists to achieve correct patient management; (2) neuroaxial block, particularly spinal anesthesia, is the first choice to do the cesarean if there is only moderate, but not progressive thrombocytopenia; (3) if a general anesthesia is required, it is necessary to control the response to stress produced by intubation, especially in patients with either severe high blood pressure or neurological signs, or to prevent major cerebral complications; (4) invasive techniques, e.g., as tracheostomy, arterial, and deep-vein canalization, should be considered; (5) if contraindication for neuroaxial anesthesia exists, rapid sequence intubation with general anesthesia should be regarded as an emergency in patients with full stomach; (6) increased risk of difficult airways should be taken into account. RESULTS Optimal patient management can be chosen after considering the risks and benefits of each anesthetic technique, and based on good knowledge of these patients' pathophysiological conditions. CONCLUSION Later, close patient monitoring is recommended for potential development of hemorrhagic complications, disseminated intravascular coagulation (DIC), or eclampsia.
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Affiliation(s)
- M. del-Rio-Vellosillo
- Department of Anesthesia; University Hospital Virgen de la Arrixaca; El Palmar Murcia Spain
| | - J. J. Garcia-Medina
- Department of Ophthalmology; University Hospital Reina Sofia; Murcia Spain
- Department of Ophthalmology and Optometry; University School of Medicine; University of Murcia; Murcia Spain
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