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Pastor FM, de Melo Ocarino N, Silva JF, Reis AMS, Serakides R. Bone development in fetuses with intrauterine growth restriction caused by maternal endocrine-metabolic dysfunctions. Bone 2024; 186:117169. [PMID: 38880170 DOI: 10.1016/j.bone.2024.117169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 05/21/2024] [Accepted: 06/13/2024] [Indexed: 06/18/2024]
Abstract
Intrauterine growth restriction (IUGR) affects a large proportion of infants, particularly in underdeveloped countries. Among the main causes of IUGR, maternal endocrine-metabolic dysfunction is highlighted, either due to its high incidence or due to the severity of the immediate and mediated changes that these dysfunctions cause in the fetus and the mother. Although the effects of endocrine and metabolic disorders have been widely researched, there are still no reviews that bring together and summarize the effects of these conditions on bone development in cases of IUGR. Therefore, the present literature review was conducted with the aim of discussing bone changes observed in fetuses with IUGR caused by maternal endocrine-metabolic dysfunction. The main endocrine dysfunctions that occur with IUGR include maternal hyperthyroidism, hypothyroidism, and hypoparathyroidism. Diabetes mellitus, hypertensive disorders, and obesity are the most important maternal metabolic dysfunctions that compromise fetal growth. The bone changes reported in the fetus are, for the most part, due to damage to cell proliferation and differentiation, as well as failures in the synthesis and mineralization of the extracellular matrix, which results in shortening and fragility of the bones. Some maternal dysfunctions, such as hyperthyroidism, have been widely studied, whereas conditions such as hypoparathyroidism and gestational hypertensive disorders require further study regarding the mechanisms underlying the development of bone changes. Similarly, there is a gap in the literature regarding changes related to intramembranous ossification, as most published articles only describe changes in endochondral bone formation associated with IUGR. Furthermore, there is a need for more research aimed at elucidating the late postnatal changes that occur in the skeletons of individuals affected by IUGR and their possible relationships with adult diseases, such as osteoarthritis and osteoporosis.
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Affiliation(s)
- Felipe Martins Pastor
- Departamento de Cínica e Cirurgia Veterinárias, Escola de Veterinária, Universidade Federal de Minas Gerais, Avenida Antônio Carlos 6627, 31270-901 Belo Horizonte, Minas Gerais, Brazil
| | - Natália de Melo Ocarino
- Departamento de Cínica e Cirurgia Veterinárias, Escola de Veterinária, Universidade Federal de Minas Gerais, Avenida Antônio Carlos 6627, 31270-901 Belo Horizonte, Minas Gerais, Brazil
| | - Juneo Freitas Silva
- Centro de Microscopia Eletrônica, Departamento de Ciências Biológicas, Universidade Estadual de Santa Cruz, Rodovia Jorge Amado, Km 16, 45662-900 Ilhéus, Bahia, Brazil
| | - Amanda Maria Sena Reis
- Departamento de Patologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Avenida Antônio Carlos 6627, 31270-901 Belo Horizonte, Minas Gerais, Brazil
| | - Rogéria Serakides
- Departamento de Cínica e Cirurgia Veterinárias, Escola de Veterinária, Universidade Federal de Minas Gerais, Avenida Antônio Carlos 6627, 31270-901 Belo Horizonte, Minas Gerais, Brazil.
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Kojima N, Kuroda K, Tani M, Kanazawa T, Shimizu K, Maki J, Masuyama H, Morimatsu H. Therapeutic plasma exchange in postpartum HELLP syndrome: a case report. JA Clin Rep 2023; 9:9. [PMID: 36805852 PMCID: PMC9939561 DOI: 10.1186/s40981-023-00602-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 02/11/2023] [Accepted: 02/13/2023] [Indexed: 02/21/2023] Open
Abstract
BACKGROUND Postpartum hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is more difficult to treat than HELLP syndrome during pregnancy. We describe a case of postpartum HELLP syndrome that responded to plasma exchange (PE) therapy. CASE PRESENTATION A 30-year-old primipara woman was hospitalized for gestational hypertension at 33 weeks of gestation and underwent an emergent cesarean section at 36 weeks and 6 days of gestation due to rapidly progressing pulmonary edema. After delivery, liver dysfunction and a rapid decrease in platelet count were observed, and the patient was diagnosed with severe HELLP syndrome. She experienced multiple organ failure despite intensive care, and PE therapy was initiated. Her general condition dramatically stabilized within a few hours of PE therapy. CONCLUSION It is controversial whether PE therapy should be used primarily in the management of HELLP syndrome, but early initiation of PE therapy could be effective for severe HELLP syndrome.
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Affiliation(s)
- Nana Kojima
- grid.412342.20000 0004 0631 9477Department of Anesthesiology and Resuscitology, Okayama University Hospital, 2-5-1 Shikatacho, Kitaku, Okayama 700-8558 Japan ,grid.278276.e0000 0001 0659 9825Department of Anesthesiology, Kochi Health Sciences Center, Kochi, Japan
| | - Kosuke Kuroda
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, 2-5-1 Shikatacho, Kitaku, Okayama, 700-8558, Japan.
| | - Makiko Tani
- grid.412342.20000 0004 0631 9477Department of Anesthesiology and Resuscitology, Okayama University Hospital, 2-5-1 Shikatacho, Kitaku, Okayama 700-8558 Japan
| | - Tomoyuki Kanazawa
- grid.412342.20000 0004 0631 9477Department of Anesthesiology and Resuscitology, Okayama University Hospital, 2-5-1 Shikatacho, Kitaku, Okayama 700-8558 Japan
| | - Kazuyoshi Shimizu
- grid.412342.20000 0004 0631 9477Department of Anesthesiology and Resuscitology, Okayama University Hospital, 2-5-1 Shikatacho, Kitaku, Okayama 700-8558 Japan
| | - Jota Maki
- grid.412342.20000 0004 0631 9477Department of Obstetrics and Gynecology, Okayama University Hospital, Okayama, Japan
| | - Hisashi Masuyama
- grid.412342.20000 0004 0631 9477Department of Obstetrics and Gynecology, Okayama University Hospital, Okayama, Japan
| | - Hiroshi Morimatsu
- grid.412342.20000 0004 0631 9477Department of Anesthesiology and Resuscitology, Okayama University Hospital, 2-5-1 Shikatacho, Kitaku, Okayama 700-8558 Japan
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Adorno M, Maher-Griffiths C, Grush Abadie HR. HELLP Syndrome. Crit Care Nurs Clin North Am 2022; 34:277-288. [DOI: 10.1016/j.cnc.2022.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Morrison MA, Chung Y, Heneghan MA. Managing hepatic complications of pregnancy: practical strategies for clinicians. BMJ Open Gastroenterol 2022; 9:bmjgast-2021-000624. [PMID: 35292523 PMCID: PMC8928321 DOI: 10.1136/bmjgast-2021-000624] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 01/12/2022] [Indexed: 12/17/2022] Open
Abstract
Liver disorders specific to pregnancy are rare but can have potentially serious consequences for mother and fetus. Pregnancy-related liver disorders are the most common cause of liver disease in otherwise healthy pregnant women and pose a challenge to physicians because of the need to take into account both maternal and fetal health. A good knowledge of these disorders is necessary as prompt diagnosis and appropriate management results in improved maternal and fetal outcomes. This review will focus on pregnancy-specific disorders and will aim to serve as a guide for physicians in their diagnosis, management and subsequent monitoring.
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Affiliation(s)
| | - Yooyun Chung
- Institute of Liver Studies, King's College Hospital, London, UK
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Lisonkova S, Bone JN, Muraca GM, Razaz N, Wang LQ, Sabr Y, Boutin A, Mayer C, Joseph K. Incidence and risk factors for severe preeclampsia, hemolysis, elevated liver enzymes, and low platelet count syndrome, and eclampsia at preterm and term gestation: a population-based study. Am J Obstet Gynecol 2021; 225:538.e1-538.e19. [PMID: 33974902 DOI: 10.1016/j.ajog.2021.04.261] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 04/22/2021] [Accepted: 04/29/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The majority of previous studies on severe preeclampsia, eclampsia, and hemolysis, elevated liver enzymes, and low platelet count syndrome were hospital-based or included a relatively small number of women. Large, population-based studies examining gestational age-specific incidence patterns and risk factors for these severe pregnancy complications are lacking. OBJECTIVE This study aimed to assess the gestational age-specific incidence rates and risk factors for severe preeclampsia, hemolysis, elevated liver enzymes, and low platelet count syndrome, and eclampsia. STUDY DESIGN We carried out a retrospective, population-based cohort study that included all women with a singleton hospital birth in Canada (excluding Quebec) from 2012 to 2016 (N=1,078,323). Data on the primary outcomes (ie, severe preeclampsia, hemolysis, elevated liver enzymes, and low platelet count syndrome, and eclampsia) were obtained from delivery hospitalization records abstracted by the Canadian Institute for Health Information. A Cox regression was used to assess independent risk factors (eg, maternal age and chronic comorbidity) for each primary outcome and to assess differences in the effects at preterm vs term gestation (<37 vs ≥37 weeks). RESULTS The rates of severe preeclampsia (n=2533), hemolysis, elevated liver enzymes, and low platelet count syndrome (n=2663), and eclampsia (n=465) were 2.35, 2.47, and 0.43 per 1000 singleton pregnancies, respectively. The cumulative incidence of term-onset severe preeclampsia was lower than that of preterm-onset severe preeclampsia (0.87 vs 1.54 per 1000; rate ratio, 0.57; 95% confidence intervals, 0.53-0.62), the rates of hemolysis, elevated liver enzymes, and low platelet count syndrome were similar (1.32 vs 1.23 per 1000; rate ratio, 0.93; 95% confidence interval, 0.86-1.00), and the preterm-onset eclampsia rate was lower than the term-onset rate (0.12 vs 0.33 per 1000; rate ratio, 2.64; 95% confidence interval, 2.16-3.23). For each primary outcome, chronic comorbidity and congenital anomalies were stronger risk factors for preterm- vs term-onset disease. Younger mothers (aged <25 years) were at higher risk for severe preeclampsia at term and for eclampsia at all gestational ages, whereas older mothers (aged ≥35 years) had elevated risks for severe preeclampsia and hemolysis, elevated liver enzymes, and low platelet count syndrome. Regardless of gestational age, nulliparity was a risk factor for all outcomes, whereas socioeconomic status was inversely associated with severe preeclampsia. CONCLUSION The risk for severe preeclampsia declined at term, eclampsia risk increased at term, and hemolysis, elevated liver enzymes, and low platelet count syndrome risk was similar for preterm and term gestation. Young maternal age was associated with an increased risk for eclampsia and term-onset severe preeclampsia. Prepregnancy comorbidity and fetal congenital anomalies were more strongly associated with severe preeclampsia, hemolysis, elevated liver enzymes, and low platelet count syndrome, and eclampsia at preterm gestation.
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Varlas VN, Bohîlțea R, Gheorghe G, Bostan G, Angelescu GA, Penes ON, Bors RG, Cloțea E, Bacalbasa N, Diaconu CC. State of the Art in Hepatic Dysfunction in Pregnancy. Healthcare (Basel) 2021; 9:1481. [PMID: 34828527 PMCID: PMC8618725 DOI: 10.3390/healthcare9111481] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 10/25/2021] [Accepted: 10/28/2021] [Indexed: 12/21/2022] Open
Abstract
Hepatic dysfunction in pregnant women is always challenging for the obstetrician, as the spectrum of hepatic abnormalities can be very large and have various implications, both for mother and fetus. There is a diagnostic and therapeutic polymorphism of hepatic dysfunction in pregnancy and insufficient knowledge related to the etiopathogenesis and epidemiology of this disease. The clinical forms of hepatic dysfunction encountered in pregnancy can vary from liver diseases related to pregnancy (e.g., HELLP syndrome, intrahepatic cholestasis, hyperemesis gravidarum, or acute fatty liver of pregnancy) to de novo ones occurring in pregnancy, and pre-existing liver disease (cholelithiasis, Budd-Chiari syndrome, and cirrhosis). We performed a systematic literature search over 10 years. The review protocol assumed a search of two databases (PubMed®/MEDLINE and Web of Science Core Collection). The strategy regarding the management of these diseases involves multidisciplinary teams composed of different specialists (obstetricians, gastroenterologists and anesthetists) from specialized tertiary centers. Despite the improving prognosis of pregnant women with liver diseases, the risk of maternal-fetal complications remains very high. Therefore, it is necessary to ensure careful monitoring by a multidisciplinary team and to inform the patients of the potential risks.
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Affiliation(s)
- Valentin Nicolae Varlas
- Department of Obstetrics and Gynecology, Filantropia Clinical Hospital, 011132 Bucharest, Romania; (V.N.V.); (R.G.B.); (E.C.)
- “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (G.A.A.); (O.N.P.); (N.B.)
| | - Roxana Bohîlțea
- Department of Obstetrics and Gynecology, Filantropia Clinical Hospital, 011132 Bucharest, Romania; (V.N.V.); (R.G.B.); (E.C.)
- “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (G.A.A.); (O.N.P.); (N.B.)
| | - Gina Gheorghe
- Department of Internal Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania;
- Department of Gastroenterology, Clinical Emergency Hospital of Bucharest, 105402 Bucharest, Romania
| | - Georgiana Bostan
- Department of Obstetrics and Gynecology, County Emergency Hospital “St. John the New”, 720034 Suceava, Romania;
| | - Gabriela Anca Angelescu
- “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (G.A.A.); (O.N.P.); (N.B.)
- Department of Internal Medicine, County Emergency Hospital Ilfov, 022115 Bucharest, Romania
| | - Ovidiu Nicolae Penes
- “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (G.A.A.); (O.N.P.); (N.B.)
- Department of Anesthesiology and Intensive Care, University Clinical Hospital, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Roxana Georgiana Bors
- Department of Obstetrics and Gynecology, Filantropia Clinical Hospital, 011132 Bucharest, Romania; (V.N.V.); (R.G.B.); (E.C.)
| | - Eliza Cloțea
- Department of Obstetrics and Gynecology, Filantropia Clinical Hospital, 011132 Bucharest, Romania; (V.N.V.); (R.G.B.); (E.C.)
| | - Nicolae Bacalbasa
- “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (G.A.A.); (O.N.P.); (N.B.)
- Department of Visceral Surgery, “Fundeni” Clinical Institute, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Camelia Cristina Diaconu
- Department of Internal Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania;
- Department of Internal Medicine, Clinical Emergency Hospital of Bucharest, 105402 Bucharest, Romania
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7
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Pécourt M. Highlights on HELLP syndrome. JOURNAL DE MEDECINE VASCULAIRE 2021; 46:207-208. [PMID: 34862013 DOI: 10.1016/j.jdmv.2021.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Affiliation(s)
- M Pécourt
- Vascular Medicine Department, Paris Saint-Joseph Hospital Group, 185, rue Raymond-Losserand, 75014 Paris, France.
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8
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Is the presence of antiphospholipid antibodies a poor prognostic factor for patients with hemolysis, elevated liver enzymes, and low platelet count syndrome? Am J Obstet Gynecol 2021; 225:432.e1-432.e7. [PMID: 33812811 DOI: 10.1016/j.ajog.2021.03.039] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 03/15/2021] [Accepted: 03/30/2021] [Indexed: 11/20/2022]
Abstract
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.
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Bohn MK, Adeli K. Physiological and metabolic adaptations in pregnancy: importance of trimester-specific reference intervals to investigate maternal health and complications. Crit Rev Clin Lab Sci 2021; 59:76-92. [PMID: 34587857 DOI: 10.1080/10408363.2021.1978923] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Diagnosis, prognostication, and monitoring of maternal health throughout pregnancy relies on laboratory testing, including but not limited to key markers of thyroid, hepatic, cardiac, hematology, and renal function. Dynamic physiological processes during gestation significantly influence the maternal biochemistry that supports both the mother and fetus. Resultant changes in blood biochemistry alter the expected values of common laboratory tests. However, the importance of pregnancy-specific reference intervals for laboratory test result interpretation and appropriate monitoring of maternal health and complications is underappreciated. Most clinical laboratories continue to use non-pregnant adult reference intervals for laboratory test interpretation in pregnancy. The current review summarizes and critically evaluates the available literature regarding physiological and metabolic adaptations in pregnancy and their influence on common biomarkers of health and disease. The main laboratory parameters discussed include thyroid, hepatic, metabolic, renal, hematology, inflammatory, and cardiac markers. Considering the available data, further studies are urgently needed to establish trimester-specific reference intervals in healthy pregnant women on updated analytical platforms. Without such data, the standard of clinical laboratory service in pregnancy remains compromised and affects the quality of maternal-fetal healthcare.
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Affiliation(s)
- Mary Kathryn Bohn
- CALIPER Program, Pediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada.,Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Khosrow Adeli
- CALIPER Program, Pediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada.,Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
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McCormick PA, Higgins M, McCormick CA, Nolan N, Docherty JR. Hepatic infarction, hematoma, and rupture in HELLP syndrome: support for a vasospastic hypothesis. J Matern Fetal Neonatal Med 2021; 35:7942-7947. [PMID: 34130599 DOI: 10.1080/14767058.2021.1939299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Purpose: HELLP syndrome is a relatively uncommon pregnancy-related condition characterized by hemolysis, elevated liver function tests, and low platelets. It can be accompanied by life-threatening hepatic complications including hepatic infarction, hematoma formation, and hepatic rupture. HELLP syndrome occurs in approximately 0.2% of pregnancies. Major hepatic complications occur in less than 1% of HELLP patients suggesting an incidence of 1/50,000. The pathogenesis is incompletely understood and in particular, it is difficult to understand a disorder with both major thrombotic and bleeding manifestations.Methods: Literature review.Results: On the basis of reports in the published literature, and our own clinical experience, we suggest that vasospasm is one of the principal drivers with hepatic ischemia, infarction, and hemorrhage as secondary events. It is known that vasoactive substances are released by the failing placenta. We suggest these cause severe vasospasm, most likely affecting the small post-sinusoidal hepatic venules. This leads to patchy or confluent hepatic ischemia and/or necrosis with a resultant increase in circulating liver enzymes. Reperfusion is associated with a fall in platelet count and microvascular hemorrhage if the microvasculature is infarcted. Blood tracks to the subcapsular space causing hematoma formation. If the hematoma ruptures the patient presents with severe abdominal pain, intra-abdominal hemorrhage, and shock.Conclusions: We suggest that hepatic and other complications associated with HELLP syndrome including placental abruption, acute renal failure, and posterior reversible encephalopathy syndrome (PRES) may also be due to regional vasospasm.
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Affiliation(s)
- P A McCormick
- Liver Unit, St Vincent's University Hospital, Dublin, Ireland
| | - M Higgins
- University College Dublin Perinatal Research Centre, National Maternity Hospital, Dublin, Ireland
| | - C A McCormick
- Department of Obstetrics and Gynaecology, The Royal Women's Hospital, Melbourne, Australia
| | - N Nolan
- Histopathology Department, St Vincent's University Hospital, Dublin, Ireland
| | - J R Docherty
- Physiology Department, Royal College of Surgeons in Ireland, Dublin, Ireland
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Cui C, Ma S, Qiao R. Prenatal Plasma Fibrinogen Level Predicts Postpartum Hemorrhage of Patients With HELLP Syndrome. Clin Appl Thromb Hemost 2020; 26:1076029619894057. [PMID: 32013532 PMCID: PMC7273540 DOI: 10.1177/1076029619894057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Hemolysis, elevated
liver enzymes, and low
platelets (HELLP) syndrome is a serious complication
of pregnancy. Postpartum hemorrhage indicates poor prognosis of pregnant women
with HELLP syndrome. The aim of our study is to investigate the predictive value
of coagulation markers for postpartum hemorrhage of pregnant women with HELLP
syndrome. In a retrospective cohort study, 106 patients who were diagnosed as
pregnant women with HELLP syndrome in Peking University Third Hospital from
August 2010 to January 2017 were analyzed. The demographic characters of
maternal and fetus, days of hospital stay, postpartum complications, and the
laboratory tests of coagulation markers within 3 days before delivery were
collected. In addition, 100 healthy pregnant women were collected as a control
group. The result showed that the incidence of preeclampsia in pregnant women
with postpartum hemorrhage was higher than that in pregnant women without
hemorrhage (P = .011). The level of fibrinogen (FIB) in
postpartum hemorrhage pregnant women with HELLP syndrome was lower than that in
nonpostpartum hemorrhage pregnant women with HELLP syndrome and healthy pregnant
women (2.3 [1.68-2.81] vs 3.64 ± 0.95, P = .000; 2.3
[1.68-2.81] vs 4.48 ± 0.62, P = .000). Multivariate analysis
showed that decreased FIB levels independently predicted the postpartum
hemorrhage of pregnant women with HELLP syndrome (odds ratio = 7.374, 95%
confidence interval [CI], 1.551-35.05, P = .012). The receiver
operating characteristic curve showed that the area under the curve of FIB level
when predicting postpartum hemorrhage is 0.841 (95% CI, 0.708-0.976). When the
cutoff value of FIB was 3.04 g/L, the sensitivity was 90.90% and the specificity
was75.80%. Therefore, the low level of prenatal FIB is a reliable biomarker to
predict postpartum hemorrhage of pregnant women with HELLP syndrome, which make
it useful for pregnant women with HELLP syndrome in guiding surveillance therapy
and prognosis assessment.
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Affiliation(s)
- Chanjuan Cui
- Department of Laboratory Medicine, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Sisi Ma
- Department of Laboratory Medicine, Peking University Third Hospital, Haidian District, Beijing, China
| | - Rui Qiao
- Department of Laboratory Medicine, Peking University Third Hospital, Haidian District, Beijing, China
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12
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Genetic and molecular evidence for complement dysregulation in patients with HELLP syndrome. Thromb Res 2020; 196:167-174. [PMID: 32890900 DOI: 10.1016/j.thromres.2020.08.038] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 07/14/2020] [Accepted: 08/25/2020] [Indexed: 12/30/2022]
Abstract
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.
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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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Byrne JJ, Seasely A, Nelson DB, Mcintire DD, Cunningham FG. Comparing acute fatty liver of pregnancy from hemolysis, elevated liver enzymes, and low platelets syndrome. J Matern Fetal Neonatal Med 2020; 35:1352-1362. [PMID: 32308076 DOI: 10.1080/14767058.2020.1754790] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Acute fatty liver of pregnancy (AFLP) and hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome are both associated with significant maternal and perinatal morbidity and mortality. Because of the overlap of several clinical and laboratory findings differentiation can sometimes be difficult. Both disorders have been of interest for more than 100 years, however they were not completely characterized until the early 1980s. It was not until the 1980s that AFLP and HELLP syndrome, and more specifically their clinical, laboratory, and pathologic findings, were further differentiated in the literature. More recently, the pathophysiologic mechanisms have been elucidated. In this review, we outline the similarities and differences in the clinical presentation, laboratory findings, maternal and perinatal outcomes, and clinical recovery for women diagnosed with these two syndromes. From our observations, we suggest that levels of fibrinogen, creatinine, cholesterol, and total bilirubin be used to assist with differentiating AFLP from HELLP syndrome upon admission in women presenting with either suspected disease. The rationale for identifying the specific conditions is that clinical consequences for recovery vary considerably. Specifically, AFLP is associated with significantly more hepatic and renal dysfunction as well as coagulopathy. Fortunately, both conditions can be managed with supportive measures with overall improved perinatal outcomes including morbidity and mortality.
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Affiliation(s)
- John J Byrne
- Department of Obstetrics and Gynecology, University of Texas, Southwestern Medical Center, Parkland Health and Hospital Systems, Dallas, TX, USA
| | - Angela Seasely
- Department of Obstetrics and Gynecology, University of Texas, Southwestern Medical Center, Parkland Health and Hospital Systems, Dallas, TX, USA
| | - David B Nelson
- Department of Obstetrics and Gynecology, University of Texas, Southwestern Medical Center, Parkland Health and Hospital Systems, Dallas, TX, USA
| | - Donald D Mcintire
- Department of Obstetrics and Gynecology, University of Texas, Southwestern Medical Center, Parkland Health and Hospital Systems, Dallas, TX, USA
| | - F Gary Cunningham
- Department of Obstetrics and Gynecology, University of Texas, Southwestern Medical Center, Parkland Health and Hospital Systems, Dallas, TX, USA
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Lisonkova S, Razaz N, Sabr Y, Muraca GM, Boutin A, Mayer C, Joseph KS, Kramer MS. Maternal risk factors and adverse birth outcomes associated with HELLP syndrome: a population-based study. BJOG 2020; 127:1189-1198. [PMID: 32189413 DOI: 10.1111/1471-0528.16225] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVES We assessed the incidence, risk factors and adverse birth outcomes associated with elevated liver enzymes and low platelets (HELLP) syndrome. DESIGN A retrospective population-based cohort study. SETTING Canada (excluding Quebec), 2012/2013-2015/2016. POPULATION Mothers with a singleton hospital live birth or stillbirth at ≥24 weeks' gestation (n = 1 078 323). METHODS HELLP syndrome was identified using ICD-10-CA diagnostic code from delivery hospitalisation data. We used logistic regression to identify independent risk factors for HELLP syndrome by obtaining adjusted odds ratios (AOR) and 95% confidence intervals (CI), and to assess the associations with adverse outcomes. MAIN OUTCOME MEASURES Adverse maternal (e.g. eclampsia) and fetal/neonatal outcomes (e.g. intraventricular haemorrhage, perinatal death). RESULTS The incidence of HELLP syndrome was 2.5 per 1000 singleton deliveries (n = 2663). Risk factors included: age ≥35 years, rural residence, nulliparity, parity ≥4, pre-pregnancy and gestational hypertension and diabetes, assisted reproduction, chronic cardiac conditions, systemic lupus erythematosus, obesity, chronic hepatic conditions, placental disorders (e.g. fetomaternal transfusion) and congenital anomalies. PROM and age <25 years were inversely associated with HELLP syndrome (P-values <0.05). Women with the syndrome had a 10-fold higher maternal mortality (95% CI 1.6-84.3) and elevated severe maternal morbidity (9.6 versus 121.7 per 1000; AOR 12.5, 95% CI 11.1-14.1); and higher perinatal mortality (4.3 versus 21.0 per 1000; AOR 4.5, 95% CI 3.5-5.9) and perinatal mortality/severe neonatal morbidity (21.2 versus 202.4 per 1000; AOR 10.7, 95% CI 9.7-11.8). CONCLUSION HELLP syndrome is associated with specific pre-pregnancy and pregnancy risk factors, higher rates of maternal death, and substantially higher severe maternal morbidity, perinatal mortality and severe neonatal morbidity. TWEETABLE ABSTRACT HELLP syndrome is associated with higher maternal death rate, and substantially higher severe maternal and neonatal morbidity, and perinatal mortality.
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Affiliation(s)
- S Lisonkova
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada.,Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - N Razaz
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Y Sabr
- Department of Obstetrics and Gynaecology, King Saud University, Riyadh, Saudi Arabia
| | - G M Muraca
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - A Boutin
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada.,Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, BC, Canada
| | - C Mayer
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada.,Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, BC, Canada
| | - K S Joseph
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada.,Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - M S Kramer
- Departments of Paediatrics and of Epidemiology, Biostatistics and Occupational Health, McGill University Faculty of Medicine, Montreal, QC, Canada
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Szczepanski J, Griffin A, Novotny S, Wallace K. Acute Kidney Injury in Pregnancies Complicated With Preeclampsia or HELLP Syndrome. Front Med (Lausanne) 2020; 7:22. [PMID: 32118007 PMCID: PMC7020199 DOI: 10.3389/fmed.2020.00022] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 01/15/2020] [Indexed: 01/12/2023] Open
Abstract
Acute kidney injury that occurs during pregnancy or in the post-partum period (PR-AKI) is a serious obstetric complication with risk of significant associated maternal and fetal morbidity and mortality. Recent data indicates that the incidence of PR-AKI is increasing, although accurate calculation is limited by the lack of a uniform diagnostic criteria that is validated in pregnancy. Hypertensive and thrombotic microangiopathic disorders of pregnancy have been identified as major contributors to the burden of PR-AKI. As is now accepted regarding preeclampsia, HELLP syndrome and atypical hemolytic uremic syndrome, it is believed that PR-AKI may have long-term renal, cardiovascular and neurocognitive consequences that persist beyond the post-partum period. Further research regarding PR-AKI could be advanced by the development of a pregnancy-specific validated definition and classification system; and the establishment of refined animal models that would allow researchers to further elucidate the mechanisms and sequelae of the disorder.
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Affiliation(s)
- Jamie Szczepanski
- Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, MS, United States
| | - Ashley Griffin
- Program in Neuroscience, University of Mississippi Medical Center, Jackson, MS, United States
| | - Sarah Novotny
- Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, MS, United States
| | - Kedra Wallace
- Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, MS, United States.,Department of Neurobiology and Anatomical Sciences, University of Mississippi Medical Center, Jackson, MS, United States
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17
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Acute kidney injury associated with preeclampsia or hemolysis, elevated liver enzymes, and low platelets syndrome. Pregnancy Hypertens 2020; 19:94-99. [PMID: 31927326 DOI: 10.1016/j.preghy.2019.11.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 11/02/2019] [Accepted: 11/25/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To determine the prevalence of acute kidney injury (AKI), placental abruption and postpartum hemorrhage in patients with preeclampsia or HELLP syndrome. STUDY DESIGN A retrospective study of patients with preeclampsia or HELLP syndrome treated at the University of Mississippi Medical Center from January 2000 through December 2010. MAIN OUTCOME MEASURES Relationships among the obstetric complications of placental abruption, postpartum hemorrhage, and AKI (serum creatinine >107 µmol/L) of women with preeclampsia or HELLP syndrome. Additional analysis was undertaken to explore if there was a correlation between postpartum hemorrhage/placental abruption and the severity of HELLP syndrome according to the Mississippi classification system. RESULTS Data from 1276 women over 11 years were included in the analysis. 67 of 466 patients (14.4%) with HELLP syndrome and 38 of 810 preeclampsia patients (4.7%) met criteria for AKI. Women with either placental abruption or postpartum hemorrhage had statistically significant increased odds of also having AKI (p < 0.01). Women with HELLP and AKI were also more likely to experience either placental abruption or postpartum hemorrhage. Women with Class 1 HELLP with placental abruption or postpartum hemorrhage were also more likely to have AKI than women with preeclampsia. CONCLUSION HELLP syndrome, AKI and placental abruption or postpartum hemorrhage appear to be interrelated. AKI occurs more frequently in women with HELLP syndrome with or without associated postpartum hemorrhage and placental abruption.
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18
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Maged AM, Elsherief A, Hassan H, Salaheldin D, Omran KA, Almohamady M, Dahab S, Fahmy R, AbdelHak A, Shoab AY, Lotfy R, Lasheen YS, Nabil H, Elbaradie SMY. Maternal, fetal, and neonatal outcomes among different types of hypertensive disorders associating pregnancy needing intensive care management. J Matern Fetal Neonatal Med 2020; 33:314-321. [PMID: 29914278 DOI: 10.1080/14767058.2018.1491030] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Objective: To assess the relationship between maternal, fetal, and neonatal outcomes and different forms of hypertensive disorders associating pregnancy in women needed intensive care units (ICUs) admission.Methods: A prospective case control study was conducted on 1238 women admitted to hypertensive ICU at three university hospitals. They were classified into four groups. Group I included 472 women with severe preeclampsia (PE), Group II included 243 women with eclampsia (E), Group III included 396 women diagnosed with E associated with HELLP syndrome, and Group IV included 127 women diagnosed as HELLP syndrome. All women received magnesium sulfate to prevent and/or control convulsions and nifedipine to control their blood pressure. Primary outcome parameter was maternal mortality. Other outcomes included maternal morbidities, fetal, and neonatal outcomes.Results: There was a significant difference among the study groups regarding the need for blood transfusion (58.1%, 70%, 84.3%, and 42.5% respectively, p < .001), number of transferred units (2.4 ± 1, 2.9 ± 0.9, 3.4 ± 1.1, and 3.5 ± 0.8 respectively, p < .001), placental abruption (23.3%, 16.5%, 30.3%, and 19.7% respectively, p < .001), pulmonary edema (14.8%, 22.6%, 19.9%, and 34.6% respectively, p < .001), multiple complications (12.5%, 12.3%, 19.9%, and 26% respectively, p < .001), and maternal mortality (1.9%, 4.1%, 6.1%, and 5.5% respectively, p < .001). Regarding fetal and neonatal outcomes, there was a significant difference among the four groups regarding Apgar score at 1 and 5 min, neonatal birth weight, neonatal intensive care unit (NICU) admission, NICU admission days, intrauterine growth restriction, perinatal death, respiratory distress syndrome, intraventricular hemorrhage, sepsis, and the need for mechanical ventilation (p < .001). Higher rate of vaginal delivery was reported in women with HELLP (40.9%) and severe PE (39.8%) and higher rates of performing cesarean section (CS) in women with eclampsia (77.8%). Maternal mortality is significantly related to delivery with CS, younger maternal age with lower parity, and the presence of placental abruption or pulmonary edema. For Groups III and IV, which included HELLP cases, there are significant differences between both groups as regards HELLP classes according to Mississippi classification, also significant differences were seen between both groups as regards, maternal mortality, abruptio placenta, pulmonary edema, multiple organ damage, NICU admission, perinatal deaths, and need for mechanical ventilation.Conclusion: Both maternal mortality and morbidity (placental abruption and need for blood transfusion) are significantly higher in women with HELLP syndrome worsens to become class 1 regardless of whether eclampsia is present or not.Synopsis: Maternal mortality and unfavorable outcome are significantly higher in women with HELLP syndrome whether it was associated with eclampsia or not.
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Affiliation(s)
- Ahmed M Maged
- Obstetrics and Gynecology Department, Cairo University, Cairo, Egypt
| | - Ameer Elsherief
- Obstetrics and Gynecology Department, Minya University, Minya, Egypt
| | - Hany Hassan
- Obstetrics and Gynecology Department, Minya University, Minya, Egypt
| | - Doaa Salaheldin
- Obstetrics and Gynecology Department, Cairo University, Cairo, Egypt
| | - Khaled A Omran
- Obstetrics and Gynecology Department, Cairo University, Cairo, Egypt
| | - Maged Almohamady
- Obstetrics and Gynecology Department, Cairo University, Cairo, Egypt
| | - Sherif Dahab
- Obstetrics and Gynecology Department, Cairo University, Cairo, Egypt
| | - Radwa Fahmy
- Obstetrics and Gynecology Department, Cairo University, Cairo, Egypt
| | - Ahmed AbdelHak
- Obstetrics and Gynecology Department, Cairo University, Cairo, Egypt
| | - Amira Y Shoab
- Obstetrics and Gynecology Department, Cairo University, Cairo, Egypt
| | - Rehab Lotfy
- Obstetrics and Gynecology Department, Cairo University, Cairo, Egypt
| | - Yossra S Lasheen
- Obstetrics and Gynecology Department, Cairo University, Cairo, Egypt
| | - Hala Nabil
- Obstetrics and Gynecology Department, Cairo University, Cairo, Egypt
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19
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Choi M, Butler E, Clarke A, Girard LP, Gibson P, Skeith L. Managing pregnancy-associated clinical emergencies in systemic lupus erythematosus: a case-based approach. Expert Rev Clin Immunol 2019; 16:5-22. [PMID: 31791152 DOI: 10.1080/1744666x.2019.1699057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: Systemic lupus erythematosus (SLE)-related thrombocytopenia during pregnancy and the postpartum period have been associated with adverse pregnancy outcomes and perinatal complications. In this case report, we present two SLE patients with thrombocytopenia emergencies secondary to HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome and thrombotic thrombocytopenic purpura (TTP).Areas covered: The first case involved a 26-year-old woman, G1P0 at 26 weeks gestation (GA), with high-titer antiphospholipid antibodies (aPL) (positive lupus anticoagulant, anti-beta 2 glycoprotein-1 (aβ2GP1), anti-cardiolipin) and non-criteria aPL to phosphatidylserine/prothrombin complex and anti-domain 1 β2GP1. This case highlights the risks associated with aPL in pregnancy, considers management issues relating to anticoagulation during pregnancy and highlights the importance of maintaining a high index of suspicion for diagnosis of HELLP in SLE patients. The second case was a 36-year-old female, G3P2 at 32 weeks GA, with class III lupus nephritis (LN) who developed severe pre-eclampsia, which included mild thrombocytopenia. This case illustrates the challenges in identifying and differentiating between three pregnancy emergencies that can be seen in SLE patients (pre-eclampsia, LN, and TTP) and presents the management of TTP in peripartum SLE.Expert opinion: These two cases remind us of the importance of timely diagnosis and management of thrombocytopenia in this population.
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Affiliation(s)
- May Choi
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Erin Butler
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ann Clarke
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Louis Phillipe Girard
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Paul Gibson
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Obstetrics & Gynecology, University of Calgary, Calgary, Alberta, Canada
| | - Leslie Skeith
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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20
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Diagnosis of HELLP Syndrome: A 10-Year Survey in a Perinatology Centre. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16010109. [PMID: 30609811 PMCID: PMC6339138 DOI: 10.3390/ijerph16010109] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 12/27/2018] [Accepted: 12/28/2018] [Indexed: 11/16/2022]
Abstract
HELLP (Hemolysis, Elevated Liver enzymes, Low Platelet count) syndrome is a severe and rapidly progressing condition that requires distinct diagnostic considerations. The aim of this study was to evaluate the impact of the Mississippi triple-class system on the HELLP syndrome diagnosis, treatment, and outcomes in a perinatology centre during a 10-year period, and consider its effectiveness and necessity in everyday practice. A retrospective observational cohort study was carried out using the medical records of a tertiary perinatology centre with the diagnosis of HELLP syndrome from the period of time between 2005 and 2014. The patients who fit the HELLP syndrome diagnosis were grouped by the Mississippi triple-class system. The means of diagnosis and treatment outcomes within those groups were analysed statistically. There was insufficient statistical evidence of the blood pressure levels corresponding to the severity of patients’ condition (p > 0.05 in all of the groups). The clinical presentation varied within all of the classes, and the only objective means of diagnosis and evaluation of progression of the condition were laboratory tests. Even though HELLP syndrome is considered a hypertensive multi-organ disorder of pregnancy, the level of hypertension does not correlate to the severity of the condition; hence, the diagnosis should be based on biochemical laboratory evidence. Vigilance in suspicion and the recognition of HELLP syndrome and appropriate treatment are essential in order to ensure better maternal and neonatal outcomes.
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21
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Role and mechanism of AT1-AA in the pathogenesis of HELLP syndrome. Sci Rep 2018; 8:279. [PMID: 29321548 PMCID: PMC5762787 DOI: 10.1038/s41598-017-18553-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 12/14/2017] [Indexed: 02/08/2023] Open
Abstract
HELLP syndrome remains a leading cause of maternal and neonatal mortality and morbidity worldwide, which symptoms include hemolysis, elevated liver enzymes and low platelet count. The objective of this study was to determine whether HELLP is associated with AT1-AA. The positive rate and titer of AT1-AA in plasma from pregnant women were determined, and the correlation of AT1-AA titer with the grade of HELLP was analyzed. A HELLP rat model established by intravenous injection of AT1-AA. Our experimental results show the AT1-AA titer and positive rate were significantly higher in HELLP group, and AT1-AA titer were positively correlated with the level of TNF-α and ET-1 in plasma and the grade of HELLP syndrome. The results of animal experiments showed that the typical features of HELLP in the pregnant rats after AT1-AA injection. The levels of TNF-α and ET-1 in plasma and liver tissue were significantly increased in AT1-AA-treated rats compared with control rats. The HELLP syndrome induced by AT1-AA was attenuated markedly after administration of losartan. These data support the hypothesis that one the potential pathway that AT1-AA induce damage to capillary endothelial cells and liver during pregnancy is through activation of TNF-α and ET-1.
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22
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Kappler S, Ronan-Bentle S, Graham A. Thrombotic Microangiopathies (TTP, HUS, HELLP). Hematol Oncol Clin North Am 2018; 31:1081-1103. [PMID: 29078925 DOI: 10.1016/j.hoc.2017.08.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Thrombocytopenia, strictly defined as a platelet count less than 150,000, is common in the emergency department. Recognition, diagnostic investigation, and proper disposition of a thrombocytopenic patient are imperative. One group of disorders leading to thrombocytopenia is the thrombotic microangiopathies, hallmarked by platelet destruction. These thrombotic microangiopathies include thrombotic thrombocytopenic purpura (TTP), hemolytic uremic syndrome (HUS) and hemolysis, elevated liver enzyme levels, low platelet count (HELLP), which should be distinguished from similar disease processes such as immune thrombocytopenia (ITP), disseminated intravascular coagulation (DIC) and heparin induced thrombocytopenia (HIT). In this article, clinical presentations, pathophysiology, diagnostic workup, management plans, complications, and dispositions are addressed for this complex group of platelet disorders.
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Affiliation(s)
- Shane Kappler
- Department of Emergency Medicine, Medstar Georgetown University Hospital, Washington Hospital Center, 3800 Reservoir Road, Northwest, Washington, DC 20007, USA.
| | - Sarah Ronan-Bentle
- Department of Emergency Medicine, University of Cincinnati, University Hospital, 231 Albert Sabin Way, PO Box 670769, Cincinnati, OH 45267, USA
| | - Autumn Graham
- Department of Emergency Medicine, Medstar Georgetown University Hospital, Washington Hospital Center, 3800 Reservoir Road, Northwest, Washington, DC 20007, USA.
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Bean C, Spencer SK, Bowles T, Kyle PB, Williams JM, Gibbens J, Wallace K. Inhibition of T-cell activation attenuates hypertension, TNFα, IL-17, and blood-brain barrier permeability in pregnant rats with angiogenic imbalance. Am J Reprod Immunol 2016; 76:272-9. [PMID: 27476638 PMCID: PMC5023479 DOI: 10.1111/aji.12547] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 07/05/2016] [Indexed: 12/26/2022] Open
Abstract
PROBLEM Angiogenic imbalance during pregnancy is associated with immune activation, hypertension, increased T cell infiltration, and neurological insults. METHOD OF STUDY On gestational day (GD) 12, timed-pregnant rats were infused with anti-angiogenic factors sFlt-1 and sEndoglin (4.7 and 7 μg/kg) to create HELLP syndrome via mini-osmotic pumps for 8 days, with a subset of these rats having Orencia (2 mg/kg) infused on GD13. On GD19, blood-brain barrier (BBB) permeability was evaluated via Evan's Blue infusion, blood was collected for T-cell measurements, inflammatory cytokine secretion. Brain tissues were also collected to examine inflammatory cytokine infiltration. RESULTS T-cell attenuation with Orencia decreased circulating CD4(+) and CD8(+) T cells, circulating tumor necrosis factor alpha (TNFα) and IL-17, BBB permeability and significantly decreased biochemical evidence of HELLP compared to untreated HELLP rats. CONCLUSIONS These data support the hypothesis that T cells have a critical role in contributing to the pathophysiology that is seen in angiogenic imbalance during pregnancy.
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Affiliation(s)
- Cynthia Bean
- Department of Obstetrics & Gynecology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Shauna-Kay Spencer
- Department of Obstetrics & Gynecology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Teylor Bowles
- Department of Obstetrics & Gynecology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Patrick B Kyle
- Department of Pathology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Jan M Williams
- Department of Pharmacology & Toxicology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Jacob Gibbens
- Department of Obstetrics & Gynecology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Kedra Wallace
- Department of Obstetrics & Gynecology, University of Mississippi Medical Center, Jackson, MS, USA.
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Anterior Ischemic Optic Neuropathy as a Manifestation of HELLP Syndrome. Case Rep Crit Care 2014; 2014:671976. [PMID: 25328716 PMCID: PMC4195348 DOI: 10.1155/2014/671976] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Revised: 09/14/2014] [Accepted: 09/18/2014] [Indexed: 11/17/2022] Open
Abstract
Thrombotic microangiopathies (TMAs) are a group of disorders characterized by occurrence of thrombi of fibrin and/or platelets with microvascular occlusion and organ ischemia especially the kidney and brain. Hemolysis with a microangiopathic blood smear, elevated liver enzymes, and low platelet count (HELLP syndrome) is a type of TMA peculiar to pregnancy and may be associated with neurological complications. Visual complications in HELLP are usually related to cortical blindness. We present the first case of HELLP associated with bilateral anterior ischemic optic neuropathy (AION) and blindness which resolved with plasma exchange.
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25
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Kappler S, Ronan-Bentle S, Graham A. Thrombotic Microangiopathies (TTP, HUS, HELLP). Emerg Med Clin North Am 2014; 32:649-71. [DOI: 10.1016/j.emc.2014.04.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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26
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Risk factors, management, and outcomes of hemolysis, elevated liver enzymes, and low platelets syndrome and elevated liver enzymes, low platelets syndrome. Obstet Gynecol 2014; 123:618-627. [PMID: 24499757 DOI: 10.1097/aog.0000000000000140] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To describe the risk factors, management and outcomes of hemolysis, elevated liver enzymes, and low platelets (HELLP) and elevated liver enzymes, low platelets (ELLP) syndrome in the United Kingdom. METHODS A case-control study was conducted using the U.K. Obstetric Surveillance System between June 2011 and May 2012, including 129 women diagnosed with HELLP, 81 diagnosed with ELLP, and 476 control women. RESULTS Women with HELLP were more likely than those in the control group to be 35+ years old (33% compared with 22%, adjusted odds ratio [OR] 1.85, 95% confidence interval [CI] 1.12-3.06), nulliparous (67% compared with 43%, adjusted OR 4.16, 95% CI 2.48-6.98), have had a previous gestational hypertensive disorder (9% compared with 7%, adjusted OR 3.47, 95% CI 1.49-8.09), and have a multiple pregnancy (7% compared with 2%, adjusted OR 4.51, 95% CI 1.45-14.06). Women with ELLP were more likely than those in the control group to be nulliparous (79% compared with 43%, adjusted OR 8.35, 95% CI 3.88-17.95), and have had a previous gestational hypertensive disorder (7% compared with 7%, adjusted OR 4.66, 95% CI 1.37-15.89). Of the women diagnosed antenatally with HELLP or ELLP, 51% (71/138) had planned management of immediate delivery, 43% (60/138) had delivery planned within 48 hours, and 5% (7/138) had planned expectant (conservative) management. No differences were found between women who had delivery planned within 48 hours and those who had planned immediate delivery in terms of the proportion who received blood products (37% compared with 33%, P=.681); were admitted to the intensive care unit (57% compared with 61%, P=.652); experienced severe morbidity (10% compared with 4%, P=.300); or had a neonate with major complications (6% compared with 11%, P=.342). CONCLUSION A short delay in the delivery of women diagnosed antenatally with HELLP or ELLP syndrome may be considered. However, the rarity of the condition limits study power.
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DIC score in pregnant women--a population based modification of the International Society on Thrombosis and Hemostasis score. PLoS One 2014; 9:e93240. [PMID: 24728139 PMCID: PMC3984105 DOI: 10.1371/journal.pone.0093240] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Accepted: 03/04/2014] [Indexed: 01/26/2023] Open
Abstract
Objectives The objectives of this study were: 1) To determine the component needed to generate a validated DIC score during pregnancy. 2) To validate such scoring system in the identification of patients with clinical diagnosis of DIC. Material and Methods This is a population based retrospective study, including all women who gave birth at the ‘Soroka University Medical Center’ during the study period, and have had blood coagulation tests including complete blood cell count, prothrombin time (PT)(seconds), partial thromboplastin time (aPTT), fibrinogen, and D-dimers. Nomograms for pregnancy were established, and DIC score was constructed based on ROC curve analyses. Results 1) maternal plasma fibrinogen concentrations increased during pregnancy; 2) maternal platelet count decreased gradually during gestation; 3) the PT and PTT values did not change with advancing gestation; 4) PT difference had an area under the curve (AUC) of 0.96 (p<0.001), and a PT difference ≥1.55 had an 87% sensitivity and 90% specificity for the diagnosis of DIC; 5) the platelet count had an AUC of 0.87 (p<0.001), an 86% sensitivity and 71% specificity for the diagnosis of DIC; 6) fibrinogen concentrations had an AUC of 0.95 (p<0.001) and a cutoff point ≤3.9 g/L had a sensitivity of 87% and a specificity of 92% for the development of DIC; and 7) The pregnancy adjusted DIC score had an AUC of 0.975 (p<0.001) and at a cutoff point of ≥26 had a sensitivity of 88%, a specificity of 96%, a LR(+) of 22 and a LR(−) of 0.125 for the diagnosis of DIC. Conclusion We could establish a sensitive and specific pregnancy adjusted DIC score. The positive likelihood ratio of this score suggests that a patient with a score of ≥26 has a high probability to have DIC.
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Darby M, Martin JN, Mitchell SQ, Owens MY, Wallace K. Using case reports to determine when liver bleeding occurs during disease progression in HELLP syndrome. Int J Gynaecol Obstet 2013; 123:7-9. [DOI: 10.1016/j.ijgo.2013.06.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Revised: 03/26/2013] [Accepted: 06/21/2013] [Indexed: 11/28/2022]
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