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Giannubilo SR, Marzioni D, Tossetta G, Ciavattini A. HELLP Syndrome and Differential Diagnosis with Other Thrombotic Microangiopathies in Pregnancy. Diagnostics (Basel) 2024; 14:352. [PMID: 38396391 PMCID: PMC10887663 DOI: 10.3390/diagnostics14040352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 01/24/2024] [Accepted: 01/27/2024] [Indexed: 02/25/2024] Open
Abstract
Thrombotic microangiopathies (TMAs) comprise a distinct group of diseases with different manifestations that can occur in both pediatric and adult patients. They can be hereditary or acquired, with subtle onset or a rapidly progressive course, and they are particularly known for their morbidity and mortality. Pregnancy is a high-risk time for the development of several types of thrombotic microangiopathies. The three major syndromes are hemolysis, elevated liver function tests, and low platelets (HELLP); hemolytic uremic syndrome (HUS); and thrombotic thrombocytopenic purpura (TTP). Because of their rarity, clinical information and therapeutic results related to these conditions are often obtained from case reports, small series, registries, and reviews. The collection of individual observations, the evolution of diagnostic laboratories that have identified autoimmune and/or genetic abnormalities using von Willebrand factor post-secretion processing or genetic-functional alterations in the regulation of alternative complement pathways in some of these TMAs, and, most importantly, the introduction of advanced treatments, have enabled the preservation of affected organs and improved survival rates. Although TMAs may show different etiopathogenesis routes, they all show the presence of pathological lesions, which are characterized by endothelial damage and the formation of thrombi rich in platelets at the microvascular level, as a common denominator, and thrombotic damage to microcirculation pathways induces "mechanical" (microangiopathic) hemolytic anemia, the consumption of platelets, and ischemic organ damage. In this review, we highlight the current knowledge about the diagnosis and management of these complications during pregnancy.
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Affiliation(s)
| | - Daniela Marzioni
- Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Via Tronto 10/a, 60126 Ancona, Italy; (D.M.); (G.T.)
| | - Giovanni Tossetta
- Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Via Tronto 10/a, 60126 Ancona, Italy; (D.M.); (G.T.)
| | - Andrea Ciavattini
- Department of Clinical Sciences, Polytechnic University of Marche, Via Corridoni 11, 60123 Ancona, Italy;
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Hypertensive Disorders of Pregnancy: Common Clinical Conundrums. Obstet Gynecol Surv 2022; 77:234-244. [PMID: 35395093 DOI: 10.1097/ogx.0000000000000996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Importance Hypertensive complications of pregnancy comprise 16% of maternal deaths in developed countries and 7.4% of deaths in the United States. Rates of preeclampsia increased 25% from 1987 to 2004, and rates of severe preeclampsia have increased 6.7-fold between 1980 and 2003. Objective The aim of this study was to review current and available evidence for common clinical questions regarding the management of hypertensive disorders of pregnancy. Evidence Acquisition Original research articles, review articles, and guidelines on hypertension in pregnancy were reviewed. Results Severe gestational hypertension should be managed as preeclampsia with severe features. Serum uric acid levels can be useful in predicting development of superimposed preeclampsia for women with chronic hypertension. When presenting with preeclampsia with severe features before 34 weeks, expectant management should be considered only when both maternal and fetal conditions are stable. In the setting of hypertensive disorders of pregnancy, oral antihypertensive medications should be initiated when systolic blood pressure is greater than 160 mm Hg or when diastolic blood pressure is greater than 110 mm Hg, with the most ideal agents being labetalol or nifedipine. Furthermore, although risk of preeclampsia recurrence in future pregnancy is low, women with a history of preeclampsia should be managed with 81 mg aspirin daily for preeclampsia prevention. Conclusions and Relevance Despite the frequency with which hypertensive disorders of pregnancy are encountered clinically, situations arise frequently with limited evidence to guide providers in their management. An urgent need exists to better understand this disease to optimize outcomes for impacted patients.
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Hogg JP, Szczepanski JL, Collier C, Martin JN. Immediate postpartum management of patients with severe hypertensive disorders of pregnancy: pathophysiology guiding practice. J Matern Fetal Neonatal Med 2020; 35:2009-2019. [PMID: 32519919 DOI: 10.1080/14767058.2020.1776251] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Developing clinically-focused evidence and experience-based approaches to improve maternity care is a national priority. Safety and quality collaborative initiatives related to management of hypertensive disorders of pregnancy are vital in the implementation of improved care. We reviewed the obstetric literature to construct a concise summary of the core pathophysiologic issues, practice principles and clinical interventions which are foundational for physicians providing immediate postpartum care for patients with severe pregnancy-related hypertension (including those with eclampsia, HELLP syndrome, and superimposed preeclampsia inclusive of those with gestational hypertension that develop severe range blood pressures). While based largely upon the American College of Obstetrics and Gynecology (ACOG) Hypertension Task Force Guidelines released in 2013 as well as updated 2018 guidelines set forth by ACOG for hypertensive disorders of pregnancy, this summary goes beyond the basic safety bundles for hypertension management and lays a pathophysiologic foundation for the immediate postpartum care of patients with severe hypertensive disorders of pregnancy.
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Affiliation(s)
- James P Hogg
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Jamie L Szczepanski
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Charlene Collier
- Department of Obstetrics and Gynecology, Division of Women's Health, University of Mississippi Medical Center, Jackson, MS, USA
| | - James N Martin
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Mississippi Medical Center, Jackson, MS, USA
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Rambaldi MP, Weiner E, Mecacci F, Bar J, Petraglia F. Immunomodulation and preeclampsia. Best Pract Res Clin Obstet Gynaecol 2019; 60:87-96. [DOI: 10.1016/j.bpobgyn.2019.06.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 04/10/2019] [Accepted: 06/17/2019] [Indexed: 01/08/2023]
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Takahashi A, Kita N, Tanaka Y, Tsuji S, One T, Ishiko A, Kimura F, Takahashi K, Murakami T. Effects of high-dose dexamethasone in postpartum women with class 1 haemolysis, elevated liver enzymes and low platelets (HELLP) syndrome. J OBSTET GYNAECOL 2018; 39:335-339. [DOI: 10.1080/01443615.2018.1525609] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Akimasa Takahashi
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, Otsu, Japan
| | - Nobuyuki Kita
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, Otsu, Japan
| | - Yuji Tanaka
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, Otsu, Japan
| | - Shunichiro Tsuji
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, Otsu, Japan
| | - Tetsuo One
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, Otsu, Japan
| | - Akiko Ishiko
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, Otsu, Japan
| | - Fuminori Kimura
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, Otsu, Japan
| | - Kentaro Takahashi
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, Otsu, Japan
| | - Takashi Murakami
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, Otsu, Japan
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High-Dose Methylprednisolone to Prevent Platelet Decline in Preeclampsia: A Randomized Controlled Trial. Obstet Gynecol 2017; 128:153-8. [PMID: 27275791 DOI: 10.1097/aog.0000000000001470] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate whether early administration of high-dose methylprednisolone limits the fall of platelets in preeclampsia. METHODS A randomized trial of 180 mg methylprednisolone or placebo administered in divided doses over 36 hours was conducted in women admitted for preeclampsia and platelet counts below 150×10/L in four French academic centers. Patients were not included when platelet counts were below 50×10/L or when immediate delivery was required. The primary study outcome was the proportion of patients with platelet counts above 100×10/L 36 hours after the first dose of study medication. The total sample size needed to detect a 23% difference in the rate of this outcome between groups with a one-tailed α of 0.05 and 90% power was 94 patients. RESULTS Thirty-six patients were randomly assigned to receive methylprednisolone and 34 placebo between October 2007 and May 2011. Platelet counts above 100×10/L at 36 hours after the first dose of study medication were recorded in 30 (83%) in the active group and 29 (85%) in the placebo group (relative risk 0.98, 95% confidence interval 0.80-1.20; P=.82). The only adverse potentially study-related event was hyperglycemia in one woman allocated to methylprednisolone. CONCLUSION In women with preeclampsia and platelet counts under 150×10/L, methylprednisolone was not effective in maintaining platelet counts above 100×10/L. CLINICAL TRIAL REGISTRATION EU Clinical Trials Register, http://clinicaltrialsregister.eu, EudraCT 2006-004881-15-FR.
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Magann EF, Haram K, Ounpraseuth S, Mortensen JH, Spencer HJ, Morrison JC. Use of antenatal corticosteroids in special circumstances: a comprehensive review. Acta Obstet Gynecol Scand 2017; 96:395-409. [DOI: 10.1111/aogs.13104] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 01/20/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Everett F. Magann
- Department of Obstetrics and Gynecology; Department of Biostatistics; University of Arkansas for the Medical Sciences; Little Rock AR USA
| | - Kjell Haram
- Haukeland University Hospital; Department of Public and Primary Care; University of Bergen; Bergen Norway
| | - Songthip Ounpraseuth
- Department of Obstetrics and Gynecology; Department of Biostatistics; University of Arkansas for the Medical Sciences; Little Rock AR USA
| | - Jan H. Mortensen
- Haukeland University Hospital; Department of Public and Primary Care; University of Bergen; Bergen Norway
| | - Horace J. Spencer
- Haukeland University Hospital; Department of Public and Primary Care; University of Bergen; Bergen Norway
| | - John C. Morrison
- Department of Obstetrics and Gynecology; University of Mississippi Medical Center; Jackson MS USA
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Abstract
Thrombotic thrombocytopenia purpura (TTP) and the hemolytic uremic syndrome (HUS) are rare thrombotic microangiopathies that can be rapidly fatal. Although the acquired versions of TTP and HUS are generally highest on this broad differential, multiple rarer entities can produce a clinical picture similar to TTP/HUS, including microangiopathic hemolysis, renal failure, and neurologic compromise. More recent analysis has discovered a host of genetic factors that can produce microangiopathic hemolytic syndromes. This article discusses the current understanding of thrombotic microangiopathy and outlines the pathophysiology and causative agents associated with each distinct syndrome as well as the most accepted treatments.
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Affiliation(s)
- Joseph J Shatzel
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA
| | - Jason A Taylor
- Division of Hematology and Medical Oncology, The Hemophilia Center, Portland VA Medical Center, Knight Cancer Institute, Oregon Health & Science University, 3181 Southwest Sam Jackson Park Road, L586, Portland, OR 97239, USA.
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Paternoster DM, Fantinato S, Stella A, Nanhornguè KN, Milani M, Plebani M, Nicolini U, Girolami A. C-Reactive Protein in Hypertensive Disorders in Pregnancy. Clin Appl Thromb Hemost 2016; 12:330-7. [PMID: 16959687 DOI: 10.1177/1076029606291382] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Hypertension is the most frequent medical complication of pregnancy. A recent report demonstrates the flogistic pathogenesis of pregnancy-induced hypertension. Because C-reactive protein (CRP) is a marker of inflammation, it can be used in the differential diagnosis of hypertensive disorders of pregnancy. A total of 322 pregnant women at 24 to 32 weeks’ gestation were enrolled. The control group (A) comprised 190 women. Sixty-three women had preeclampsia (PE, group B), 31 women presented transient hypertension (TH, group C), 19 had HELLP syndrome (HS, group D) and 19 had chronic hypertension (CH, group E). CRP serum concentrations were significantly higher in groups B, C, and D in comparison with the group A. In the whole population, systolic and diastolic pressure value inversely correlate with weight at delivery and weeks of gestation at delivery. CPR levels in patients with PE and HS inversely correlate with birth weight and gestational week at delivery. Normal plasma levels of CRP may be an important marker of differential diagnosis between TH and CH. In TH, PE, and HS, CRP levels were higher than in the control and CH groups, suggesting that inflammation may be the common pathogenetic cause of TH and PE. Finally CRP levels in preeclampsia are believed to correlate with preeclamptic process severity.
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Abstract
Thrombocytopenia is a common laboratory finding in the intensive care unit (ICU) patient. Because the causes can range from laboratory artifact to life-threatening processes such as thrombotic thrombocytopenic purpura (TTP), identifying the cause of thrombocytopenia is important. In the evaluation of the thrombocytopenia patient, one should incorporate all clinical clues such as why the patient is in the hospital, medications the patient is on, and other abnormal laboratory findings. One should ensure that the patient does not suffer from heparin-induced thrombocytopenia (HIT) or one of the thrombotic microangiopathies (TMs). HIT can present in any patient on heparin and requires specific testing and antithrombotic therapy. TMs cover a spectrum of disease ranging from TTP to pregnancy complications and can have a variety of presentations. Management of disseminated intravascular coagulation depends on the patient’s condition and complication. Other causes of ICU thrombocytopenia include sepsis, medication side effects, post-transfusion purpura, catastrophic anti phospholipid antibody disease, and immune thrombocytopenia.
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Yang L, Ren C, Mao M, Cui S. Prognostic Factors of the Efficacy of High-dose Corticosteroid Therapy in Hemolysis, Elevated Liver Enzymes, and Low Platelet Count Syndrome During Pregnancy: A Meta-analysis. Medicine (Baltimore) 2016; 95:e3203. [PMID: 27043683 PMCID: PMC4998544 DOI: 10.1097/md.0000000000003203] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The aim of this study was to identify the factors which can affect the efficacy of corticosteroid (CORT) therapy in the management of hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. Research articles reporting the efficacy of CORT therapy to HELLP syndrome patients were searched in several electronic databases including EMBASE, Google Scholar, Ovid SP, PubMed, and Web of Science. Study selection was based on predefined eligibility criteria. Efficacy was defined by the changes from baseline in HELLP syndrome indicators after CORT therapy. Meta-analyses were carried out with Stata software. Data of 778 CORT-treated HELLP syndrome patients recruited in 22 studies were used in the analyses. Corticosteroid treatment to HELLP syndrome patients was associated with significant changes from baseline in platelet count; serum levels of aspartate aminotransaminase, alanine transaminase, and lactic dehydrogenase (LDH); mean blood pressure; and urinary output. Lower baseline platelet count predicted higher change in platelet count after CORT therapy. Lower baseline platelet count and lower baseline urinary output predicted greater changes in LDH levels after CORT therapy. There was also an inverse relationship between the change from baseline in LDH levels and intensive care duration. Higher CORT doses were associated with greater declines in the aspartate aminotransaminase, alanine transaminase, and LDH levels. Incidence of cesarean delivery was inversely associated with the gestation age. The percentage of nulliparous women had a positive association with the intensive care stay duration. High-dose CORT therapy to HELLP syndrome patients provides benefits in improving disease markers and reducing intensive care duration, especially in cases such as mothers with much lower baseline platelet count and LDH levels.
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Affiliation(s)
- Li Yang
- From the Department of Gynecology & Obstetrics (LY, CR, SC), The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan; and West Zone (MM), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
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Mao M, Chen C. Corticosteroid Therapy for Management of Hemolysis, Elevated Liver Enzymes, and Low Platelet Count (HELLP) Syndrome: A Meta-Analysis. Med Sci Monit 2015; 21:3777-83. [PMID: 26633822 PMCID: PMC4672720 DOI: 10.12659/msm.895220] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Background Hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is a severe condition of pregnancy that is associated with significant morbidity and mortality. Corticoteroid (CORT) therapy is common in the management of HELLP syndrome. This study evaluates the efficacy of CORT therapy to patients with HELLP Syndrome. Material/Methods A literature search was carried out in multiple electronic databases. Meta-analyses of means difference and odds ratio were carried under the random-effects model. Results Fifteen studies (675 CORT treated and 787 control HELLP patients) were included. CORT treatment significantly improved platelet count (mean difference between CORT treated and controls in changes from baseline, MD: 38.08 [15.71, 60.45]×109; p=0.0009), lactic dehydrogenase (LDH) levels (MD: −440 [−760, −120] IU/L; p=0.007), and alanine aminotransferase (ALT) levels (MD: −143.34 [−278.69, −7.99] IU/L; p=0.04) but the decrease in aspartate aminotransferase (AST) levels was not statistically significant (MD: −48.50 [−114.32, 17.32] IU/L; p=0.15). Corticosteroid treatment was also associated with significantly less blood transfusion rate (odds ratio, OR: 0.42 [0.24, 0.76]; p=0.004) and hospital/ICU stay (MD: −1.79 [−3.54, −0.05] days; p=0.04). Maternal mortality (OR: 1.27 [0.45, 3.60]; p=0.65), birth weight (MD: 0.09 [−0.11, 0.28]; p=0.38) and the prevalence of morbid conditions (OR: 0.79 [0.58, 1.08]; p=0.14) did not differ significantly between both groups. Conclusions Corticosteroid administration to HELLP patients improves platelet count, and the serum levels of LDH and ALT, and reduces hospital/ICU stay and blood transfusion rate, but is not significantly associated with better maternal mortality and overall morbidity.
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Affiliation(s)
- Minhong Mao
- West Zone, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China (mainland)
| | - Chen Chen
- West Zone, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China (mainland)
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Abstract
Thrombocytopenia during pregnancy is quite common. Evaluation of blood counts of pregnant women has shown that thrombocytopenia is the second most common haematological problem in pregnancy, after anaemia. While mostly thrombocytopenia has no consequences for either the mother or the foetus, in some cases it is associated with substantial maternal and/or neonatal morbidity and mortality. It may result from a number of diverse aetiologies. Adequate knowledge of these causes will help the clinicians in making proper diagnosis and management of thrombocytopenia in pregnancy. The evaluation of thrombocytopenia is essential to rule out any systemic disorders that may affect pregnancy management as thrombocytopenia can present as an isolated finding or in combination with underlying conditions. In this concise review, we have provided the overview of thrombocytopenia diagnosed during pregnancy.
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Affiliation(s)
- A Palta
- a Department of Pathology , Government medical college and hospital , Chandigarh , India
| | - P Dhiman
- b Department of Clinical Hematology , Institute of liver and biliary sciences , New Delhi , India
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Stepan H, Kuse-Föhl S, Klockenbusch W, Rath W, Schauf B, Walther T, Schlembach D. Diagnosis and Treatment of Hypertensive Pregnancy Disorders. Guideline of DGGG (S1-Level, AWMF Registry No. 015/018, December 2013). Geburtshilfe Frauenheilkd 2015; 75:900-914. [PMID: 28435172 PMCID: PMC5396549 DOI: 10.1055/s-0035-1557924] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Purpose: Official guideline published and coordinated by the German Society of Gynecology and Obstetrics (DGGG). Hypertensive pregnancy disorders contribute significantly to perinatal as well as maternal morbidity and mortality worldwide. Also in Germany these diseases are a major course for hospitalization during pregnancy, iatrogenic preterm birth and long-term cardiovascular morbidity. Methods: This S1-guideline is the work of an interdisciplinary group of experts from a range of different professions who were commissioned by DGGG to carry out a systematic literature search of positioning injuries. Members of the participating scientific societies develop a consensus in an informal procedure. Afterwards the directorate of the scientific society approves the consensus. Recommendations: This guideline summarizes the state-of-art for classification, risk stratification, diagnostic, treatment of hypertensive pregnancy disorders.
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Affiliation(s)
- H. Stepan
- Abteilung für Geburtsmedizin, Universitätsklinikum Leipzig,
Leipzig
| | - S. Kuse-Föhl
- Abteilung für Geburtsmedizin, Universitätsklinikum Leipzig,
Leipzig
| | - W. Klockenbusch
- Universitätsklinikum Münster, Klinik und Poliklinik für Frauenheilkunde und
Geburtshilfe, Abt. für Geburtshilfe, Münster
| | - W. Rath
- Frauenklinik für Gynäkologie und Geburtshilfe, Universitätsklinikum RWTH
Aachen, Aachen
| | - B. Schauf
- Frauenklinik Sozialstiftung Bamberg, Bamberg
| | - T. Walther
- Department of Pharmacology and Therapeutics, University College Cork, Cork,
Ireland
| | - D. Schlembach
- Klinik für Geburtsmedizin, Vivantes Klinikum Neukölln, Berlin
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Nasrollahi S, Hoseini Panah SM, Tavilani H, Tavasoli S, Naderan M, Shoar S. Antioxidant status and serum levels of selectins in pre-eclampsia. J OBSTET GYNAECOL 2014; 35:16-8. [PMID: 25280210 DOI: 10.3109/01443615.2014.935710] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
A cross-sectional study was conducted in a university hospital, enrolling 40 patients with pre-eclampsia (case group) and 40 healthy normotensive pregnant women (control group). Plasma activity of antioxidants and some adhesion molecules involved in oxidative stress were measured and compared between the two groups, according to the patients' age. In patients over the age of 30 years, serum levels of L-selectin and E-selectin were lower in pre-eclamptic patients (p < 0.05); antioxidants, catalase and superoxide dismutase did not significantly differ between the two groups, while glutathione peroxidase was significantly higher in the normotensive group (p < 0.05). In patients under the age of 30 years, E-selectin was significantly higher in the pre-eclampsia group (p < 0.05), while P-selectin, catalase and superoxide dismutase were not significantly different between the two groups (p > 0.05). Total antioxidative activity was similar between pre-eclamptic and normotensive patients (p > 0.05). This study revealed no relationship between total antioxidant activity and pre-eclampsia.
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Affiliation(s)
- S Nasrollahi
- Department of Obstetrics and Gynecology, Fatemieh Hospital, Hamedan University of Medical Sciences , Hamedan
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McCrae KR. Thrombocytopenia in Pregnancy. Platelets 2013. [DOI: 10.1016/b978-0-12-387837-3.00044-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Abstract
This article briefly discusses gestational physiologic changes and thereafter reviews liver diseases during pregnancy, which are divided into 3 main categories. The first category includes conditions that are unique to pregnancy and generally resolve with the termination of pregnancy, the second category includes liver diseases that are not unique to the pregnant population but occur commonly or are severely affected by pregnancy, and the third category includes diseases that occur coincidentally with pregnancy and in patients with underlying chronic liver disease, with cirrhosis, or after liver transplant who become pregnant.
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Affiliation(s)
- Ayaz Matin
- Division of Gastroenterology and Hepatology, Drexel University College of Medicine, 12th Floor New College Building, 245 North 15th Street, Suite 12324, Philadelphia, PA 19102, USA
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Abstract
BACKGROUND Hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome is a severe form of pre-eclampsia. Pre-eclampsia is a multi-system disease of pregnancy associated with an increase in blood pressure and increased perinatal and maternal morbidity and mortality. Eighty per cent of women with HELLP syndrome present before term. There are suggestions from observational studies that steroid treatment in HELLP syndrome may improve disordered maternal hematological and biochemical features and perhaps perinatal mortality and morbidity. OBJECTIVES To summarise the evidence on the effects of corticosteroids on maternal and neonatal mortality and morbidity in women with HELLP syndrome. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group trials register (October 2003). We scanned lists of references from review articles and primary studies. SELECTION CRITERIA Randomised and quasi-randomised trials evaluating the effects of adjunctive corticosteroids in patients diagnosed with HELLP syndrome were sought. DATA COLLECTION AND ANALYSIS The two authors independently applied inclusion criteria, assessed trial quality and extracted relevant data. MAIN RESULTS Of the five studies reviewed (n = 170), three were conducted antepartum and two postpartum. Four of the studies randomised participants to standard therapy or dexamethasone. One study compared dexamethasone with betamethasone. Dexamethasone versus control There were no significant differences in the primary outcomes of maternal mortality and morbidity due to placental abruption, pulmonary oedema and liver hematoma or rupture. Of the secondary maternal outcomes, there was a tendency to a greater platelet count increase over 48 hours, statistically significantly less mean number of hospital stay days (weighted mean difference (WMD) -4.50, 95% confidence interval (CI) -7.13 to -1.87), mean interval (hours) to delivery (41 +/- 15) versus (15 +/- 4.5) (p = 0.0068) in favour of women allocated to dexamethasone.There were no significant differences in perinatal mortality or morbidity due to respiratory distress syndrome, need for ventilatory support, intracerebral hemorrhage, necrotizing enterocolitis and a five minute Apgar less than seven. The mean birthweight was significantly greater in the group allocated to dexamethasone (WMD 247.00, 95% CI 65.41 to 428.59).Dexamethasone versus betamethasone There were no significant differences in all the maternal and perinatal mortality and in primary morbidity outcomes.Women randomised to dexamethasone fared significantly better for: oliguria, mean arterial pressure, mean increase in platelet count, mean increase in urinary output and liver enzyme elevations. AUTHORS' CONCLUSIONS There is insufficient evidence to determine whether adjunctive steroid use in HELLP syndrome decreases maternal and perinatal mortality, major maternal and perinatal morbidity.
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Affiliation(s)
- Patrice T Matchaba
- Novartis Pharmaceuticals Corporation, One Health Plaza, East Hanover, NJ 07936-1080, USA
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Suñer DB, Salais SF, García CD, Almela VD, Marín AP. Rotura hepática asociada a preeclampsia y síndrome HELLP, con resultados catastróficos. ACTA ACUST UNITED AC 2009. [DOI: 10.1016/s0304-5013(09)71810-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Haram K, Svendsen E, Abildgaard U. The HELLP syndrome: clinical issues and management. A Review. BMC Pregnancy Childbirth 2009; 9:8. [PMID: 19245695 PMCID: PMC2654858 DOI: 10.1186/1471-2393-9-8] [Citation(s) in RCA: 286] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2008] [Accepted: 02/26/2009] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The HELLP syndrome is a serious complication in pregnancy characterized by haemolysis, elevated liver enzymes and low platelet count occurring in 0.5 to 0.9% of all pregnancies and in 10-20% of cases with severe preeclampsia. The present review highlights occurrence, diagnosis, complications, surveillance, corticosteroid treatment, mode of delivery and risk of recurrence. METHODS Clinical reports and reviews published between 2000 and 2008 were screened using Pub Med and Cochrane databases. RESULTS AND CONCLUSION About 70% of the cases develop before delivery, the majority between the 27th and 37th gestational weeks; the remainder within 48 hours after delivery. The HELLP syndrome may be complete or incomplete. In the Tennessee Classification System diagnostic criteria for HELLP are haemolysis with increased LDH (> 600 U/L), AST (>or= 70 U/L), and platelets < 100 x 10(9)/L. The Mississippi Triple-class HELLP System further classifies the disorder by the nadir platelet counts. The syndrome is a progressive condition and serious complications are frequent. Conservative treatment (>or= 48 hours) is controversial but may be considered in selected cases < 34 weeks' gestation. Delivery is indicated if the HELLP syndrome occurs after the 34th gestational week or the foetal and/or maternal conditions deteriorate. Vaginal delivery is preferable. If the cervix is unfavourable, it is reasonable to induce cervical ripening and then labour. In gestational ages between 24 and 34 weeks most authors prefer a single course of corticosteroid therapy for foetal lung maturation, either 2 doses of 12 mg betamethasone 24 hours apart or 6 mg or dexamethasone 12 hours apart before delivery. Standard corticosteroid treatment is, however, of uncertain clinical value in the maternal HELLP syndrome. High-dose treatment and repeated doses should be avoided for fear of long-term adverse effects on the foetal brain. Before 34 weeks' gestation, delivery should be performed if the maternal condition worsens or signs of intrauterine foetal distress occur. Blood pressure should be kept below 155/105 mmHg. Close surveillance of the mother should be continued for at least 48 hours after delivery.
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Affiliation(s)
- Kjell Haram
- Department of Obstetrics and Gynaecology, Haukeland University Hospital, Bergen, Norway.
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Ozer A, Kanat-Pektas M, Ozer S, Tapisiz OL, Zulfikaroglu EE, Danisman N. The effects of betamethasone treatment on clinical and laboratory features of pregnant women with HELLP syndrome. Arch Gynecol Obstet 2008; 280:65-70. [PMID: 19089438 DOI: 10.1007/s00404-008-0865-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2008] [Accepted: 11/24/2008] [Indexed: 11/27/2022]
Abstract
AIM The present study aims to investigate the effects of betamethasone treatment on clinical outcome and laboratory data of pregnant women diagnosed with HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome. METHODS A prospective, randomized and placebo-controlled clinical trial was undertaken in a total of 60 pregnant women with HELLP syndrome who were treated at the perinatology department of the study center between January 2005 and February 2008. Betamethasone treatment (intramuscular injection of 12 mg in every 24 h) was given to 30 subjects while remaining 30 subjects received placebo. The treatment and control groups were compared in the aspects of clinical outcome and laboratory data. RESULTS The alterations in platelet counts, alanine aminotransferase, aspartate aminotransferase and lactate dehydrogenase levels of women treated with betamethasone were statistically similar to those of the placebo group. Although there was a significant decrease in diastolic blood pressure values of control group (P = 0.04), alterations in systolic blood pressure values were statistically indifferent in both study groups. Hematological and metabolic complications occurred significantly less in women treated with betamethasone (P < 0.05). Interestingly, the percentage of women who received platelet transfusion was significantly higher in the control group (P < 0.005). No case of maternal mortality occurred. CONCLUSIONS The betamethasone treatment has ended up with insignificant alterations in clinical outcomes and laboratory data of women with HELLP syndrome except beneficial effects on metabolic complications and need for platelet transfusion. Further investigation is required to assess the efficiency of betamethasone in management of HELLP syndrome.
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Affiliation(s)
- Alev Ozer
- Department of Perinatology, Dr. Zekai Tahir Burak Women Health Research and Education Hospital, Ankara, Turkey
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Beucher G, Simonet T, Dreyfus M. Prise en charge du HELLP syndrome. ACTA ACUST UNITED AC 2008; 36:1175-90. [DOI: 10.1016/j.gyobfe.2008.08.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2008] [Accepted: 08/09/2008] [Indexed: 11/26/2022]
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Uszyński M, Uszyński W, Zekanowska E. P-selectin in placenta and gestational myometrium: its measurements and hypothetical role in hemostasis of placental bed after labor. J Perinat Med 2008; 36:213-6. [PMID: 18576930 DOI: 10.1515/jpm.2008.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AIM P-selectin is a member of selectin family (E, L- and P-selectins) which plays a crucial role in reproduction and hemostasis as well as in pathogenesis of preeclampsia. There are no regular studies on P-selectin in placenta and it is not clear whether it is present in gestational myometrium. In the present study, we have asked whether P-selectin is present in placenta and myometrium and in what concentration. MATERIAL AND METHODS The study group consisted of 33 healthy pregnant women at term and/or at the beginning of labor who delivered by cesarean section because of fetal distress or elective reasons. Strips of placenta and myometrium as well as venous blood were obtained during the operation. P-selectin was measured in tissue extracts and plasma with the use of immunoenzymatic assays (ELISA). RESULTS The median of the level of P-selectin in placenta was 31.65 ng/mg P (total protein), quartiles (Q1-Q3): 24.54-43.35 ng/mg P, and in myometrium 25.54 ng/mg P, quartiles (Q1-Q3): 21.83-35.65 ng/mg P, whereas the median and quartiles (Q1-Q3) of soluble P-selectin in the mother's plasma was 1.14: 0.76-1.63 ng/mg P. The plasma/tissue ratio for placenta was 1:30, and for myometrium -1:25. CONCLUSIONS P-selectin is present in placenta and gestational myometrium; its concentration is relatively high - respectively 30- and 25-times higher than in plasma. On the basis of our studies, we hypothesize about the role of placental and myometrial P-selectin in hemostasis of placental bed after labor.
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Affiliation(s)
- Mieczysław Uszyński
- Department of Propedeutics of Medicine, Nicolaus Copernicus University, Collegium Medicum in Bydgoszcz, Poland.
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Pourrat O, Pierre F. Que faire en pratique à la découverte d’une thrombopénie en cours de grossesse ? Rev Med Interne 2008; 29:808-14. [DOI: 10.1016/j.revmed.2007.11.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2007] [Revised: 10/29/2007] [Accepted: 11/05/2007] [Indexed: 10/22/2022]
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Postpartum dexamethasone for women with hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome: a double-blind, placebo-controlled, randomized clinical trial. Am J Obstet Gynecol 2008; 198:283.e1-8. [PMID: 18194800 DOI: 10.1016/j.ajog.2007.10.797] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2007] [Revised: 08/17/2007] [Accepted: 10/11/2007] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The purpose of this study was to determine the effectiveness of postpartum dexamethasone in patients with hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome. STUDY DESIGN A prospective, randomized, double-blind trial was conducted in which 105 women with HELLP syndrome were enrolled and assigned randomly to treatment or placebo groups following delivery. Duration of hospital stay, maternal morbidity, and laboratory and clinical parameters were evaluated. RESULTS There was no difference in maternal morbidity or mortality between the 2 groups. There was also no difference in duration of hospitalization and the need for rescue scheme or the use of blood products between groups. Linear model adjustments showed no significant difference between groups with respect to the pattern of platelet count recovery, aspartate aminotransferase, lactate dehydrogenase, hemoglobin, or diuresis. CONCLUSION These findings do not support the use of dexamethasone in the puerperium for recovery of patients with HELLP syndrome.
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Holzgreve W, Hahn S, Zhong XY, Lapaire O, Hösli I, Tercanli S, Mindy P. Genetic communication between fetus and mother: short- and long-term consequences. Am J Obstet Gynecol 2007; 196:372-81. [PMID: 17403426 DOI: 10.1016/j.ajog.2006.12.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2006] [Accepted: 12/12/2006] [Indexed: 01/26/2023]
Affiliation(s)
- Wolfgang Holzgreve
- Department of Obstetrics and Gynecology, University of Basel, Basel, Switzerland.
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Martin JN, Rose CH, Briery CM. Understanding and managing HELLP syndrome: the integral role of aggressive glucocorticoids for mother and child. Am J Obstet Gynecol 2006; 195:914-34. [PMID: 16631593 DOI: 10.1016/j.ajog.2005.08.044] [Citation(s) in RCA: 178] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2005] [Revised: 07/13/2005] [Accepted: 08/18/2005] [Indexed: 11/16/2022]
Abstract
Antepartum or postpartum HELLP syndrome constitutes an obstetric emergency that requires expert knowledge and management skills. The insidious and variable nature of disease presentation and progression challenges the clinician and complicates consensus on universally accepted diagnostic and classification criteria. A critical review of published research about this variant form of severe preeclampsia, focused primarily on what is known about the pathogenesis of this disorder as it relates to patient experience with corticosteroids for its management, leads to the conclusion that there is maternal-fetal benefit realized when potent glucocorticoids are aggressively used for its treatment. Although acknowledging the need for definitive multicenter trials to better define the limits of benefit and the presence of any maternal or fetal risk, and given an understanding of the nature of the disorder with its potential to cause considerable maternal morbidity and mortality, we recommend for the present that aggressively used potent glucocorticoids constitute the cornerstone of management for patients considered to have HELLP syndrome.
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Affiliation(s)
- James N Martin
- Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, MS, USA
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Elovitz MA. Anti-inflammatory interventions in pregnancy: now and the future. Semin Fetal Neonatal Med 2006; 11:327-32. [PMID: 16828353 DOI: 10.1016/j.siny.2006.03.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2006] [Indexed: 10/24/2022]
Abstract
A growing body of evidence implicates inflammatory pathways in adverse reproductive outcomes. This expanding evidence suggests that anti-inflammatory interventions may hold promise in reducing the maternal and neonatal morbidities and mortalities associated with these obstetrical complications. Preterm birth, preeclampsia, pregnancy loss and adverse neonatal outcomes have all been associated with the activation of inflammatory pathways during pregnancy. Because of the number of observational human studies, as well as animal models of preterm birth, the mechanisms by which inflammation may promote preterm parturition and adverse effects on the fetus are beginning to be elucidated. Although the future use of anti-inflammatory interventions in this context holds significant promise, much research is still warranted. Only when the pathogenesis of obstetrical complications is more fully understood can meaningful therapeutic interventions become a realistic goal.
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Affiliation(s)
- Michal A Elovitz
- Department of Obstetrics and Gynecology, University of Pennsylvania School of Medicine, 421 Curie Boulevard, 1353 BRB 2/3, Philadelphia, PA 19104-6142, USA.
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Basama FMS, Granger K. Case report: post partum class 1 HELLP syndrome. Arch Gynecol Obstet 2006; 275:187-9. [PMID: 16819612 DOI: 10.1007/s00404-006-0199-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2006] [Accepted: 05/24/2006] [Indexed: 10/24/2022]
Abstract
The objective of this case report is to highlight the lack of screening tests that is capable of predicting HELLP syndrome before its occurrence. The patient developed severe pre-eclamptic toxaemia at 34+ weeks gestation. The foetus was growth retarded. The patient received anti-hypertensive therapy and was delivered by an emergency caesarean section. The patient developed post partum HELLP syndrome that required supportive treatment and renal haemodialysis; nevertheless, the patient fully recovered.
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Affiliation(s)
- F M S Basama
- Royal Lancaster Infirmary Hospital, Ashton Road, Lancaster, Lancashire, UK.
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Mould S, Paruk F, Moodley J. High-dose dexamethasone in the treatment of HELLP syndrome. Int J Gynaecol Obstet 2006; 93:140-1. [PMID: 16542658 DOI: 10.1016/j.ijgo.2006.01.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2005] [Revised: 01/16/2006] [Accepted: 01/17/2006] [Indexed: 11/26/2022]
Affiliation(s)
- S Mould
- Women's Health and HIV Research Group and Department of Obstetrics and Gynecology, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
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Vigil-De Gracia P. Addition of platelet transfusions to corticosteroids does not increase the recovery of severe HELLP syndrome. Eur J Obstet Gynecol Reprod Biol 2006; 128:194-8. [PMID: 16388885 DOI: 10.1016/j.ejogrb.2005.11.038] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2004] [Revised: 09/03/2005] [Accepted: 11/14/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The objective was to evaluate the effect of dexamethasone and platelet transfusion treatment on recovery in patients with class 1 hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome. MATERIAL AND METHODS All women with class 1 HELLP syndrome (true HELLP syndrome) who were seen at the hospital Complejo Hospitalario de la Caja de Seguro Social de Panama, Panama between July 1996 and June 2004 took part in a retrospective, comparative study. They were divided into two groups. One group received dexamethasone and the other group received dexamethasone plus platelet transfusion. True HELLP syndrome was defined as hemolysis, elevated liver enzymes, and maternal platelet nadir < or =50,000 platelets/microl. MAIN OUTCOME MEASURE The primary endpoint was resolution of the HELLP syndrome as recognized by normalization of the platelet count (> or =150,000/microl) and the mean length (measured in days) of the postpartum stay in hospital. RESULTS Forty-six women with true HELLP syndrome were studied. Twenty-six patients received dexamethasone and 20 received dexamethasone plus platelet transfusion. The normalization of the platelet count was significantly more rapid in the dexamethasone group (p<0.004) and the postpartum hospital stay was significantly more prolonged in the dexamethasone plus platelet transfusion group (p<0.02). There was no maternal death. CONCLUSIONS The findings suggest the initiation of high-dose dexamethasone therapy in women with true HELLP syndrome, with the next step being delivery, and probably platelet count < or =50,000/microl alone is not always an indication for platelet transfusion.
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Affiliation(s)
- Paulino Vigil-De Gracia
- Obstetric Intensive Unit, Department of Gynecology and Obstetrics, Complejo Hospitalario "Arnulfo Arias Madrid" Caja de Seguro Social, Apartado Postal 87 32 24, Zona 7, Panama.
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Fonseca JE, Méndez F, Cataño C, Arias F. Dexamethasone treatment does not improve the outcome of women with HELLP syndrome: a double-blind, placebo-controlled, randomized clinical trial. Am J Obstet Gynecol 2005; 193:1591-8. [PMID: 16260197 DOI: 10.1016/j.ajog.2005.07.037] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2005] [Revised: 04/04/2005] [Accepted: 07/05/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The purpose of this study was to determine the efficacy of dexamethasone for treatment of HELLP (hemolysis, elevated liver enzymes and low platelet count) syndrome. STUDY DESIGN A prospective, double-blind clinical trial was conducted among 132 women with HELLP syndrome who were assigned randomly to treatment or placebo groups. Pregnant women in the experimental group received 10-mg doses of dexamethasone intravenously every 12 hours until delivery and 3 additional doses after delivery. Puerperal women received 3 10-mg doses of dexamethasone after delivery. The same schedule was used in the placebo group. The main outcome variable was the duration of hospitalization. In addition, we evaluated treatment effects on the time to recovery of laboratory and clinical parameters and on frequency of complications. RESULTS The mean duration of hospitalization of patients who received dexamethasone therapy was shorter than in the placebo group (6.5 vs 8.2 days), but this difference was not statistically significant (P = .37). No significant differences were found in the time to recovery of platelet counts (hazard ratio, 1.2; 95% CI, 0.8-1.8), lactate dehydrogenase (hazard ratio, 0.9; 95% CI, 0.5-1.5), aspartate aminotransferase (hazard ratio, 0.6; 95% CI, 0.4-1.1) and to the development of complications. The results were found in both pregnant and puerperal women. CONCLUSION The results of this investigation do not support the use of dexamethasone for treatment of HELLP syndrome.
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Abstract
Coagulation problems are very common in intensive care patients. It is important to recognize potential problems, perform a rapid assessment, and start therapy. The author reviews general clinical and laboratory approaches to diagnosis and treatment of the bleeding patient and to correction of coagulopathies. This review outlines a set of often catastrophic coagulation problems, which may present both thrombotic and bleeding challenges. These include heparin induced thrombocytopenia, thrombotic thrombocytopenic purpura, and disseminated intravascular coagulation.
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Affiliation(s)
- Thomas G DeLoughery
- Oregon Health & Science University, Hematology L586, 3181 SW Sam Jackson Park Road, Portland, OR 97201-3098, USA.
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Affiliation(s)
- John M O'Brien
- Perinatal Diagnostic Center, Central Baptist Hospital, Lexington, Kentucky 40503, USA.
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Barrilleaux PS, Martin JN, Klauser CK, Bufkin L, May WL. Postpartum intravenous dexamethasone for severely preeclamptic patients without hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome: a randomized trial. Obstet Gynecol 2005; 105:843-8. [PMID: 15802415 DOI: 10.1097/01.aog.0000154887.57440.d1] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We compared maternal outcomes for patients with severe preeclampsia who were managed postpartum with or without adjunctive intravenous dexamethasone. METHODS This study was a randomized, blinded placebo-controlled clinical trial comparing the use of dexamethasone postpartum (10 mg-10 mg-5 mg-5 mg intravenously every 12 hours) with a saline control in patients with severe preeclampsia. The Student t and chi(2) tests were used for data analysis, with P < .05 considered significant. RESULTS Data from 157 patients (77 patients receiving dexamethasone, 80 patients receiving placebo) who were treated during 2000-2003 were analyzed. Demographics, diagnostic criteria, baseline laboratory values, and postpartum outcomes were similar between groups. Although dexamethasone-treated patients had fewer returns (6.5% compared with 11.3%) to the labor/delivery/recovery unit for uncontrolled hypertension than control patients, no significant differences were found in blood pressure, antihypertensive requirements, laboratory values, length of hospitalization, interval urine output at 48 hours postpartum, or major maternal morbidity. Two control patients developed hemolysis, elevated liver enzymes, low platelets syndrome. CONCLUSION Adjunctive use of intravenous dexamethasone for postpartum patients with severe preeclampsia does not reduce disease severity or duration. LEVEL OF EVIDENCE I.
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Affiliation(s)
- P Scott Barrilleaux
- Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, Mississippi 39216-4505, USA
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Detti L, Mecacci F, Piccioli A, Ferrarello S, Carignani L, Mello G, Ferguson JE, Scarselli G. Postpartum heparin therapy for patients with the syndrome of hemolysis, elevated liver enzymes, and low platelets (HELLP) is associated with significant hemorrhagic complications. J Perinatol 2005; 25:236-40. [PMID: 15703776 DOI: 10.1038/sj.jp.7211265] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To compare the outcome of two groups of 16 patients with hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome treated with heparin therapy or treated conservatively in the postpartum period. STUDY DESIGN This is a retrospective cohort study comparing 16 consecutive patients with HELLP syndrome admitted to the ICU at the University of Florence (Italy) after delivery and treated with heparin, to 16 patients with the same disease admitted to the University of Virginia (UVA, USA) and treated with supportive therapy. RESULTS Nine patients in the Florence group developed disseminated intravascular coagulation (DIC). Six of them developed postpartum hemorrhage that was medically and surgically controlled. Five hysterectomies were performed and seven other laparotomies were necessary in four patients to control further bleeding complications. In the UVA group, one patient developed DIC and another one a retroperitoneal hematoma that resolved with no need for surgical intervention. CONCLUSIONS Heparin therapy for postpartum patients with HELLP syndrome was associated with bleeding complications. We speculate that the heparin therapy was the cause for the bleeding complications occurred in the Florence group of patients.
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Affiliation(s)
- Laura Detti
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, MI 48201, USA
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van Runnard Heimel PJ, Franx A, Schobben AFAM, Huisjes AJM, Derks JB, Bruinse HW. Corticosteroids, pregnancy, and HELLP syndrome: a review. Obstet Gynecol Surv 2005; 60:57-70; quiz 73-4. [PMID: 15618920 DOI: 10.1097/01.ogx.0000150346.42901.07] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Corticosteroids are potent antiinflammatory and immunosuppressive drugs, which are used in the treatment of a wide range of medical disorders. During pregnancy, several corticosteroids are administered for maternal as well as fetal reasons. Prednisone and prednisolone show limited transplacental passage and are thus used for treatment of maternal disease. Dexamethasone and betamethasone, drugs that can easily cross the placenta, are more suitable for fetal indications. During the last decade, administration of corticosteroids was introduced in the treatment of hemolysis, elevated liver enzymes, and low platelets (HELLP syndrome), a severe form of preeclampsia unique to human pregnancy. Several randomized, controlled trials as well as other prospective and retrospective studies have been performed to investigate this beneficial effect of corticosteroids on biochemical measures and clinical signs. This review discusses the characteristics of corticosteroids in humans and details the use of corticosteroids during pregnancy. A review of literature on the effect of corticosteroids on HELLP syndrome is given and possible mechanisms of action are discussed.
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Affiliation(s)
- P J van Runnard Heimel
- Department of Perinatology and Gynecology, University Medical Center, Utrecht, The Netherlands.
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Abstract
UNLABELLED Preeclampsia/eclampsia has been recognized for centuries and continues to plague both the patient and the obstetrician. A severe variant, the syndrome of hemolysis, elevated liver enzymes, and low platelets (HELLP), has been recognized for 50 years. Although much new data has been elucidated about the condition, only several observations have withstood the test of time. These are the uniqueness of the disease to humans, the progressive nature of the disease, and the fact that delivery is the sole therapy. TARGET AUDIENCE Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES After completion of this article, the reader should be able to outline the history of HELLP syndrome and describe the pathophysiology of HELLP syndrome, to summarize the clinical presentation and differential diagnosis of HELLP syndrome, and to list the various management options.
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Affiliation(s)
- Jason K Baxter
- Department of Obstetrics and Gynecology, Fellow, Division of Maternal-Fetal Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
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Martin JN, Thigpen BD, Moore RC, Rose CH, Cushman J, May W. Stroke and severe preeclampsia and eclampsia: a paradigm shift focusing on systolic blood pressure. Obstet Gynecol 2005; 105:246-54. [PMID: 15684147 DOI: 10.1097/01.aog.0000151116.84113.56] [Citation(s) in RCA: 337] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To identify important clinical correlates of stroke in patients with preeclampsia and eclampsia. METHODS The case histories of 28 patients who sustained a stroke in association with severe preeclampsia and eclampsia were scrutinized with particular attention to blood pressures. RESULTS Stroke occurred antepartum in 12 patients, postpartum in 16. Stroke was classified as hemorrhagic-arterial in 25 of 27 patients (92.6%) and thrombotic-arterial in 2 others. Multiple sites were involved in 37% without distinct pattern. In the 24 patients being treated immediately before stroke, systolic pressure was 160 mm Hg or greater in 23 (95.8%) and more than 155 mm Hg in 100%. In contrast, only 3 of 24 patients (12.5%) exhibited prestroke diastolic pressures of 110 mm Hg or greater, only 5 of 28 reached 105 mm Hg, and only 6 (25%) exceeded a mean arterial pressure of 130 mm Hg before stroke. Only 3 patients received prestroke antihypertensives. Twelve patients sustained a stroke while receiving magnesium sulfate infusion; 8 had eclampsia. Although all blood pressure means after stroke were significantly higher than prestroke, only 5 patients exhibited more than 110 mm Hg diastolic pressures. In 18 of 28 patients, hemolysis, elevated liver enzymes, low platelets syndrome did not significantly alter blood pressures compared with non-hemolysis, elevated liver enzymes, low platelets. Mean systolic and diastolic changes from pregnancy baseline to prestroke values were 64.4 and 30.6 mm Hg, respectively. Maternal mortality was 53.6%; only 3 patients escaped permanent significant morbidity. CONCLUSION In contrast to severe systolic hypertension, severe diastolic hypertension does not develop before stroke in most patients with severe preeclampsia and eclampsia. A paradigm shift is needed toward considering antihypertensive therapy for severely preeclamptic and eclamptic patients when systolic blood pressure reaches or exceeds 155-160 mm Hg. LEVEL OF EVIDENCE III.
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Affiliation(s)
- James N Martin
- Department of Obstetrics and Gynecology, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216-4505, USA.
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Barton JR, Sibai BM. Diagnosis and management of hemolysis, elevated liver enzymes, and low platelets syndrome. Clin Perinatol 2004; 31:807-33, vii. [PMID: 15519429 DOI: 10.1016/j.clp.2004.06.008] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Pregnancies complicated by hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome require a well-formulated management plan. The development of this syndrome after 34 weeks' gestation or with documentation of maternal or fetal compromise is an indication for delivery. Acute fatty liver of pregnancy, hemolytic uremic syndrome, and thrombotic thrombocytopenic purpura may present with signs, symptoms, and laboratory abnormalities that may be confused with HELLP syndrome. Thorough investigation is warranted because of the differences in proper management among these various complications of pregnancy. Expectant management in patients with HELLP syndrome remote from term and the use of corticosteroids to improve postpartum maternal outcome remain experimental.
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Affiliation(s)
- John R Barton
- Central Baptist Hospital, Perinatal Diagnostic Center, 1740 Nicholasville Road, Lexington, KY 40503-1499, USA.
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Henry CS, Biedermann SA, Campbell MF, Guntupalli JS. Spectrum of hypertensive emergencies in pregnancy. Crit Care Clin 2004; 20:697-712, ix. [PMID: 15388197 DOI: 10.1016/j.ccc.2004.05.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Hypertension in pregnancy represents a spectrum of clinical entities, including pregnancy-induced hypertension (PIH), preeclampsia, eclampsia, and hemolysis, elevated liver enzyme levels, low platelet count syndrome. Although hypertension is a common denominator in this group of disorders, the pathogenesis, clinical features, and clinical course of these disorders is variable and somewhat distinct. Therapy must be tailored to the clinical entity and the patient. The incidence and prevalence of preeclampsia and eclampsia is decreasing worldwide. This decrease partly may be caused by the improved treatment of PIH and improved obstetrical services.
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Affiliation(s)
- Charles S Henry
- Division of Renal Diseases and Hypertension, Department of Internal Medicine, University of Texas Medical School, 6431 Fannin, MSB 4.126, Houston, TX 77030, USA
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Abstract
The hypertensive diseases of pregnancy commonly refer to a group of disorders whose definitions have changed over time within and among professional organizations. Pre-eclampsia, either mild or severe, is managed best with a policy of delivery at or beyond 37 and 34 weeks' gestation, respectively. Similarly, chronic hypertension,gestational hypertension, and chronic hypertension with superimposed pre-eclampsia are conditions wherein it is difficult to justify expectant management beyond 37 weeks' gestation. The approach to management before these gestational ages is subject to interpretation of a limited body of literature.
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Affiliation(s)
- Anthony R Gregg
- Department of Obstetrics and Gynecology, Department of Molecular and Human Genetics, Baylor College of Medicine, 6550 Fannin Suite, 901A, Houston, TX 77030, USA.
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Clenney TL, Viera AJ. Corticosteroids for HELLP (haemolysis, elevated liver enzymes, low platelets) syndrome. BMJ 2004; 329:270-2. [PMID: 15284151 PMCID: PMC498027 DOI: 10.1136/bmj.329.7460.270] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/13/2004] [Indexed: 11/04/2022]
Affiliation(s)
- Timothy L Clenney
- Uniformed Services University of Health Sciences, F Edward Hébert School of Medicine, Bethesda, MD, USA.
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Sibai BM. Diagnosis, controversies, and management of the syndrome of hemolysis, elevated liver enzymes, and low platelet count. Obstet Gynecol 2004; 103:981-91. [PMID: 15121574 DOI: 10.1097/01.aog.0000126245.35811.2a] [Citation(s) in RCA: 406] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome has been recognized as a complication of preeclampsia-eclampsia for decades. Recognition of this syndrome in women with preeclampsia is increasing because of the frequency of blood test results that reveal unexpected thrombocytopenia or elevated liver enzymes. The diagnosis of HELLP syndrome requires the presence of hemolysis based on examination of the peripheral smear, elevated indirect bilirubin levels, or low serum haptoglobin levels in association with significant elevation in liver enzymes and a platelet count below 100,000/mm(3) after ruling out other causes of hemolysis and thrombocytopenia. The presence of this syndrome is associated with increased risk of adverse outcome for both mother and fetus. During the past 15 years, several retrospective and observational studies and a few randomized trials have been published in an attempt to refine the diagnostic criteria, to identify risk factors for adverse pregnancy outcome, and to treat women with this syndrome. Despite the voluminous literature, the diagnosis and management of this syndrome remain controversial. Recent studies suggest that some women with partial HELLP syndrome may be treated with expectant management or corticosteroid therapy. This review will emphasize the controversies surrounding the diagnosis and management of this syndrome. Recommendation for diagnosis, management, and counseling of these women is also provided based on results of recent studies and my own clinical experience.
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Affiliation(s)
- Baha M Sibai
- Department of Obstetrics and Gynecology, University of Cincinnati, Cincinnati, Ohio 45267, USA.
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Abstract
BACKGROUND Hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome is a severe form of pre-eclampsia. Pre-eclampsia is a multi-system disease of pregnancy associated with an increase in blood pressure and increased perinatal and maternal morbidity and mortality. Eighty per cent of women with HELLP syndrome present before term. There are suggestions from observational studies that steroid treatment in HELLP syndrome may improve disordered maternal hematological and biochemical features and perhaps perinatal mortality and morbidity. OBJECTIVES To summarise the evidence on the effects of corticosteroids on maternal and neonatal mortality and morbidity in women with HELLP syndrome. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group trials register (October 2003). We scanned lists of references from review articles and primary studies. SELECTION CRITERIA Randomised and quasi-randomised trials evaluating the effects of adjunctive corticosteroids in patients diagnosed with HELLP syndrome were sought. DATA COLLECTION AND ANALYSIS The two authors independently applied inclusion criteria, assessed trial quality and extracted relevant data. MAIN RESULTS Of the five studies reviewed (n = 170), three were conducted antepartum and two postpartum. Four of the studies randomised participants to standard therapy or dexamethasone. One study compared dexamethasone with betamethasone. DEXAMETHASONE VERSUS CONTROL: There were no significant differences in the primary outcomes of maternal mortality and morbidity due to placental abruption, pulmonary oedema and liver hematoma or rupture. Of the secondary maternal outcomes, there was a tendency to a greater platelet count increase over 48 hours, statistically significantly less mean number of hospital stay days (weighted mean difference (WMD) -4.50, 95% confidence interval (CI) -7.13 to -1.87), mean interval (hours) to delivery (41 +/- 15) versus (15 +/- 4.5) (p = 0.0068) in favour of women allocated to dexamethasone. There were no significant differences in perinatal mortality or morbidity due to respiratory distress syndrome, need for ventilatory support, intracerebral hemorrhage, necrotizing enterocolitis and a five minute Apgar less than seven. The mean birthweight was significantly greater in the group allocated to dexamethasone (WMD 247.00, 95% CI 65.41 to 428.59). DEXAMETHASONE VERSUS BETAMETHASONE: There were no significant differences in all the maternal and perinatal mortality and in primary morbidity outcomes. Women randomised to dexamethasone fared significantly better for: oliguria, mean arterial pressure, mean increase in platelet count, mean increase in urinary output and liver enzyme elevations. REVIEWER'S CONCLUSIONS There is insufficient evidence to determine whether adjunctive steroid use in HELLP syndrome decreases maternal and perinatal mortality, major maternal and perinatal morbidity.
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Affiliation(s)
- P Matchaba
- Novartis Pharmaceuticals Corporation, CD & MA, Building 122, One Health Plaza, East Hanover, NJ 07936-1080, USA
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Martin JN, Thigpen BD, Rose CH, Cushman J, Moore A, May WL. Maternal benefit of high-dose intravenous corticosteroid therapy for HELLP syndrome. Am J Obstet Gynecol 2003; 189:830-4. [PMID: 14526324 DOI: 10.1067/s0002-9378(03)00763-4] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE We compared maternal outcomes for patients with HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome treated with or without high-dose corticosteroids to ameliorate maternal disease. STUDY DESIGN An analysis of data for patients with HELLP syndrome (platelets, <or=100,000/microL; lactate dehydrogenase level, >or=600 IU/L; aspartate aminotransferase and/or alanine aminotransferase level, >or=70 IU/L) who were treated during the 7-year epochs before and after the clinical trials in 1992 and 1993 demonstrated maternal benefit with high-dose dexamethasone. RESULTS Corticosteroid use increased from 16% (39/246 patients) for fetal indication from 1985 to 1991 to 90% (205/228 patients) for maternal-fetal indications from 1994 to 2000. Significantly reduced composite maternal disease from 1994 to 2000 was evidenced by improvements in laboratory parameters, disease progression to class 1 HELLP syndrome, the degree of hypertension, the need for antihypertensive therapy, the use of transfusion, and the presence of maternal morbidity (P<.05). Indices of postpartum recovery also were shortened significantly (P<.001). CONCLUSION Routine early initiation of high-dose intravenous corticosteroids for patients with HELLP syndrome significantly lessened maternal disease, reduced maternal morbidity, and expedited recovery.
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Affiliation(s)
- James N Martin
- Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, USA
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Buyon JP, Friedman DM. Autoantibody-associated congenital heart block: the clinical perspective. Curr Rheumatol Rep 2003; 5:374-8. [PMID: 12967520 DOI: 10.1007/s11926-003-0024-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Congenital heart block (CHB) can occur in association with structural heart disease, such as atrioventricular septal defects, left atrial isomerism, and abnormalities of the great arteries, with tumors, such as mesotheliomas, or as an isolated defect. In 1928, Aylward reported the occurrence of CHB in two children whose mother "suffered from Mikulicz's disease." This curious clinical observation was further solidified by the 1970s, with reports of CHB in children whose mothers had autoimmune diseases and that the maternal sera contained antibodies to Ro ribonucleoproteins. It was subsequently reported that many mothers also had antibodies to La. Other abnormalities affecting the skin, liver, and blood elements were associated with anti-Ro/La antibodies in the maternal and fetal circulation, and are now grouped under the heading of neonatal lupus syndromes. Neonatal lupus was termed because the cutaneous lesions of the neonate resembled those seen in systemic lupus erythematosus.
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Affiliation(s)
- Jill P Buyon
- Department of Rheumatology, Hospital for Joint Diseases, 301 East 17th Avenue, Room 1608, New York, NY 10003, USA.
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