Secondary Trauma Among Caregivers: A Reflexive Narrative About the Intersection of Personal and Professional Traumatic Experiences

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Complete versus partial HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome

Syndrome of Hemolysis, Elevated Liver Enzymes, and Low Platelet Count (The HELLP Syndrome): A Case Report

Hypertensive disorders of pregnancy, particularly preeclampsia, are significant contributors to maternal and fetal mortality worldwide. HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome constitutes a severe manifestation of preeclampsia. Subcapsular liver hematoma (SLH) is a rare complication of HELLP syndrome, resulting from blood accumulation between the liver parenchyma and the Glisson's capsule. We present a unique case of a pregnant patient with HELLP syndrome complicated by SLH, leading to gastric outlet obstruction (GOO). The patient's medical history, clinical presentation, diagnostic evaluation, and management are discussed. The patient, with a history of pregnancy-induced hypertension, presented with HELLP syndrome at 34 weeks of gestation. Elevated blood pressure, liver enzymes, and low platelet count were observed. Postpartum, the patient developed SLH causing GOO. Conservative management, including intravenous fluids, pain control, and a nasogastric tube, was employed. Imaging confirmed SLH and GOO. Multidisciplinary collaboration guided the treatment approach, emphasizing close monitoring, nonoperative strategies, and dietary adjustments. The patient's condition improved, and she was discharged on postpartum day 20.This case report underscores the challenges of managing HELLP syndrome complications, especially SLH-induced GOO. Early diagnosis, appropriate medical interventions, and interdisciplinary coordination are pivotal in ensuring positive outcomes. Conservative management can be effective in stable patients, but timely recognition and monitoring remain crucial for averting potential complications. This case contributes to the limited literature on managing such complex scenarios and highlights the importance of tailored strategies in multifaceted medical conditions.

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

Background:The hemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome is a serious complication in pregnancy occurring in 0.5–0.9% of all pregnancies and in 10–20% of cases with severe pre-eclampsia. Previous studies described HELLP syndrome without hemolysis without any further details.Objectives:This report represents the criteria for the diagnosis of Abdelazim and AbuFaza elevated liver enzymes, low platelet count (ELLP) syndrome as a variant of HELLP syndrome.Case Reports:A 39-year-old woman, pregnant 32 weeks’ gestation, previous five cesarean sections, admitted with severe pre-eclampsia (blood pressure 160/110 mmHg, proteinuria +3, 700 mg proteins/24 h urine, and protein/creatinine ratio ≥0.9 in spot urine sample). Laboratory investigation showed elevated liver enzymes, low platelet (PLT) count, and no evidence of hemolysis. A 31-year-old woman, pregnant 33+4 weeks’ gestation, previous one cesarean section, admitted with severe pre-eclampsia (blood pressure 170/120 mmHg, proteinuria +2, 1200 mg proteins/24 h urine, and protein/creatinine ratio 1.1 in spot urine sample). Laboratory investigations showed elevated liver enzymes, low PLT count, and no evidence of hemolysis. Both patients delivered by cesarean section after stabilization of their blood pressure and dexamethasone for induction of fetal lung maturity and MgSO4 for prevention of eclampsia. Both patients had uneventful intraoperative and postoperative stay in the hospital. The liver enzymes and the PLT count were completely normal on the 5th postoperative day, and they were discharged from the hospital in good general condition.Conclusion:Abdelazim and AbuFaza ELLP syndrome is variant of HELLP syndrome without hemolysis in women with severe pre-eclampsia. Abdelazim and AbuFaza ELLP syndrome diagnostic criteria are as follows: (1) Elevated liver enzymes; (2) Low PLT count; and (3) Absence of hemolysis (normal total and unconjugated bilirubin, absence of schizocytes, and polychromatic red cells in peripheral blood smear, and normal reticulocyte count).

The recent special issue (September 2007) of ClinicalSocial Work Journal on ‘‘Compassion Fatigue’’ highlightsthe important topic of the social worker’s subjectiveresponse to the stressors that are inevitably encountered insocial work practice. Brian Bride, Charles Figley and theircolleagues have provided an important service to our pro-fession by highlighting these issues in a series of articles,books and research studies over the past 20 years. Whilesocial workers focus daily on caring for others, issues ofself-care are too often neglected. The constructs of‘‘compassion fatigue’’ and ‘‘secondary traumatization’’have played an important role in raising awareness of theseself-care issues throughout the social work profession: indirect practice, administration and academia.At the same time, our colleagues in the ‘‘compassionfatigue’’ realm have taken a largely ahistorical approach intheir scholarly pursuits, specifically neglecting a large bodyof literature on countertransference which greatly enhancesour appreciation of the self-care issues involved in socialwork practice. For example, in a recent NASW article,Brian Bride suggests that ‘‘secondary traumatization’’ isconceptualized as distinct from ‘‘pronounced counter-transference’’ (Stoesen 2007, p. 4). In this recent specialissue of CSWJ, countertransference is barely mentioned,although it is frequently discussed in this journal’s pages.Reviewing Figley’s extensive writings, it appears that heuses an outdated and limited definition of countertransfer-ence which suggest that the social worker’s past lifeexperiences trigger an emotional reaction to current workexperiences. According to Figley (2002), countertransfer-ence is ‘‘an emotional reaction to a client by the therapist—irrespective of empathy, the trauma, or suffering. It isdefined as the process of seeing oneself in the client, ofover identifying with the client, or of meeting needsthrough the client (Corey 1991). In contrast to compas/sionfatigue, countertransference is chronic attachment associ-ated with family of origin relationships and has much lessto do with empathy toward the client that causes trauma’’(pp. 1433–1434).Although Figley acknowledges that the concept ofcountertransference has emerged from ‘‘psychodynamictherapy,’’ his sole reference (to Corey’s book) is to thecounseling literature. In my limited review of Figley’swritings, I could not find a single reference to the volu-minous psychoanalytic or clinical social work literature oncountertransference.Figley’s differentiation of countertransference andcompassion fatigue is illustrated by a clinical vignette in anarticle written for psychotherapists (Figley 2002). Hereports on a client, Jane, a young graduate student incounseling psychology who ‘‘was not responding well to anassigned client’’ and was making ‘‘clinical errors’’ whichwere ‘‘associated more with how the client’s story wasupsetting her.’’ The client was a female college studentwho was having adjustment problems in separating fromher family. Jane’s supervisors noticed that ‘‘her client feltguilty about leaving her mother; that the client had beenover-functioning while the mother had developed a con-siderable dependency that needed addressing.’’ Jane oftenshifted the focus of therapy to other issues. In therapy,‘‘Jane wanted to talk about and face these clinical errors...and, reluctantly, her mother’s chronic illness. We quicklymoved to Jane’s feelings of guilt about her own mother’scondition...’’ (p. 1434).

There is no tool to accurately predict who is at risk of developing neurologic complications of preeclampsia, and there is no objective method to determine disease severity. We assessed whether plasma concentrations of the cerebral biomarkers neurofilament light, tau, and glial fibrillary acidic protein could reflect disease severity in several phenotypes of preeclampsia. Furthermore, we compared the cerebral biomarkers with the angiogenic biomarkers soluble fms-like tyrosine kinase 1, placental growth factor, and soluble endoglin. In this observational study, we included women from the South African Preeclampsia Obstetric Adverse Events biobank. Plasma samples taken at diagnosis (preeclampsia cases) or admission for delivery (normotensive controls) were analyzed for concentrations of neurofilament light, tau, glial fibrillary acidic protein, placental growth factor, soluble fms-like tyrosine kinase 1, and soluble endoglin. The cerebrospinal fluid concentrations of inflammatory markers and albumin were analyzed in a subgroup of 15 women. Analyses were adjusted for gestational age, time from seizures and delivery to sampling, maternal age, and parity. Compared with 28 women with normotensive pregnancies, 146 women with preeclampsia demonstrated 2.18-fold higher plasma concentrations of neurofilament light (95% confidence interval, 1.64-2.88), 2.17-fold higher tau (95% confidence interval, 1.49-3.16), and 2.77-fold higher glial fibrillary acidic protein (95% confidence interval, 2.06-3.72). Overall, 72 women with neurologic complications (eclampsia, cortical blindness, and stroke) demonstrated increased plasma concentrations of tau (2.99-fold higher; 95% confidence interval, 1.92-4.65) and glial fibrillary acidic protein (3.22-fold higher; 95% confidence interval, 2.06-5.02) compared with women with preeclampsia without pulmonary edema; hemolysis, elevated liver enzymes, and low platelet count; or neurologic complications (n=31). Moreover, angiogenic markers were higher, but to a lesser extent. Women with hemolysis, elevated liver enzymes, and low platelet count (n=20) demonstrated increased plasma concentrations of neurofilament light (1.64-fold higher; 95% confidence interval, 1.06-2.55), tau (4.44-fold higher; 95% confidence interval, 1.85-10.66), and glial fibrillary acidic protein (1.82-fold higher; 95% confidence interval, 1.32-2.50) compared with women with preeclampsia without pulmonary edema; hemolysis, elevated liver enzymes, and low platelet count; or neurologic complications. There was no difference shown in the angiogenic biomarkers. There was no difference between 23 women with preeclampsia complicated by pulmonary edema and women with preeclampsia without pulmonary edema; hemolysis, elevated liver enzymes, and low platelet count; or neurologic complications for any of the biomarkers. Plasma concentrations of tau and glial fibrillary acidic protein were increased in women with several neurologic complications compared with women with eclampsia only. Plasma neurofilament light, glial fibrillary acidic, and tau were candidate biomarkers for the diagnosis and possibly prediction of cerebral complications of preeclampsia.

Misogyny, Projective Identification, and Mentalization looks at how the psychoanalytic concepts of projective identification and mentalization may explain the construction of society and how they have enabled misogyny to be expressed in social, political, and institutional settings. Karyne E. Messina explores how misogyny has affected the perception and treatment of women through analysis of a range of examples of individual women and groups. The first part explores projective identification as a mechanism for the suppression of women, looking at the origins of the concept in psychoanalysis and its expansion. The author examines the story of Clara Thompson as an example, arguing that her virtual disappearance from the history of psychiatry and psychoanalysis itself is a telling example of this process at work. The second part of the book uses four examples of individuals, including the recent election loss by Hillary Clinton in 2016, to show that projective identification can (particularly in political and cultural settings) overtake and motivate groups as well as individuals, and lead to violence, atrocity, humiliation, and dismissal of and against women. Part three then features case studies of four groups of women from the 20th century, including victims of the 1994 Rwandan genocide, showing how projective identification against groups has occurred. With specific reference to the erasure of women's contributions in society, both individually and collectively, and the trauma that arises from the many effects of regarding women as a group as "less" or "other", this is a book which sets a new agenda for understanding how misogyny is expressed socially. Misogyny, Projective Identification, and Mentalization will be of interest to psychoanalysts and psychoanalytic psychotherapists as well as scholars of politics, gender, and cultural studies.

The paper attempts to answer a key question: does the concept of projective identification (PI) still have a place in the metapsychology of post-Bionian analytic field theory (AFT)? Over time, PI has been characterized as increasingly interpersonal, especially as revised by Bion and Ogden. Beginning with the Barangers, writers on AFT have also spoken about what might best be called “crossing” PI as the foundation of the analytic field. However, on the one hand, they have understood this intersection negatively, as the basis of paired bastions or collusions; on the other hand, with Bion, they have always maintained a certain unidirectionality in writing that the flow of PI normally goes from the patient to the analyst, and can only occasionally be reversed. Strictly speaking, this notion clashes with the radically intersubjective idea that every fact of analysis is unconsciously co-created and represents a "character" in the analytic field or an affective hologram of the couple. The author suggests that this apparent contradiction can be resolved and, if properly rethought, PI can retain an important place in the metapsychology of AFT. If we consider the dialectic of recognition to be at the centre of therapeutic action, PI is the concept in psychoanalysis that best describes it. In order to highlight this theoretical and heuristic value of PI, the proposal is to re-read it in the light of some of Merleau-Ponty's concepts (chiasmus, entanglement, intercorporeality, flesh of the world, etc.) that emphasize the essentially social and embodied texture of subjectivity.

COVID-19 Prevalence and Outcomes in Postpartum Women and Newborns in a Community Hospital System

Doppler velocimetry of hepatic blood flow in postpartum patients with HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets)

Evaluation and management of severe preeclampsia before 34 weeks' gestation

Background: Thrombocytopenia (TCP) is the second most common haematological finding in pregnancy next to anaemia. It carries a risk for both the mother and the fetus, associated with substantial maternal or neonatal morbidity and mortality. However, a specific therapy, if instituted promptly, improves the outcome for affected patients and their offspring. In patients in India, TCP during pregnancy is an underexplored condition. Objectives: To assess the aetiology of TCP in pregnancy and to assess the maternal outcomes of TCP in pregnancy. Methodology: The authors included a total of 133 patients in their third trimester (>32 weeks), with a platelet count <149,000 /mm3, admitted to the authors’ institution from 1st January 2021 to 31st December 2021. Patient-related data such as menstrual and obstetric history, presenting complaints, obstetric examination, and basic investigations were collected in a pre-designed, pre-tested proforma. All cases were followed until delivery to record any maternal complications, or any other morbidities. The data were analysed using SPSS (International Business Machines Corporation, Armonk, New York, USA) software. χ2 test was used to compare the proportions between the groups. p<0.05 was considered significant. Results: Overall, 64.7% of patients were in the 18–25 years age group and 49.6% of patients were primigravida. Furthermore, 60.9% of patients were diagnosed to have mild TCP, 32.3% had moderate TCP, and only 6.8% patients had severe TCP. The majority (75.2%) of cases were of gestational TCP. In total, 15.8% of cases had pregnancy-induced hypertension (PIH); 3.0% had dengue; 2.3% were COVID-19 positive; 1.5% were diagnosed with haemolysis, elevated liver enzymes, and low platelets syndrome; 1.5% had immune TCP; and only one patient had leptospirosis. Four percent of cases had gestational TCP, 9.5% had PIH, one patient (25.0%) had dengue, and both cases of immune TCP had severe TCP. Twenty-eight percent of gestational TCP cases; 47.6% of PIH cases, both cases of haemolysis, elevated liver enzymes, and low platelets syndrome; 50.0% of dengue cases; and one COVID-19 positive case (33.0%) had moderate TCP. Finally, 6.25% of patients who underwent lower segment caesarean section had severe TCP, 6.00% of patients who underwent vaginal delivery had severe TCP, and out of two patients who had a spontaneous abortion, one (50.00%) had severe TCP at the time of admission. The association was significant (p<0.05). Conclusion: TCP is a crucial condition among pregnant patients. Mild TCP is a common type. Correct aetiological diagnosis, and promptly administered adequate and specific therapy are, therefore, essential to significantly improve the outcomes of pregnant patients and their offspring.

Postpartum corticosteroids: Accelerated recovery from the syndrome of hemolysis, elevated liver enzymes, and low platelets (HELLP)