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

Hepatic Infarct: Uncommon Causes of an Uncommon Vascular Complication Revealed at Nontransplant Medical Autopsies

Background and aims

Hepatic infarcts are uncommon vascular lesions due to dual vascular supply of the liver characterized by the peripherally-located wedge-shaped large zones of necrosis in the hepatic parenchyma. They are commonly seen as a complication of liver transplant.

Material and methods

The cases of hepatic infarcts of the native liver detected in medical autopsies were searched in the archives and their clinical, biochemical, gross, and histomorphological details were retrieved.

Results

Three cases of hepatic infarct of the native liver were detected from among 1865 consecutive cases of adult and pediatric autopsies (0.2%). These cases were caused by hornet stings, acute pancreatitis, and hemolysis, elevated liver enzymes, low platelet syndrome (HELLP) in a 24-year-old male, 19-year-old male, and a 28-year-old postpartum female, respectively. The first two cases showed 50-150 times elevated transaminases and conjugated hyperbilirubinemia. All cases showed hyperemic to pale subcapsular infarcts. The HELLP syndrome case showed intrasinusoidal fibrin-rich microthrombi, while the other two cases showed the presence of fibrin-rich/organized microthrombi involving variable-sized portal and central venous radicles. Two of these cases (hornet sting and HELLP syndrome) did not show any macroscopic thrombi in the portal vein, hepatic artery, or hepatic veins.

Conclusion

Hepatic infarcts are rare vascular lesions found in the nontransplant liver. The gross and histomorphology of these lesions depend on the age of these lesions. They can occur in the presence of vascular microthrombi in the absence of any documented macroscopic thrombus.

Twin Birth and Hemolysis, Elevated Liver Enzymes, and Low Platelets (HELLP) Syndrome: A Population-Based Study

OBJECTIVES

Although twin pregnancies are known to have higher rates of preeclampsia, the association between twin pregnancy and Hemolysis, Elevated Liver Enzymes, and Low Platelet Count (HELLP) syndrome has not been adequately studied. We assessed the association between twin pregnancy and HELLP syndrome, and also examined gestational age-specific rates of HELLP syndrome in twin and singleton pregnancies.

METHODS

We conducted a retrospective cohort study of women with singleton or twin live births or stillbirths between 200 and 436 weeks gestation in British Columbia, Canada, from 2008/09 to 2019/20. Data on the demographic and clinical characteristics were obtained from the British Columbia Perinatal Database Registry. Logistic regression was used to estimate adjusted odds ratios and 95% CIs, adjusted for maternal age, body mass index, smoking, and other potential confounders.

RESULTS

Among 524 236 women (515 953 singleton and 8283 twin pregnancies), 1510 were diagnosed with HELLP syndrome (2.9 per 1000 women). HELLP syndrome occurred in 181 twin pregnancies (21.9 per 1000 women), while 1329 cases occurred in singleton pregnancies (2.6 per 1000 women) (rate ratio 8.5 [95% CI 7.3-9.9]). The adjusted odds ratio for the associations between HELLP syndrome and twin versus singleton pregnancies was 7.1 (CI 6.0-8.5). In twin pregnancies, the incidence of HELLP syndrome increased markedly from 260 to 286 weeks gestation until 370 to 396 weeks. In contrast, the incidence of HELLP syndrome increased more gradually from 230 to 406 weeks gestation in singleton pregnancies.

CONCLUSIONS

Twin pregnancy is strongly associated with HELLP syndrome. HELLP syndrome risk in twin pregnancies increases markedly from 260 weeks gestation onwards.

Rare association of posterior reversible encephalopathy syndrome (PRES) with hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome - A case report and review of the literature

Introduction

The hemolysis-elevated liver enzymes-low platelet counts (HELLP) syndrome and posterior reversible encephalopathy syndrome (PRES) are rare conditions that can complicate pregnancy and the early postpartum period. Although both are closely related to hypertensive pregnancy disorders, their association is rarely described, so the outcome of these patients remains unknown. We present a case report of PRES associated with HELLP syndrome and a review of all previously published cases, including demographic characteristics, clinical presentation, treatment, and outcome.

Case presentation

A previously healthy 31-year-old woman in the 38th week of pregnancy was admitted to the obstetric department due to elevated blood pressure. The first laboratory findings were consistent with HELLP, which is why she was delivered by emergency caesarean section. Forty-four hours after the cesarean section, she presented with a severe headache, blurred vision, and instability, followed by two seizures. Magnetic resonance imaging (MRI) of the brain showed T2-weighted/FLAIR left-sided hyperintensity consistent with PRES. She was treated with antihypertensive, antiedematous, and other symptomatic therapy. The control brain MRI showed complete regression of the previously described changes, and she was discharged without a neurological deficit. So far, 33 cases of HELLP associated with PRES have been reported in the literature, including our case. Our review of 30 cases showed that although most patients have good outcomes, if not treated in time, patients may develop serious somatic complications and permanent neurological deficits, or even fatal outcomes.

Conclusion

PRES associated with HELLP syndrome is a rare combination of third trimester/postpartum complications which usually present with seizures, altered sensorium, headache, hypertension, and laboratory disorders. These disorders require mutual neurological, internal and gynaecological treatment, and if timely treated resolve completely in most of the cases. However, caution is required as these patients may develop serious somatic complications and permanent neurological deficits or even fatal outcomes.

Rescue of a spontaneous subcapsular hepatic hematoma associated with HELLP syndrome: A case report

RATIONALE

Spontaneous subcapsular hepatic hematoma (SSHH) is a rare yet severe complication of hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome that can lead to life-threatening situations for both the mother and fetus. Determining an appropriate therapeutic strategy remains challenging, as it involves choosing between surgery, microinvasive percutaneous transhepatic drainage, or conservative treatment alone. Further successful cases are needed to support the optimal option. We retrospectively collected a patient's clinical record and imaging data to elucidate the natural progression, response to noninvasive treatment, and outcome of SSHH associated with HELLP syndrome.

PATIENT CONCERNS

A 34-year-old woman, who underwent a cesarean section due to suspected fetal distress, developed SSHH accompanied by the potential risk of rupture and deteriorated serology within the first 24 hours after delivery.

DIAGNOSES

Emergency blood routine examination, serum biochemistry analysis, and computed tomography of the abdomen revealed a SSHH associated with HELLP syndrome.

INTERVENTIONS

The main rescue measures included the use of corticosteroids, antihypertensive drugs, and platelet transfusion.

OUTCOMES

A positive effect on the patient's condition was exhibited within 24 to 48 hours. The majority of the subcapsular hepatic hematoma could be absorbed without any sequelae over a period of 7 months.

LESSONS

For patients with pregnancy-induced hypertension, there is a heightened risk of HELLP syndrome occurrence in subsequent pregnancies. The assessment and treatment of SSHH should be conducted by an experienced multidisciplinary team. In addition to timely delivery, the administration of corticosteroids, usage of antihypertensive medication, and platelet transfusion are necessary, particularly within the first 48 hours if the patient's condition permits. This approach would provide valuable insights for further therapeutic decisions and facilitate a preliminary prognosis assessment.

The Role of Hypertension for Maternal Outcomes of Women with HELLP Syndrome - a Retrospective Study from a Tertiary Obstetric Center

Introduction

HELLP syndrome is a serious disorder that can occur in pregnancy; it has many possible complications and is associated with adverse maternal outcome. Due to the lack of predictive parameters for HELLP syndrome, finding the right time for delivery is challenging. In contrast to preeclampsia, hypertension is not an essential part of the diagnosis; nevertheless, many women with HELLP syndrome are hypertensive. The role and possible implications of hypertension in HELLP syndrome are not fully understood.

Material and Methods

In this retrospective cohort study, we analyzed the maternal outcomes of 59 patients diagnosed with HELLP syndrome. The patients were divided into three groups according to their blood pressure levels during their stay in hospital. These three groups were compared in terms of patient characteristics and maternal outcomes. A combined endpoint for adverse maternal outcome was defined which included blood pressure and antihypertensive medication at discharge from hospital, severe postpartum anemia, and eclampsia.

Results

Women with hypertensive crises had an unfavorable outcome compared to women with lower blood pressure levels. Patients with higher blood pressure during pregnancy were more likely to be hypertensive at discharge and needed a combination of antihypertensive agents significantly more often. The risk of an adverse maternal outcome increased with the severity of hypertension. An increase in systolic blood pressure by 10 mmHg raised the risk of an adverse outcome by 74% (95% CI: 1.22-2.66).

Conclusion

Hypertension not only plays an important role in preeclampsia but also affects the outcomes of patients with HELLP syndrome. These patients need to be identified quickly and treated accordingly as they are at risk of cardiovascular impairment. Patients should be followed up closely after delivery to reduce cardiovascular morbidity.

A case-based narrative review of pregnancy-associated atypical hemolytic uremic syndrome/complement-mediated thrombotic microangiopathy

Atypical hemolytic uremic syndrome is a complement-mediated thrombotic microangiopathy caused by uncontrolled activation of the alternative complement pathway in the setting of autoantibodies to or rare pathogenic genetic variants in complement proteins. Pregnancy may serve as a trigger and unmask atypical hemolytic uremic syndrome/complement-mediated thrombotic microangiopathy (aHUS/CM-TMA), which has severe, life-threatening consequences. It can be difficult to diagnose aHUS/CM-TMA in pregnancy due to overlapping clinical features with other thrombotic microangiopathy syndromes including hypertensive disorders of pregnancy. However, the distinction among thrombotic microangiopathy etiologies in pregnancy is important because each syndrome has specific disease management and treatment. In this narrative review, we discuss 2 cases to illustrate the diagnostic challenges and evolving approach in the management of pregnancy-associated aHUS/CM-TMA. The first case involves a 30-year-old woman presenting in the first trimester who was diagnosed with aHUS/CM-TMA and treated with eculizumab from 19 weeks' gestation. Genetic testing revealed a likely pathogenic variant in CFI. She successfully delivered a healthy infant at 30 weeks' gestation. In the second case, a 22-year-old woman developed severe postpartum HELLP syndrome, requiring hemodialysis. Her condition improved with supportive management, yet investigations assessing for aHUS/CM-TMA remained abnormal 6 months postpartum consistent with persistent complement activation but negative genetic testing. Through detailed case discussion describing tests assessing for placental health, fetal anatomy, complement activation, autoantibodies to complement regulatory proteins, and genetic testing for aHUS/CM-TMA, we describe how these results aided in the clinical diagnosis of pregnancy-associated aHUS/CM-TMA and assisted in guiding patient management, including the use of anticomplement therapy.

Prepregnancy body mass index and other risk factors for early-onset and late-onset haemolysis, elevated liver enzymes and low platelets (HELLP) syndrome: a population-based retrospective cohort study in British Columbia, Canada

BACKGROUND

Obesity increases risk of pre-eclampsia, but the association with haemolysis, elevated liver enzymes and low platelets (HELLP) syndrome is understudied.

OBJECTIVE

To examine the association between prepregnancy body mass index (BMI) and HELLP syndrome, including early-onset versus late-onset disease.

STUDY DESIGN

A retrospective cohort study using population-based data.

SETTING

British Columbia, Canada, 2008/2009-2019/2020.

POPULATION

All pregnancies resulting in live births or stillbirths at ≥20 weeks' gestation.

METHODS

BMI categories (kg/m2) included underweight (<18.5), normal (18.5-24.9), overweight (25.0-29.9) and obese (≥30.0). Rates of early-onset and late-onset HELLP syndrome (<34 vs ≥34 weeks, respectively) were calculated per 1000 ongoing pregnancies at 20 and 34 weeks' gestation, respectively. Cox regression was used to assess the associations between risk factors (eg, BMI, maternal age and parity) and early-onset versus late-onset HELLP syndrome.

MAIN OUTCOME MEASURES

Early-onset and late-onset HELLP syndrome.

RESULTS

The rates of HELLP syndrome per 1000 women were 2.8 overall (1116 cases among 391 941 women), and 1.9, 2.5, 3.2 and 4.0 in underweight, normal BMI, overweight and obese categories, respectively. Overall, gestational age-specific rates of HELLP syndrome increased with prepregnancy BMI. Obesity (compared with normal BMI) was more strongly associated with early-onset HELLP syndrome (adjusted HR (AHR) 2.24 (95% CI 1.65 to 3.04) than with late-onset HELLP syndrome (AHR 1.48, 95% CI 1.23 to 1.80) (p value for interaction 0.025). Chronic hypertension, multiple gestation, bleeding (<20 weeks' gestation and antepartum) also showed differing AHRs between early-onset versus late-onset HELLP syndrome.

CONCLUSIONS

Prepregnancy BMI is positively associated with HELLP syndrome and the association is stronger with early-onset HELLP syndrome. Associations with early-onset and late-onset HELLP syndrome differed for some risk factors, suggesting possible differences in aetiological mechanisms.

Administration of corticosteroid therapy for HELLP syndrome in pregnant women: evidences from seven randomized controlled trials

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.

Expression of insulin-like growth factor binding protein-3 in HELLP syndrome

OBJECTIVE

To investigate the expression of insulin-like growth factor binding protein-3(IGFBP-3) in HELLP syndrome and its possible role in the pathogenesis of this disease.

METHODS

1) 87 subjects were enrolled, including 29 patients with HELLP syndrome, 29 patients with pre-eclampsia (PE), and 29 healthy gravidae as control. The levels of IGFBP-3, IGF-1, TGF-β1, and VEGF in maternal and umbilical blood of them were detected using ELISA. Correlation analysis was used to observe the correlation between IGFBP-3 and IGF-1/TGF-β1/VEGF in maternal and umbilical blood, as well as that between maternal serum IGFBP-3 and clinical diagnostic indicators of HELLP syndrome. 2) Human hepatic sinusoid endothelial cells (HLSEC) and human umbilical vein endothelial cells (HUVEC) were cultured with different concentrations of IGFBP-3. After 72 h of culture, cell apoptosis and the normal living cells rate were detected and compared.

RESULTS

1) In both maternal and umbilical blood of HELLP group, levels of IGFBP-3 and TGF-β1 were higher than control and PE group, IGF-1was lower than control group, VEGF was lower than control and PE group. IGFBP-3 in maternal blood was correlated with IGF-1/TGF-β1/ VEGF, while IGFBP-3 in umbilical blood was linked to IGF-1/TGF-β1. In maternal blood, there was a negative correlation between PLT and IGFBP-3, and a positive correlation between ALT/AST/LDH and IGFBP-3. 2) After cultured with IGFBP-3, the total apoptosis rate of either HLSEC or HUVEC was considerably elevated, while the normal living rate was decreased.

CONCLUSION

The expression of IGFBP-3 is elevated in HELLP syndrome, which may subsequently promote cell apoptosis by affecting the expression and function of IGF-1, VEGF, and TGFβ1 in the IGF/PI3K/Akt, TGF-β1/Smad3, and VEGF/eNOS/NO pathways. IGFBP-3 aggravates inflammatory reactions of the vascular endothelium and liver under hypoxia, affects the normal function of cells, and plays a role in the pathogenesis of diseases.

Obesity Correlates with Chronic Inflammation of the Innate Immune System in Preeclampsia and HELLP Syndrome during Pregnancy

HELLP syndrome is characterized by hemolysis, elevated liver enzymes, and a low platelet count and poses an increased risk to the pregnant woman and the unborn child. Individual risk factors such as obesity may alter immunocompetence and influence the course of preeclampsia (PE) or HELLP syndrome. Blood samples were collected from 21 pregnant women (7 healthy, 6 with PE, and 8 with HELLP syndrome) and polymorphonuclear neutrophils (PMNs) were subsequently isolated. Production of radical oxygen species (ROS), cell movement, and NETosis were assessed by live-cell imaging. Surface protein expression and oxidative burst were analyzed by flow cytometry. PE and HELLP patients had significantly higher BMI compared to the healthy control group. Depending on the expression of CD11b, CD62L, and CD66b on PMNs, a surface protein activation sum scale (SPASS) was calculated. PMNs from patients with high SPASS values showed prolonged and more targeted migration with delayed ROS production and NETosis. Obesity is associated with a chronic inflammatory state, which in combination with immunological triggers during pregnancy could modulate PMN functions. Pregnant women with higher BMI tend to have higher SPASS values, indicating activation of the innate immune system that could co-trigger PE or HELLP syndrome.

Value of proteinuria in evaluating the severity of HELLP and its maternal and neonatal outcomes

BACKGROUND

HELLP syndrome refers to a group of clinical syndromes characterized by hemolysis, elevated liver enzymes and low platelet, and the evidence on the association between proteinuria and the severity of HELLP and its maternal and neonatal outcomes is rare.

METHODS

106 pregnant women were assigned to the proteinuric group (24-hUPro ≥ 0.3 g, 79 cases) and the non-proteinuric group (24-hUPro < 0.3 g, 27 cases). The proteinuric group was further divided into three subgroups: mild group (24-hUPro:0.3-2.0 g, 33 cases), moderate group (24-hUPro:2.0-5.0 g, 21 cases) and severe group (24-hUPro: ≥5.0 g, 25 cases). The general clinical data, laboratory indexes, complications and pregnancy outcome and adverse neonatal outcomes of HELLP with or without proteinuric were analyzed.

RESULTS

Compared with proteinuric group, the non-albuminuric group or in the three proteinuric subgroups of HELLP pregnant women's, increased proteinuria was associated with earlier onset gestations, higher incidence of abdominal pain, skin jaundice, headache, blurred vision (p < 0.05 respectively), and also the higher levels of ALT, AST, LDH, Fib, APTT, ATII, proportions of tubular urine and lower levels of ALB, PLT (p < 0.05 respectively). In the three subgroups of the proteinuric group, the ratio of fetal growth restriction, cesarean section and postpartum hemorrhage were compared, and the difference was statistically significant (p < 0.05 respectively). Compared with the proteinuric group, the non-proteinuric group had higher birth weight, birth length, and lower SGA, admission rate in NICU (p < 0.05 respectively). In the three subgroups of the proteinuric group, significant differences were identified in the adverse outcomes of newborns (p < 0.05 respectively), and the incidence of adverse outcomes in neonates tended to be higher. Significant differences were identified in birth weight, birth length, and lower SGA and NICU occupancy rate among the three subgroups (p < 0.05 respectively).

CONCLUSIONS

HELLP syndrome is a severe complication of pregnancy, involving multiple systems of the whole body. It has posed a great challenge to obstetricians for its acute onset, dangerous condition, rapid progress, and great harm. Thus, insights into HELLP syndrome should be gained, and early diagnosis, early treatment and timely termination of pregnancy should be conducted to reduce the incidence of maternal and fetal adverse outcomes and improve maternal and fetal prognosis.

The Role of Endothelial Dysfunction in the Pathogenesis of Pregnancy-Related Pathological Conditions: A Review

In the recent decades, endothelial dysfunction (ED) has been recognized as a significant contributing factor in the pathogenesis of many pathological conditions. In interaction with atherosclerosis, hypercholesterolemia, and hypertension, ED plays a crucial role in the pathogenesis of coronary artery disease, chronic renal disease, and microvascular complications in diabetes mellitus. Although ED plays a significant role in the pathogenesis of several pregnancy-related disorders such as preeclampsia, HELLP syndrome, fetal growth restriction, and gestational diabetes mellitus, the exact pathogenetic mechanisms are still a matter of debate. The increased prevalence of these entities in patients with preexisting vascular diseases highlights the essential pathological role of the preexisting ED in these patients. The abnormal uteroplacental circulation and the release of soluble factors from the ischemic placenta into the maternal bloodstream are the main causes of the maternal ED underlying the characteristic preeclamptic phenotype. Besides the increased risk for maternal and fetal poor outcomes, the preexisting ED also increases the risk of development of future cardiovascular diseases in these patients. This study aimed to look deeper into the role of ED in the pathogenesis of several pregnancy-related hypertensive and liver diseases. Hopefully, it could contribute to improvement of the awareness, knowledge, and management of these conditions and also to the reduction of the adverse outcomes and additional long-term cardiovascular complications.

Management and Prevention of Pre-Eclampsia in Nigeria

This research paper analyses the management and prevention of pre-eclampsia in Nigeria. Although efforts have been made to reduce outcomes due to pre-eclampsia, it still rears its head in the form of high maternal and perinatal morbidity and mortality. The aim of this review was to identify the main obstacles, gaps, and interventions related to the prevention and management of pre-eclampsia in order to be fully knowledgeable of the magnitude of the issue at the national level, to assess if current government policies are adequate and to recommend solutions. A search was performed on online databases and it was completed with hand searches related to the subject matter. Screening tests for early detection of pre-eclampsia are hardly available in Nigeria as many hospitals rely on the history of previous and current pregnancies, blood pressure monitoring and urinalysis-proteinuria. The administration of low-dose aspirin, antihypertensive drugs and magnesium sulphate, coupled with calcium in calcium deficit regions, was recommended. The main barriers to the wider implementation of these strategies are inadequacy of the antenatal care services in providing appropriate care, lack of resources and trained personnel, high healthcare costs, and low antennal care attendance. Improving education and awareness, use of low-cost screening modalities and low-dose aspirin can be deployed in developing countries to curb pre-eclampsia.

Conservative Treatment of Huge Hepatic Subcapsular Hematoma Complicated with Hepatic Infarction after Cesarean Section Caused by HELLP Syndrome - a Case Report and Literature Review

Hepatic subcapsular hematoma and hepatic infarction in labor are mostly secondary to HELLP syndrome and preeclampsia. There are few reported cases with a complicated diagnosis and treatment and high mortality. Here, we present a case of a huge hepatic subcapsular hematoma complicated with hepatic infarction after cesarean section that was secondary to HELLP syndrome and the patient was treated conservatively. Further, we have discussed the diagnosis and treatment of hepatic subcapsular hematoma and hepatic infarction caused by HELLP syndrome.

Reversal of H2O2-induced cell death by knockdown of HOTAIR in HTR-8/SVneo cells by mediation of miR-106b-5p/ACSL4 axis

Preeclampsia is a serious threat to the health of pregnant women. Injury of trophoblasts could contribute to the progression of preeclampsia, and H₂O₂ was able to induce apoptosis in trophoblasts. LncRNAs have been reported to be involved in the progression of preeclampsia. Additionally, lncRNA HOTAIR is upregulated in patients with preeclampsia. However, the function of HOTAIR in H₂O₂-treated trophoblasts remains unclear. To explore the function of HOTAIR in preeclampsia, HTR-8/SVneo cells were stimulated with H₂O₂. RT-qPCR was performed to measure HOTAIR expression in HTR-8/SVneo cells. The apoptosis of HTR-8/SVneo cells was measured using TUNEL staining. The mitochondrial membrane potential was measured using JC-1 staining. Western blotting was performed to detect the expression of ACSL4, GPX4, and FTH1 in HTR-8/SVneo cells. The level of HOTAIR in HTR-8/SVneo cells was upregulated by H₂O₂. In addition, H₂O₂ notably inhibited the proliferation of HTR-8/SVneo cells, whereas knockdown of HOTAIR reversed this phenomenon. The mitochondrial membrane potential in HTR-8/SVneo cells was significantly inhibited by H₂O₂ and partially abolished by HOTAIR silencing. Moreover, HOTAIR could bind to miR-106b-5p; ACSL4 was identified as the downstream target of miR-106b-5p. Furthermore, HOTAIR knockdown reversed H₂O₂-induced ferroptosis in HTR-8/SVneo cells by regulating miR-106b-5p/ACSL4. Collectively, the knockdown of HOTAIR reversed H₂O₂-induced ferroptosis in HTR-8/SVneo cells by mediating miR-106b-5p/ACSL4. Thus, HOTAIR may serve as a new therapeutic target against preeclampsia.

Serum syndecan-1 concentration in hemolysis, elevated liver enzymes, and low platelets syndrome: A case report

Background

Hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome occurs in pregnant and postpartum individuals. We observed serum syndecan-1 (SDC-1) levels, which is a component of the glycocalyx, in a patient with HELLP syndrome from admission to the postpartum period and examined their association as reflecting the pathophysiology related to endothelial injury.

Case presentation

A 31-year-old primiparous female patient without a previous medical history at a gestational age of 37 weeks and 6 days was transferred to our hospital the morning after a visit to a previous hospital with headache and nausea. Elevated transaminase, platelet count, and proteinuria were noted. Head magnetic resonance imaging revealed a caudate nucleus hemorrhage and posterior reversible encephalopathy syndrome. After she delivered her newborn through an emergency cesarean section, she was admitted to the intensive care unit. On day 4 post-delivery, the patient’s D-dimer concentration was elevated, and contrast-enhanced computed tomography was performed. The results indicated pulmonary embolism, and heparin administration was initiated. The serum SDC-1 level was highest on day 1 post-delivery and quickly decreased subsequently; however, it remained elevated during the postpartum period. Her condition gradually improved, and she was extubated on day 6 and discharged from the ICU on day 7 post-delivery.

Conclusion

We measured SDC-1 concentration in a patient with HELLP syndrome and found that the clinical course correlated with SDC-1 levels, indicating that SDC-1 is elevated immediately before and after pregnancy termination in patients with HELLP syndrome. Therefore, SDC-1 fluctuations, combined with the elevation of the D-dimer level, may be a potential marker for the early detection of HELLP syndrome and estimation of the syndrome’s severity in the future.

First-Trimester Screening for HELLP Syndrome—Prediction Model Based on MicroRNA Biomarkers and Maternal Clinical Characteristics

We evaluated the potential of cardiovascular-disease-associated microRNAs for early prediction of HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome. Gene expression profiling of 29 microRNAs was performed on whole peripheral venous blood samples collected between 10 and 13 weeks of gestation using real-time RT-PCR. The retrospective study involved singleton pregnancies of Caucasian descent only diagnosed with HELLP syndrome (n = 14) and 80 normal-term pregnancies. Upregulation of six microRNAs (miR-1-3p, miR-17-5p, miR-143-3p, miR-146a-5p, miR-181a-5p, and miR-499a-5p) was observed in pregnancies destined to develop HELLP syndrome. The combination of all six microRNAs showed a relatively high accuracy for the early identification of pregnancies destined to develop HELLP syndrome (AUC 0.903, p < 0.001, 78.57% sensitivity, 93.75% specificity, cut-off > 0.1622). It revealed 78.57% of HELLP pregnancies at a 10.0% false-positive rate (FPR). The predictive model for HELLP syndrome based on whole peripheral venous blood microRNA biomarkers was further extended to maternal clinical characteristics, most of which were identified as risk factors for the development of HELLP syndrome (maternal age and BMI values at early stages of gestation, the presence of any kind of autoimmune disease, the necessity to undergo an infertility treatment by assisted reproductive technology, a history of HELLP syndrome and/or pre-eclampsia in a previous gestation, and the presence of trombophilic gene mutations). Then, 85.71% of cases were identified at a 10.0% FPR. When another clinical variable (the positivity of the first-trimester screening for pre-eclampsia and/or fetal growth restriction by the Fetal Medicine Foundation algorithm) was implemented in the HELLP prediction model, the predictive power was increased further to 92.86% at a 10.0% FPR. The model based on the combination of selected cardiovascular-disease-associated microRNAs and maternal clinical characteristics has a very high predictive potential for HELLP syndrome and may be implemented in routine first-trimester screening programs.

Fructose might be a clue to the origin of preeclampsia insights from nature and evolution

Preeclampsia is a hypertensive disorder of pregnancy and is due to abnormal placentation. The pathogenesis remains unclear. Fructose is biologically distinct from glucose and has a critical role in fetal growth in early pregnancy. Many species, including humans, produce fructose in their placenta during the first trimester to assist fetal growth and survival during a time when hypoxia is significant. Fructose is preferred over glucose in hypoxic tissues, and in the developing fetus, fructose has a critical role in stimulating the production of nucleic acids, lipids and glycosaminoglycans. Fructose production normally decreases significantly following the establishment of maternal-fetal circulation following placentation. However, if there is impaired placentation, local hypoxia will continue to drive fructose production. Excessive fructose metabolism drives endothelial dysfunction, oxidative stress, elevated blood pressure, insulin resistance, fatty liver, and a rise in uric acid and vasopressin levels, all of which are features of the preeclamptic state. In addition to fructose production, dietary fructose, for example, from soft drinks, would be additive and has been reported to be a strong independent risk factor for preeclampsia. Uric acid-associated endothelial dysfunction disturbs the invasion of the spiral artery, leading to placental ischemia and further placental hypoxia. Here, we summarize the previous literature regarding the physiological and pathological roles of fructose in pregnancy and propose studies to further investigate the pathogenesis of preeclampsia. Fructose might be a Clue to the Origin of Preeclampsia Insights from Nature and Evolution Preeclampsia is a hypertensive disorder of pregnancy. The pathogenesis remains unclear. Fructose has a critical role in fetal growth in early pregnancy, and might be a key role to developing preeclampsia. Here, we summarize the previous literatures regarding the physiological andpathological roles of fructose in pregnancy to propose studies to further investigate the pathogenesis of preeclampsia.

The Need for Primary Care Beyond the Postnatal Period: Uncontrolled Hypertension-Induced Thrombotic Microangiopathy in a 32-Year-Old With a History of Preeclampsia Presenting Three Months Postpartum

A 32-year-old African American female with a past medical history of uncontrolled hypertension and preeclampsia with severe features presented to the emergency department with three days of shortness of breath, chest pain, bloody cough, and non-bloody diarrhea without any known prior viral syndrome. On presentation, she was diagnosed with a hypertensive emergency with renal and cardiac dysfunction. Laboratory workup revealed leukocytosis, normocytic anemia, and thrombocytopenia. The remainder of the laboratory data were significant for hemolysis. Differential diagnosis included thrombotic thrombocytopenic purpura (TTP)/hemolytic uremic syndrome (HUS); therefore, the patient was initiated on TTP treatment of pulsed dose steroids and plasma exchange. However, once the ADAMTS13 test returned negative, plasma exchange was stopped and the patient's profile returned to normal with supportive care and aggressive blood pressure control, as she had hypertension-induced thrombotic microangiopathy.

COVID-19 and hemolysis, elevated liver enzymes and thrombocytopenia syndrome in pregnant women - association or causation?

Pregnant women are among the high-risk population for severe coronavirus disease 2019 (COVID-19) with unfavorable peripartum outcomes and increased incidence of preterm births. Hemolysis, the elevation of liver enzymes, and low platelet count (HELLP) syndrome and severe preeclampsia are among the leading causes of maternal mortality. Evidence supports a higher odd of pre-eclampsia in women with COVID-19, given overlapping pathophysiology. Involvement of angiotensin-converting enzyme 2 receptors by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) for the entry to the host cells and its downregulation cause dysregulation of the renin-angiotensin-aldosterone system. The overexpression of Angiotensin II mediated via p38 Mitogen-Activated Protein Kinase pathways can cause vasoconstriction and uninhibited platelet aggregation, which may be another common link between COVID-19 and HELLP syndrome. On PubMed search from January 1, 2020, to July 30, 2022, we found 18 studies on of SARS-COV-2 infection with HELLP Syndrome. Most of these studies are case reports or series, did not perform histopathology analysis of the placenta, or measured biomarkers linked to pre-eclampsia/HELLP syndrome. Hence, the relationship between SARS-CoV-2 infection and HELLP syndrome is inconclusive in these studies. We intend to perform a mini-review of the published literature on HELLP syndrome and COVID-19 to test the hypothesis on association vs causation, and gaps in the current evidence and propose an area of future research.

Placental Syndromes-A New Paradigm in Perinatology

Placental syndromes include pregnancy loss, fetal growth restriction, preeclampsia, preterm delivery, premature rupture of membranes, placental abruption and intrauterine fetal demise. This paper discusses the common etiopathogenesis of those syndromes and the role of angiogenic biomarkers in their development. Pregnancy implantation, placental development and maternal adaptation are complex processes in which fetal and maternal cells interact. The syncytiotrophoblast, trophoblast, uterine natural killer cells and regulatory T cells interfere and interact in all the above-mentioned processes. The proper angioneogenesis and vasculogenesis of the placenta, as well as maternal circulatory adaptation, are dependent on angiogenic factor expression. Insufficient maternal immunotolerance, dysregulation in uterine natural killer or regulatory T cell function, syncytiotrophoblast and trophoblast ischemia and hypoxia or impaired balance in angiogenic factors are all related to the occurrence of placental syndromes. Differences in the time of impairment onset and its intensity and correlation with other dysfunctions result in the development of a specific syndrome. The clinical manifestations in the form of a combination of specific symptoms determine the diagnosis. However, they are just symptoms of an underlying complex trophoblast disorder.

Increased Serum Levels of Growth-Differentiation Factor 3 (GDF3) and Inflammasome-Related Markers in Pregnant Women during Acute Zika Virus Infection

The systemic inflammatory response elicited by acute Zika virus (ZIKV) infection during pregnancy plays a key role in the clinical outcomes in mothers and congenitally infected offspring. The present study aimed to evaluate the serum levels of GDF-3 and inflammasome-related markers in pregnant women during acute ZIKV infection. Serum samples from pregnant (n = 18) and non-pregnant (n = 22) women with acute ZIKV infection were assessed for NLRP3, IL-1β, IL-18, and GDF3 markers through an enzyme-linked immunosorbent assay. ZIKV-negative pregnant (n = 18) and non-pregnant women (n = 15) were used as control groups. All serum markers were highly elevated in the ZIKV-infected groups in comparison with control groups (p < 0.0001). Among the ZIKV-infected groups, the serum markers were significantly augmented in the pregnant women in comparison with non-pregnant women (NLRP3 p < 0.001; IL-1β, IL-18, and GDF3 p < 0.0001). The IL-18 marker was found at significantly higher levels (p < 0.05) in the third trimester of pregnancy. Bivariate and multivariate analyses showed a strong positive correlation between GDF3 and NLRP3 markers among ZIKV-infected pregnant women (r = 0.91, p < 0.0001). The findings indicated that acute ZIKV infection during pregnancy induces the overexpression of GDF-3 and inflammasome-related markers, which may contribute to congenital disorders and harmful pregnancy outcomes.

Factors Affecting ICU Stay and Length of Stay in the ICU in Patients with HELLP Syndrome in a Tertiary Referral Hospital

Objective

The study aimed to compare patients with HELLP syndrome who require intensive care and who do not require intensive care and evaluate the factors affecting the length of stay in the intensive care unit.

Methods

Patients were divided into two groups as follows: requiring intensive care (group 1) and not requiring intensive care (group 2). The data of both groups were compared in terms of demographic characteristics, transfusion amounts, length of stay in the intensive care unit, maternal complications, and mortality.

Results

14032 births in a tertiary center between 2011 and 2018 were evaluated in this study. During the study period, 342 patients were diagnosed with HELLP, and 32 (9.4%) of these were followed up in the intensive care unit. The length of stay in the intensive care unit was determined as 8.1 (7.2) days on average. Fresh frozen plasma, erythrocyte suspension, apheresis, and random thrombocyte transfusion were observed to be significantly more in group 1 patients. In the regression analysis, the most effective factor was found to be erythrocyte suspension and the length of stay in the intensive care unit was significantly longer in patients who had erythrocyte suspension transfusion. The receiver operating characteristic curve showed that the area under the curve value for erythrocyte transfusion was 70.6%. When the cutoff value of erythrocyte suspension was 450 (95% CI: 365–681) ml, the sensitivity was 43.8% and the specificity was 91.6%.

Conclusion

We think that physicians should be careful that maternal morbidity and mortality may increase as the need for erythrocyte suspension transfusion increases in patients with HELLP syndrome. Minimum transfusion to hemodynamically stable patients can be more suitable in terms of morbidity and mortality in managing patients with HELLP syndrome requiring erythrocyte suspension transfusion. Precautions and measures should be taken in this regard.

Molecular Advances in Preeclampsia and HELLP Syndrome

Preeclampsia (PE) constitutes one of the principal reasons for maternal and perinatal morbidity and mortality worldwide. The circumstance typically implicates formerly healthful normotensive women, after 20 weeks of gestation, typically withinside the third trimester, without regarded threat elements or past deliveries. PE can be further complicated with hemolysis and thrombocytopenia, leading to the emergence of HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low platelets). Both conditions are classified as hypertensive diseases of pregnancy (HDP), and their pathogenesis has been linked to an excessive maternal inflammatory response, accompanied by enhanced endothelial activation. Several studies have found that in pregnancies affected by PE/HELLP, von Willebrand factor (vWF) antigen levels (vWF:Ag) are significantly elevated, while its cleaving protease (ADAMTS-13, A Disintegrin-like and Metalloprotease with Thrombospondin type 1 motif, member 13) activity is normal to decreased. Furthermore, the higher urine excretion of the terminal complement complex C5b-9, as well as its greater deposition in the placental surface in preeclamptic women, imply that the utero-placental unit’s distinctive deficits are intimately tied to disproportionate complement activation. The goal of this updated evaluation is to provide the most up-to-date molecular advances in the pathophysiology of PE/HELLP syndromes. Recent medical data on vWF:Ag levels in patients with PE, ADAMTS-13, and dysregulation of the complement system, are highlighted and evaluated. Furthermore, we discuss the relationship between those entities and the progression of the disease, as well as their significance in the diagnostic process. Finally, considering the difficulties in analyzing and controlling those symptoms in pregnant women, we can provide a current diagnostic and therapeutic algorithm.

Gestational Thrombocytopenia: A Review on Recent Updates

Thrombocytopenia is a condition in which the blood platelet count is low. It is well established that the mild thrombocytopenia frequency is higher in normal pregnancy. This type of thrombocytopenia was named pregnancy-induced thrombocytopenia. However, recently, it has been widely known as gestational thrombocytopenia (GT). The rate is higher in women with a prior GT history and multiple pregnancies. However, it appears that GT is a physiological response to the pregnancy; placenta's peculiar structure and its unique blood flow pattern play major roles in GT development. There are no specific, precise, or known underlying pathophysiological mechanisms of GT, and no new specific management strategies are published yet. Therefore, we decided to do a non-systematic review of any recent updates that had been published in PubMed, EMBASE, and Web of Science about the pathophysiology of GT, its treatment, and other related topics.

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.

Possibility to use quanadex (dexmedetomidine) for caesarean section in patients with pre-eclampsia

A prospective, double­blind, randomized, con­trolled clinical trial was conducted at the Republican Spe­cialized Scientific and Practical Medical Center of Obstet­rics and Gynecology of the Ministry of Health of the Repub­lic of Uzbekistan. The inclusion criteria for pregnant wom­en in the study was preeclampsia. All women were divided into 2 groups. In group I, premedication was performed on the table with sibazon 5 mg. In group II, starting from the moment of premedication, 0.5 µg/kg of quanadex (Yuriya Pharm) was administered intravenously for 15 minutes. The maintaining dose was 0.5–0.8 µg/kg/h. 0.5 % hyper­baric longocaine heavy was administered intrathecally at the LII–LIV level. Hemodynamics was assessed by echocardi­ography. BAC and electrolytes, lactate, glucose, hematocrit were studied on a gas analyzer “BGA­102” Wondfo (Rain Sen Da), NTproBNP, Cystatin­C, interleukin­6 and protein S­100 were determined on an immunofluorescence ana­lyzer Finecare™ FIA MeterPlus/FS 113 (Wonfo), sedation was assessed using the Richmond scale. Newborns were assessed for Apgar scores in the 1st and 5th minutes.The data obtained showed that patients randomized to the group with dexmedetomidine (Group II) were almost al­ways better able to awaken than patients in the group with sibazon, and were distinguished by better hemodynamic stability, antinociceptive protection for surgical and anes­thetic intervention, without pronounced arterial hypoten­sion and bradycardia. It did not cause significant adverse outcomes in newborns.

Maternal Adverse Outcomes in Hypertensive Disorders of Pregnancy and Their Association with Serum Adiponectin and Redox Markers

Background: Premature termination of pregnancy because of unmanageable maternal complications in hypertensive disorders of pregnancy (HDP) results in adverse neonatal outcome. Identification of biochemical derangements associated with maternal complications may help in the better medical management of the mother resulting in better neonatal outcomes. Method: Healthy pregnant women (C); pregnant women with gestational hypertension (GH), and preeclampsia (late [LP] and early [EP] onset) were studied. Maternal serum redox markers and adipokines were evaluated for their association with maternal complications. Results: Adiponectin levels were significantly raised in preeclampsia groups when compared with control and GH groups. Univariate and multivariate analysis confirmed that malondialdehyde (MDA) and total antioxidant status (TAS) were associated with eclampsia; adiponectin and TAS with HELLP syndrome; adiponectin, MDA and TAS with severe preeclampsia; and adiponectin with impaired renal function. Conclusion: We identified that increased serum adiponectin, MDA, and TAS were associated with adverse maternal outcomes.

Animal models of preeclampsia: investigating pathophysiology and therapeutic targets

Animal models have been critical in investigating the pathogenesis, mediators, and even therapeutic options for a number of diseases, including preeclampsia. Preeclampsia is the leading cause of maternal and fetal morbidity and mortality worldwide. The placenta is thought to play a central role in the pathogenesis of this disease because it releases antiangiogenic and proinflammatory factors into the maternal circulation, resulting in the maternal syndrome. Despite the deleterious effects preeclampsia has been shown to have on the mother and baby during pregnancy and postpartum, there is still no effective treatment for this disease. Although clinical studies in patients are crucial to identify the involvement of pathogenic factors in preeclampsia, there are obvious limitations that prevent detailed investigation of the quantitative importance of time-dependent mechanisms involved in this syndrome. Animal models allow investigators to perform proof-of-concept studies and examine whether certain factors found in women with preeclampsia mediate hypertension and other manifestations of this disease. In this brief review, we summarize some of the more widely studied models used to investigate pathophysiological mechanisms that are thought to be involved in preeclampsia. These include models of placental ischemia, angiogenic imbalance, and maternal immune activation. Infusion of preeclampsia-related factors into animals has been widely studied to understand the specific mediators of this disease. These models have been included, in addition to a number of genetic models involved in overexpression of the renin-angiotensin system, complement activation, and trophoblast differentiation. Together, these models cover multiple mechanisms of preeclampsia from trophoblast dysfunction and impaired placental vascularization to the excess circulating placental factors and clinical manifestation of this disease. Most animal studies have been performed in rats and mice; however, we have also incorporated nonhuman primate models in this review. Preclinical animal models not only have been instrumental in understanding the pathophysiology of preeclampsia but also continue to be important tools in the search for novel therapeutic options for the treatment of this disease.

Liver Bleeding Due to HELLP Syndrome Treated With Embolization and Liver Transplantation: A Case Report and Review of the Literature

Background: Liver bleeding secondary to haemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is uncommon, but a life-threatening peripartum condition that needs a prompt multidisciplinary approach. Case Presentation: In this study, we presented a case of 28-year-old pregnant woman, who was presented to the obstetrics department with signs of preeclampsia and foetal growth restriction. An emergency caesarean section was performed, and the patient developed a HELLP syndrome complicated by spontaneous liver rupture. After radiological and surgical procedures, liver failure became evident and liver transplantation was successfully performed. The patient and her daughter are now alive. Conclusions: Despite the rarity of this disease, liver complications due to HELLP syndrome must be properly diagnosed and treated given the gravity of the possible evolution in young women. After diagnosis, the patients must be treated in specialised centres with gynaecological, liver surgery, and transplant skills.

Platelet Activation Mechanisms and Consequences of Immune Thrombocytopenia

Autoimmune disorders are often associated with low platelet count or thrombocytopenia. In immune-induced thrombocytopenia (IIT), a common mechanism is increased platelet activity, which can have an increased risk of thrombosis. In addition, or alternatively, auto-antibodies suppress platelet formation or augment platelet clearance. Effects of the auto-antibodies are linked to the unique structural and functional characteristics of platelets. Conversely, prior platelet activation may contribute to the innate and adaptive immune responses. Extensive interplay between platelets, coagulation and complement activation processes may aggravate the pathology. Here, we present an overview of the reported molecular causes and consequences of IIT in the most common forms of autoimmune disorders. These include idiopathic thrombocytopenic purpura (ITP), systemic lupus erythematosus (SLE), antiphospholipid syndrome (APS), drug-induced thrombocytopenia (DITP), heparin-induced thrombocytopenia (HIT), COVID-19 vaccine-induced thrombosis with thrombocytopenia (VITT), thrombotic thrombocytopenia purpura (TTP), and hemolysis, the elevated liver enzymes and low platelet (HELLP) syndrome. We focus on the platelet receptors that bind auto-antibodies, the immune complexes, damage-associated molecular patterns (DAMPs) and complement factors. In addition, we review how circulating platelets serve as a reservoir of immunomodulatory molecules. By this update on the molecular mechanisms and the roles of platelets in the pathogenesis of autoimmune diseases, we highlight platelet-based pathways that can predispose for thrombocytopenia and are linked thrombotic or bleeding events.

Relationship between anaemia, coagulation parameters during pregnancy and postpartum haemorrhage at childbirth: a prospective cohort study

OBJECTIVES

To investigate the association between coagulation parameters and severity of anaemia (moderate anaemia: haemoglobin (Hb) 7-9.9 g/dL and severe anaemia: Hb <7 g/dL) during pregnancy and relate these to postpartum haemorrhage (PPH) at childbirth.

DESIGN

A prospective cohort study of pregnant women recruited in the third trimester and followed-up after childbirth.

SETTING

Ten hospitals across four states in India.

PARTICIPANTS

1342 pregnant women.

INTERVENTION

Not applicable.

METHODS

Hb and coagulation parameters: fibrinogen, D-dimer, D-dimer/fibrinogen ratio, platelets and international normalised ratio (INR) were measured at baseline. Participants were followed-up to measure blood loss within 2 hours after childbirth and PPH was defined based on blood loss and clinical assessment. Associations between coagulation parameters, Hb, anaemia and PPH were examined using multivariable logistic regression models.

OUTCOMES MEASURES

Adjusted OR with 95% CI.

RESULTS

In women with severe anaemia during the third trimester, the D-dimer was 27% higher, mean fibrinogen 117 mg/dL lower, D-dimer/fibrinogen ratio 69% higher and INR 12% higher compared with women with no/mild anaemia. Mean platelets in severe anaemia was 37.8×109/L lower compared with women with moderate anaemia. Similar relationships with smaller effect sizes were identified for women with moderate anaemia compared with women with no/mild anaemia. Low Hb and high INR at third trimester of pregnancy independently increased the odds of PPH at childbirth, but the other coagulation parameters were not found to be significantly associated with PPH.

CONCLUSION

Altered blood coagulation profile in pregnant women with severe anaemia could be a risk factor for PPH and requires further evaluation.

Is the presence of antiphospholipid antibodies a poor prognostic factor for patients with hemolysis, elevated liver enzymes, and low platelet count syndrome?

BACKGROUND

The characteristics of antiphospholipid syndrome-associated hemolysis, elevated liver enzymes, and low platelet count syndrome are poorly described, likely because of the low frequency of this combination of syndromes.

OBJECTIVE

This study aimed to compare the characteristics and prognosis of hemolysis, elevated liver enzymes, and low platelet count syndrome in patients with and without antiphospholipid syndrome.

STUDY DESIGN

In this multicenter, case-control study, adult women diagnosed with hemolysis, elevated liver enzymes, and low platelet count syndrome before 34 weeks' gestation and who were also tested for antiphospholipid antibodies according to international diagnostic recommendations were included. Cases labeled "HELLP-APS+" were defined as patients who fulfilled the international classification criteria for antiphospholipid syndrome; they were retrospectively recruited by screening the 672 patients with antiphospholipid syndrome in our antiphospholipid syndrome database. Control cases labeled "HELLP-APS-" were defined as patients who did not fulfill the criteria for antiphospholipid syndrome; they were retrospectively recruited from our hospital admission database.

RESULTS

Overall, 71 patients were included (mean age, 30±5 years), with 23 patients in the hemolysis, elevated liver enzymes, and low platelet count syndrome with antiphospholipid syndrome group and 48 patients in the hemolysis, elevated liver enzymes, and low platelet count syndrome without antiphospholipid syndrome group. The live birth rate was significantly lower for patients with hemolysis, elevated liver enzymes, and low platelet count with antiphospholipid syndrome than for those with hemolysis, elevated liver enzymes, and low platelet count syndrome without antiphospholipid syndrome (43.5% vs 89.4%; P<.001). The patients with hemolysis, elevated liver enzymes, and low platelet count syndrome with antiphospholipid syndrome gave birth prematurely more often than the patients without antiphospholipid syndrome (24 weeks' gestation; 22.0-28.0 weeks vs 30 weeks' gestation; 27.0-33.0 weeks; P<.001). Among the patients with hemolysis, elevated liver enzymes, and low platelet count syndrome with antiphospholipid syndrome, 39% required an induced abortion owing to hemolysis, elevated liver enzymes, and low platelet count syndrome severity vs 8.5% of the patients with hemolysis, elevated liver enzymes, and low platelet count syndrome without antiphospholipid syndrome (P=.006). The intensive care unit admission rate was 61.9% in patients with hemolysis, elevated liver enzymes, and low platelet count syndrome with antiphospholipid syndrome, which was significantly higher than the rate of 27.7% in patients with hemolysis, elevated liver enzymes, and low platelet count syndrome without antiphospholipid syndrome (P=.007). None of the mothers died.

CONCLUSION

Our results suggest that the presence of antiphospholipid syndrome is a poor prognostic factor for both the mother and fetus in patients with hemolysis, elevated liver enzymes, and low platelet count syndrome.

Pathological AT1R-B2R Protein Aggregation and Preeclampsia

Preeclampsia is one of the most frequent and severe complications of pregnancy. Symptoms of preeclampsia usually occur after 20 weeks of pregnancy and include hypertension and kidney dysfunction with proteinuria. Up to now, delivery of the infant has been the most effective and life-saving treatment to alleviate symptoms of preeclampsia because a causative treatment does not exist, which could prolong a pregnancy complicated with preeclampsia. Preeclampsia is a complex medical condition, which is attributed to a variety of different risk factors and causes. Risk factors account for insufficient placentation and impaired vasculogenesis and finally culminate in this life-threatening condition of pregnancy. Despite progress, many pathomechanisms and causes of preeclampsia are still incompletely understood. In recent years, it was found that excessive protein complex formation between G-protein-coupled receptors is a common sign of preeclampsia. Specifically, the aberrant heteromerization of two vasoactive G-protein-coupled receptors (GPCRs), the angiotensin II AT1 receptor and the bradykinin B2 receptor, is a causative factor of preeclampsia symptoms. Based on this knowledge, inhibition of abnormal GPCR protein complex formation is an experimental treatment approach of preeclampsia. This review summarizes the impact of pathological GPCR protein aggregation on symptoms of preeclampsia and delineates potential new therapeutic targets.

Knockdown of Splicing Complex Protein PCBP2 Reduces Extravillous Trophoblast Differentiation Through Transcript Switching

Mutations in the LINC-HELLP non-coding RNA (HELLPAR) have been associated with familial forms of the pregnancy-specific HELLP syndrome. These mutations negatively affect extravillous trophoblast (EVT) differentiation from a proliferative to an invasive state and disturb the binding of RNA splicing complex proteins PCBP1, PCBP2, and YBX1 to LINC-HELLP. In this study, by using both in vitro and ex vivo experiments, we investigate if these proteins are involved in the regulation of EVT invasion during placentation. Additionally, we study if this regulation is due to alternative mRNA splicing. HTR-8/SVneo extravillous trophoblasts and human first trimester placental explants were used to investigate the effect of siRNA-mediated downregulation of PCBP1, PCBP2, and YBX1 genes on the differentiation of EVTs. Transwell invasion assays and proliferation assays indicated that upon knockdown of PCBP2 and, to a lesser extent, YBX1 and PCBP1, EVTs fail to differentiate toward an invasive phenotype. The same pattern was observed in placental explants where PCBP2 knockdown led to approximately 80% reduction in the number of explants showing any EVT outgrowth. Of the ones that still did show EVT outgrowth, the percentage of proliferating EVTs was significantly higher compared to explants transfected with non-targeting control siRNAs. To further investigate this effect of PCBP2 silencing on EVTs, we performed whole transcriptome sequencing (RNA-seq) on HTR-8/SVneo cells after PCBP2 knockdown. PCBP2 knockdown was found to have minimal effect on mRNA expression levels. In contrast, PCBP2 silencing led to a switch in splicing for a large number of genes with predominant functions in cellular assembly and organization, cellular function and maintenance, and cellular growth and proliferation and the cell cycle. EVTs, upon differentiation, alter their function to be able to invade the decidua of the mother by changing their cellular assembly and their proliferative activity by exiting the cell cycle. PCBP2 appears to be a paramount regulator of these differentiation mechanisms, where its disturbed binding to LINC-HELLP could contribute to dysfunctional placental development as seen in the HELLP syndrome.

Abnormal expression of the costimulatory molecule B7-H4 in placental chorionic villous and decidual basalis tissues of patients with preeclampsia and HELLP syndrome

BACKGROUND

B7-H4, a checkpoint molecule of the B7 family, regulates a broad spectrum such as T-cell activation, cytokine secretion, tumour progression, and invasion capacities. Our previous data revealed that soluble B7-H4 (sB7-H4) blood serum levels are elevated in women at high risk for the hypertensive pregnancy disorder preeclampsia (PE) in the first trimester, as well as in patients with confirmed early/late-onset PE.

AIM

We here aim to investigate the expression pattern of B7-H4 in placental tissues of PE and HELLP Syndrome versus control group.

METHODS

B7-H4 protein expression and localization were investigated by immunoblotting and co-immunohistochemistry in placental chorionic villous and decidual basalis tissues.

RESULTS

B7-H4 protein was prominently expressed at the cell membrane, in the cytoplasm of the syncytiotrophoblast (STB) and interstitial extravillous trophoblast (EVT). B7-H4 protein levels in placental chorionic villous tissue were significantly higher in women with early-onset/late-onset PE and HELLP, while it was decreased in decidual basalis tissues of early-onset PE and HELLP compared with controls.

CONCLUSION

B7-H4 was inversely expressed in placental chorionic villous and decidual basalis tissues of PE and HELLP patients. The increase in B7-H4 in the STB in PE and HELLP may lead to excessive apical expression and release of soluble B7-H4 in the maternal circulation. In contrast, the decrease in B7-H4 in decidual basalis tissues could be related to the decrease in invasion ability of the EVT in PE. Thus, the current results strongly suggest that B7-H4 is involved in the pathogenesis of PE and HELLP.

Comparison of maternal and neonatal outcomes between acute fatty liver of pregnancy and hemolysis, elevated liver enzymes and low platelets syndrome: a retrospective cohort study

BACKGROUND

Acute fatty liver of pregnancy (AFLP) and hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome are two uncommon disorders that mimic each other clinically, but are distinct pathophysiologically. This study aimed to compare maternal and neonatal outcomes between AFLP and HELLP syndrome.

METHODS

This retrospective cohort study was performed at a tertiary referral center in Taiwan between June 2004 and April 2020. We used the Swansea Criteria to diagnose AFLP, and the Tennessee Classification System to diagnose HELLP syndrome. Maternal characteristics, laboratory data, complications, and neonatal outcomes were compared. We analyzed the categorical variables with Chi-square test or Fisher's exact test and continuous variables with Student's t test or Mann-Whitney U test. Subsequent logistic regression analyses adjusting by potential confounding factors with significant difference were analyzed.

RESULTS

During the study period, 21 women had AFLP and 80 women had HELLP syndrome. There was a higher rate of preeclampsia (95.0 % versus 23.8 %) in the HELLP syndrome group compared to the AFLP group. However, the AFLP group had more other maternal complications including jaundice (85.7 % versus 13.8 %), acute kidney injury (61.9 % versus 15.0 %), disseminated intravascular coagulopathy (66.7 % versus 8.8 %), and sepsis (47.6 % versus 10.0 %) compared to the HELLP syndrome group. Nevertheless, higher rates of small for gestational age neonates (57.1 % versus 33.3 %), neonatal respiratory distress syndrome (39.2 % versus 8.3 %) and neonatal sepsis (34.2 % versus 12.5 %) were noted in the HELLP syndrome group.

CONCLUSIONS

AFLP is associated with a higher rate of multiple organ dysfunction in mothers, whereas HELLP syndrome is associated with a higher rate of neonatal morbidity.

Evaluation of Risk and Prognosis Factors of Acute Kidney Injury in Patients With HELLP Syndrome During Pregnancy

Hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome complicated with acute renal failure (AKI) is an important cause of maternal mortality and morbidity. The present retrospective study aims to identify risk and prognosis factors that are associated with AKI in patients with HELLP syndrome during pregnancy. A total of 110 pregnant HELLP patients with or without AKI from an 8-year period were studied. 65 of the patients were diagnosed with AKI based on the Kidney Disease Outcomes Quality Initiative criteria. Levels of the lowest hemoglobin and highest serum creatinine and bleeding incidence were identified as independent risk factors for AKI onset. Infection and serum creatinine level were identified as independent risk factors for maternal mortality. In addition, we also found that these factors were significantly different in AKI patients of different severity. The overall complete recovery rate was 67.7% (44 out of 65) for patients with AKI. The overall death rate was 4.5% (5 out of 110), where one of the patient was from the non-AKI group and the other four were from the AKI group. Our results provide valuable indications for clinical doctors during their diagnosis, treatment, and monitoring of recovery status in HELLP patients complicated with AKI.

Identification of Differential Expression Cytokines in Hemolysis, Elevated Liver Enzymes, and Low Platelet Syndrome by Proteome Microarray Analysis and Further Verification

To screen the differential expression cytokines (DECs) in hemolysis, elevated liver enzymes, and low platelet (HELLP) syndrome, establish its differential cytokines spectra, and provide the clues for its diagnosis and pathogenic mechanism researches. Sera from four HELLP syndrome patients and four healthy controls were detected by proteome microarray. Then the analysis of Gene Ontology (GO) enrichment, Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway, and protein–protein interaction (PPI) network were performed and possible hub proteins were selected out, further verified by Enzyme Linked Immunosorbent Assay (ELISA) in sera from 21 HELLP syndrome patients and 21 healthy controls. Thirty DECs were defined according to P-value and fold change between HELLP group and control group. GO enrichment analysis showed that DECs were mainly involved in the regulation of inflammatory response and have relationship to growth factor binding, transmembrane receptor protein kinase, and cytokine receptor activity. Seven possible hub proteins were defined by PPI analysis, including IGFBP-3/Follistatin-like 1/FLRG/Fetuin A and MMP-13/Thrombospondin-5/Aggrecan. ELISA showed higher serum levels of Fetuin A/IGFBP-3/FLGR/MMP-13/Thrombospondin-5 in HELLP group than those in controls, while the levels of Follistatin-like 1 and Aggrecan were lower in HELLP patients (all P < 0.05 or <0.01).The serological DECs spectra of HELLP syndrome was established and seven possible hub proteins that may be more closely related to the disease have been verified, providing new clues for its pathogenesis, diagnosis, and clinical treatment.

Plasma exchange and thrombotic microangiopathies: From pathophysiology to clinical practice

Thrombotic microangiopathy (TMA) brings together many diseases that have a commonality in the apparition of mechanical hemolysis with consuming thrombopenia. In all cases, these diseases can be life threatening, thereby justifying the implementation of treatment as an emergency. First-line treatment represents plasma exchange. This treatment has proven efficiency in improving the vital patient's and functional prognosis. However, the administration methods of plasma exchange can be redefined in light of the understanding of the pathophysiology of TMA. The aim of this review is to try to define, from pathophysiology, the place of plasma exchanges in the modern therapeutic arsenal of TMA.

Oxidative Stress and Preeclampsia-Associated Prothrombotic State

Preeclampsia (PE) is a common obstetric disease characterized by hypertension, proteinuria, and multi-system dysfunction. It endangers both maternal and fetal health. Although hemostasis is critical for preventing bleeding complications during pregnancy, delivery, and post-partum, PE patients often develop a severe prothrombotic state, potentially resulting in life-threatening thrombosis and thromboembolism. The cause of this thrombotic complication is multi-factorial, involving endothelial cells, platelets, adhesive ligands, coagulation, and fibrinolysis. Increasing evidence has shown that hemostatic cells and factors undergo oxidative modifications during the systemic inflammation found in PE patients. However, it is largely unknown how these oxidative modifications of hemostasis contribute to development of the PE-associated prothrombotic state. This knowledge gap has significantly hindered the development of predictive markers, preventive measures, and therapeutic agents to protect women during pregnancy. Here we summarize reports in the literature regarding the effects of oxidative stress and antioxidants on systemic hemostasis, with emphasis on the condition of PE.

A Pictorial Review of Postpartum Complications

The postpartum period, also known as the puerperium, begins immediately after delivery of the neonate and placenta and ends 6-8 weeks after delivery. The appearance of physiologic uterine changes during puerperium can overlap with that of postpartum complications, which makes imaging interpretation and diagnosis difficult. Obstetric and nonobstetric postpartum complications are a considerable source of morbidity and mortality in women of reproductive age, and the radiologist plays an important role in the assessment of these entities, which often require a multimodality imaging approach. US and contrast material-enhanced CT are the techniques of choice in the emergency department, and they can show characteristic radiologic findings that enable differentiation between normal and abnormal features to help radiologists and emergency department practitioners to reach a correct diagnosis and provide timely treatment. The spectrum of postpartum complications ranges from relatively self-limiting to life-threatening conditions that can be divided into six categories: infectious conditions (endometritis), thrombotic complications (eg, deep vein thrombosis, ovarian vein thrombophlebitis, HELLP [hemolysis, elevated liver enzymes, and low platelet count] syndrome, or cerebral sinus thrombosis), hemorrhagic conditions (eg, uterine atony, trauma of the lower portion of the genital tract, retained products of conception, uterine artery arteriovenous malformations, or uterine artery pseudoaneurysm), cesarean delivery-related complications (eg, bladder flap hematoma, subfascial hematoma, rectus sheath hematoma, abscess formation, uterine dehiscence, uterine rupture, vesicovaginal fistula, or abdominal wall endometriosis), iatrogenic conditions (eg, uterine perforation), and nonobstetric complications (eg, acute cholecystitis, acute appendicitis, uterine fibroid degeneration, renal cortical necrosis, pyelonephritis, posterior reversible encephalopathy syndrome, or pituitary gland apoplexy). The online slide presentation from the RSNA Annual Meeting is available for this article. ^©RSNA, 2020.

Acute kidney injury during pregnancy leads to increased sFlt-1 and sEng and decreased renal T regulatory cells in pregnant rats with HELLP syndrome

BACKGROUND

The incidence of acute kidney injury (AKI) during pregnancy precedes a high maternal mortality rate of 20-40%. AKI during pregnancy has multiple etiologies; however, the more common are maternal hypertensive disorders, which include preeclampsia and HELLP (hemolysis, elevated liver enzyme, low platelet) syndrome. Therefore, we sought to assess the impact of AKI on blood pressure, kidney injury, and anti-angiogenic factors during pregnancies with and without HELLP syndrome.

METHODS

On gestational day (GD) 12, mini-osmotic pumps were inserted into a subset of normal pregnant (NP) rats infusing 4.7 μg/kg soluble fms-like tyrosine kinase-1 (sFlt-1) and 7 μg/kg soluble endoglin (sEng) to induce HELLP syndrome. On GD18, the renal pedicles were occluded for 45 min to induce AKI via bilateral ischemia reperfusion in a subset of NP (n = 18) or HELLP (n = 20) rats. Control NP (n = 20) and HELLP (n = 20) rats underwent a SHAM surgery on GD18. Plasma, urine, and maternal organs were saved for further analysis. Renal injury was assessed via renal histopathology, glomerular filtration rate (GFR), T cell infiltration, and assessment of kidney injury molecule-1 (KIM-1) and neutrophil gelatinase-associated lipocalin (NGAL). Data was measured via two-way analysis of variance with Tukey's test for post hoc analysis.

RESULTS

Blood pressures were increased in HELLP+AKI rats (p = 0.0001); both NP+AKI and HELLP+AKI rats had increased lactate dehydrogenase (p < 0.0001) and aspartate aminotransferase levels (p < 0.0001), and decreased platelet levels (p < 0.001) vs. NP rats. HELLP+AKI (p = 0.002) and HELLP rats (p = 0.0002) had evidence of renal fibrosis vs. NP rats. GFR was decreased in HELLP+AKI (p = 0.01) rats vs. NP rats. Urinary KIM-1 was increased in NP+AKI rats vs. NP (p = 0.003) and HELLP rats (p = 0.01). HELLP+AKI rats had increased urinary KIM-1 vs. NP (p = 0.0008) and HELLP rats (p = 0.004) and increased NGAL vs. HELLP rats (p = 0.002). HELLP+AKI rats had increased sFlt-1 (p = 0.009) vs. NP rats. NP+AKI (p = 0.02) and HELLP+AKI (p = 0.007) rats had increased sEng vs. NP rats. CD3+CD4+ T cells were significantly increased in HELLP+AKI rats vs. NP (p = 0.0002) and NP+AKI (p = 0.05) rats. T regulatory cells were significantly decreased in HELLP+AKI (p = 0.03) and NP+AKI (p = 0.02) rats vs. NP rats; there were no changes between groups in T helper 17 cells (p = 0.34).

CONCLUSION

The findings in this study suggest that AKI during pregnancy contributes to increased blood pressure and biochemical markers for HELLP syndrome, creates an anti-angiogenic imbalance, and exacerbates kidney injury as shown on histopathology, GFR, and kidney injury markers.

Placental abruption as a trigger of DIC in women with HELLP syndrome: a population-based study

BACKGROUND

Disseminated Intravascular Coagulation (DIC) is a life-threatening condition. Hemolysis, Elevated Liver enzymes and Low Platelets (HELLP) syndrome is one of the obstetrical syndromes mostly associated with DIC and thus, high rates of fatal complications. There is a lack of information regarding epidemiologic and clinical characteristics of women who developed HELLP syndrome with and without DIC. Additionally, until now, there is no adapted and widely accepted way to diagnose DIC among pregnant women presenting with HELLP syndrome, despite the evident maternal mortality linked to the disease.

Objectives: (1) Address the gaps in knowledge regarding the prevalence, epidemiologic and clinical characteristics of women with HELLP syndrome who develop DIC; and (2) determine the risk factors for the development of DIC among women with HELLP syndrome.

STUDY DESIGN

This was a population-based retrospective cohort study, including all women who delivered at the Soroka University Medical Center between the years 2001-2017. The study population was divided into three groups: (1) comparison group (n = 207,266 deliveries); (2) HELLP syndrome without DIC (n = 320); (3) HELLP syndrome with DIC (n = 21). The diagnosis of DIC was based on the ICD-9 code as recorded in the obstetrical database of the Soroka University Medical Center. The coding is based on the diagnosis made by the attending physician during hospitalization.

RESULTS

(1) The rate of HELLP syndrome in the study population was 0.16% (341/207,607), of them 6.16% (21/341) had DIC; (2) among patients with HELLP syndrome, those with DIC had a higher median gravidity and parity; (3) a higher rate of severe maternal morbidity including blood product transfusion, placental abruption, eclampsia, acute renal failure and maternal death was observed in those who had HELLP syndrome and DIC compared to those with HELLP syndrome without DIC and the comparison group (p-value <.001 for comparison among the three groups); (4) among women with HELLP syndrome, those with DIC had a longer median PT difference, higher serum creatinine and lower AST as well as ALT median concentrations than those without DIC; (5) patients with HELLP syndrome and DIC had a higher rate of stillbirth and postpartum death than patients in the other groups (p-value <.001 for comparison among the three groups); and (6) placental abruption was an independent risk factor for the development of DIC in women with HELLP syndrome (p-value <.001).

CONCLUSIONS

(1) Among women with HELLP syndrome, those who developed DIC had a higher rate of maternal and neonatal morbidity and mortality than those without DIC; and (2) placental abruption, but not abnormal liver function, was an independent risk factor for the development of DIC in women with HELLP syndrome.

Genetic and molecular evidence for complement dysregulation in patients with HELLP syndrome

BACKGROUND

HELLP (Hemolysis, elevated liver enzymes and low platelets) syndrome is a severe and acute pregnancy-related disorder that occurs in approximately 2.5 per 1000 deliveries and represents a major cause of maternal and perinatal morbidity and mortality. This syndrome has been suggested to be a microangiopathy and delivery is the only effective treatment.

OBJECTIVES

The aim of this study was to investigate the pathophysiology of HELLP syndrome by simultaneously exploring complement, haemostasis, autoimmunity and inflammation in relation to the clinical outcome.

METHODS

We investigated 19 HELLP patients at the time of diagnosis and 3 months after delivery, for complement function, haemostasis and inflammation with immunoenzymatic methods. Complement-related gene variants were also analyzed by next generation sequencing and multiplex ligation-dependent probe amplification. Nineteen age-matched healthy pregnant women served as controls.

RESULTS

At diagnosis, HELLP patients, compared to controls, showed significantly higher plasma levels of SC5b-9 (median 710 ng/ml [range 216-1499] vs 253 ng/ml [19-371], P < 0.0001) and of C5a (20.8 ng/ml [5.6-27.5] vs 12.7 ng/ml [3.2-24.6]; P = 0.004), which decreased three months after delivery (SC5b9: 190 ng/ml [83-446] vs 160 ng/ml [107-219]; C5a: 9.28 ng/ml [2.3-21.6] vs 10.7 ng/ml [2.5-21.2]). A significantly higher frequency of genetic variants involving complement regulatory genes was also observed (52.6% vs 15.8%; P = 0.016). Moreover, at HELLP diagnosis, patients showed increased coagulation markers (fragment F1 + 2 and D-dimer; P = 0.0001) while both patients and controls had high thrombin-generation potential that decreased after delivery.

CONCLUSIONS

In the pathophysiology of HELLP syndrome, complement dysregulation, in addition to coagulation activation, is involved and may represent a potential target for treatment with the aim of delaying delivery.