Elevated Liver Enzymes Low Platelets Research Articles

HELLP syndrome and associated factors among pregnant women with preeclampsia/eclampsia at a referral hospital in southwestern Uganda: a cross-sectional study

BackgroundHemolysis Elevated Liver Enzymes Low Platelets (HELLP) syndrome, a complication of preeclampsia/eclampsia, is associated with severe maternal morbidity and mortality. In resource-limited settings, such as Uganda, gaps in routine laboratory assessments may lead to underdetection of HELLP syndrome. This study determined the prevalence and factors associated with HELLP syndrome among pregnant women with preeclampsia/eclampsia at Mbarara Regional Referral Hospital (MRRH), southwestern Uganda.MethodsA cross-sectional study was conducted at the high-risk ward of the MRRH from December 2022 to June 2023. Pregnant women diagnosed with preeclampsia or eclampsia were enrolled consecutively. Participants’ sociodemographic and clinical data were collected using an interviewer-administered questionnaire. The diagnosis of complete HELLP syndrome was made based on the Tennessee classification: aspartate aminotransferase enzyme ≥ 70 IU/L, platelet counts < 100,000 cells/µL, and serum lactate dehydrogenase enzyme ≥ 600 IU/L. We used multivariable modified Poisson regression analysis to determine factors associated with HELLP syndrome.ResultsA total of 129 participants with a mean age of 28 ± 6.6 years were enrolled in the study. The prevalence of HELLP syndrome was 18.6% (n = 24; 95% CI: 12.7–26.3%). Independent factors associated with HELLP syndrome were maternal age (adjusted prevalence ratio [aPR]: 4.96; 95% CI: 1.57–15.65; for mothers aged < 20 years compared to those aged 20–34 years), the presence of epigastric pain (aPR: 5.89; 95% CI: 1.41–14.63), and referral from other health facilities (aPR: 3.14; 95% CI: 1.27–7.72).ConclusionApproximately 2 of the 10 women who presented with preeclampsia or eclampsia had HELLP syndrome. It is more common among teenage mothers, those with a history of epigastric pain and those referred from lower health facilities. Incorporating routine laboratory testing for HELLP syndrome in the diagnostic protocol for preeclampsia or eclampsia, especially among adolescent mothers, those experiencing epigastric pain, and those referred from lower health facilities, could enhance timely detection and management of mothers with preeclampsia whose pregnancies are complicated by HELLP syndrome.

A follow up on the feasibility after national implementation of magnesium sulfate for neuroprotection prior to preterm birth.

The risk for brain injury manifested as cerebral palsy is higher in very preterm born children than in term. Prenatal administration of magnesium sulfate (MgSO4 ) has been shown to be neuroprotective and reduces the proportion of very preterm born children later diagnosed with cerebral palsy. A Swedish national clinical practice guideline was implemented in March 2020, stipulating the administration of a single intravenous dose of 6 g MgSO4 1-24 h prior to delivery before gestational age 32+0, aiming for 90% treatment coverage. The aim of this study was to evaluate the feasibility of this new clinical practice guideline in the first year of its implementation. Data on MgSO4 treatment were collected by reviewing the medical charts of women who gave birth to live born children in gestational age 22+0-31+6 during the period of March 1, 2020 to February 28, 2021, at five Swedish university hospitals. Women with pre-eclampsia, eclampsia, or high elevated liver enzymes low platelets (HELLP) were excluded. A total of 388 women were eligible and 79% received treatment with MgSO4 . Of the 21% not receiving treatment, 9% did not receive treatment due to lack of knowledge about the clinical practice guideline, 9% were not possible to treat and 3% had missing data. The proportion treated increased from 72% to 87% from the first to the last 3 months. Of those treated, 81% received the drug within the stipulated timeframe (mean 8.7 h, median 3.4 h). There was a positive trend over time in the proportion of women receiving MgSO4 treatment, but the a priori target of 90% was not reached during the first year of implementation. Our findings indicate that this target could be reached with additional information to clinicians.

Serum LDH Levels in Normotensive and Preeclamptic-Eclamptic Pregnant Women and Its Correlation With Fetomaternal Outcome.

Background One of the most prevalent medical issues observed during pregnancy is hypertension. Hypertensive disorders of pregnancy (HDP) and their consequences affect around 5-10% of all pregnancies globally. Preeclampsia is caused by endothelial dysfunction, which causes widespread endothelial leakage and contributes to potentially fatal consequences, such as eclampsia, placental abruption, disseminated intravascular coagulation (DIC), severe renal failure, pulmonary edema, and hepatocellular necrosis. As a result, looking for predictive markers for at-risk pregnancies that can suggest poor maternal or fetal outcomes is critical. Elevated levels of lactate dehydrogenase (LDH), as a sign of cellular damage and dysfunction, can be utilized as a biochemical marker in pregnancy-induced hypertension (PIH) as it represents the severity of the disease, and the occurrence of problems, and has also been demonstrated to co-relate with fetomaternal outcomes. Methodology A total of 230 singleton pregnant women of 28-40 weeks of gestational age were enrolled in this study. All women were divided into two groups - normotensive and preeclamptic-eclamptic groups; the second group was further divided intomild preeclampsia, severe preeclampsia, and eclampsia, based on blood pressure and the presence of proteinuria. Serum lactate dehydrogenase levels were measured in both groups and correlated with their fetomaternal outcome. Results Mean serum lactate dehydrogenase (LDH) levelin eclamptic women was 1515.86 ± 754, in severely preeclamptic women was 932.2 ± 448, mild preeclamptic women were 580.5±213, while in normotensive women mean LDH level was 378.6 ± 124. The difference between normotensive and preeclamptic-eclamptic women was statistically significant (p < 0.001). The complications in the preeclamptic-eclamptic group were increased significantly in women with LDH > 800 IU/L, 600-800 IU/L compared to those who had < 600 IU/L LDH levels. Conclusions Serum LDH levels were significantly higher in women of preeclamptic-eclamptic group compared to the normotensive pregnant women. Higher LDH levels were positively correlated with disease severity and maternal complications like placental abruption, hemolysis elevated liver enzymes low platelet count (HELLP), disseminated intravascular coagulation (DIC), acute renal failure, intracranial hemorrhage, pulmonary edema, and maternal death and for fetal complications like preterm, intrauterine growth restriction (IUGR), APGAR at 1 minute < 7, APGAR at 5 minutes < 7, low birth weight (LBW), neonatal intensive care unit (NICU) admission and intrauterine fetal death (IUFD).

Pregnancy-Associated Renal Cortical Necrosis and Nonenhanced Functional Magnetic Resonance Imaging: A Case Series

Pregnancy-associated renal cortical necrosis is a critical illness with a poor prognosis. We aimed to describe the clinical and magnetic resonance imaging (MRI) characteristics of a case series of patients with acute kidney injury in the setting of pregnancy-associated renal cortical necrosis. Case series. Seventeen patients from a single center diagnosed by nonenhanced functional MRI and/or kidney pathology. All patients presented with postpartum acute kidney injury stage 3. Of the 17 patients, 15 (88%) had pregnancy-associated atypical hemolytic uremic syndrome, 11 (65%) had postpartum hemorrhage, 7 (41%) had preeclampsia/hemolysis elevated liver enzymes low platelet count syndrome, and 4 (24%) had disseminated intravascular coagulation. On T2-weighted MRI, the diffuse phenotype showed outer cortex swelling in the early phase, with a dark signal rim involving the inner cortex and Bertin column, which became more apparent over time along with cortical thinning, substantially decreasing T2 signal intensity. The focal phenotype showed focally distributed hypointense signals in the cortex. After 8-101 (median: 60) months of follow-up, 4 individuals had estimated glomerular filtration rates≥60mL/min/1.73m2, 6 had estimated glomerular filtration rates of 15-60mL/min/1.73m2, and 7 had kidney failure requiring kidney replacement therapy. The diffuse phenotype was present in all of the individuals who remained kidney replacement therapy dependent. Retrospective study; small sample size. Different forms of pregnancy-associated thrombotic microangiopathy were the major causative diseases in our pregnancy-associated renal cortical necrosis case series. Nonenhanced functional MRI may provide valuable data for establishing diagnosis and kidney prognosis.

A Prospective Study of Maternal and Perinatal Outcomes in Eclampsia in a Tertiary Care Centre

Background: The term eclampsia is derived from a Greek word, meaning like a flash of lightening. The onset of convulsions in a woman with pre-eclampsia that cannot be attributed to other causes is termed eclampsia. It is a major cause of maternal and fetal mortality and morbidity in our country. The management of eclampsia is still challenging to the obstetrician, requiring the greatest skill, judgement, and patience. Methods and Materials: Our study is an observational and prospective study of 58 cases admitted with eclampsia in Mahatma Gandhi Institute of Medical Sciences (MGIMS), Sewagram. The study was extended from January 2020 to December 2021. The inclusion criteria were all the cases of eclampsia (antepartum and postpartum), primigravida and multigravida, duration of gestation&gt;20 weeks. Patients with convulsion during pregnancy or in puerperal period attributed to epilepsy or other causes were excluded from the study. Results: In our study majority of cases (58.6 %) belong to the younger age group /= 37 weeks). 55.2% had antepartum eclampsia, 36.2% postpartum and 8.6% had intrapartum eclampsia. Most common complication observed was need of blood or blood products transfusion (35 %), Hemolysis, Elevated Liver Enzymes Low Platelets (HELLP) syndrome (21%), prolonged Intensive Care Unit (ICU) admission (19%) followed by abruption, Disseminated Intravascular Coagulation (DIC), Acute Kidney Injury (AKI), Posterior Reversible Encephalopathy Syndrome (PRES), hypertensive retinopathy, pulmonary edema. Majority of patients (57%) underwent cesarean section, most common indication being poor bishop’s score with deteriorating maternal condition (54.5%). Out of 58 cases, 84.4% were live births and 15.6% were still born. 63.2% of all live births were small for gestational age, 44.8% had Neonatal Intensive Care Unit (NICU), and 8% had early neonatal death. Conclusion: Early pregnancy registration, good antenatal care and counselling about warning symptoms, early identification of pre-eclampsia and its complications, and timely intervention can reduce the incidence of eclampsia. Early identification of high-risk cases at primary healthcare facilities including severe pre-eclampsia, impending eclampsia and eclampsia and immediate referral to tertiary care centre equipped with multidisciplinary team, ICU and NICU facilities, might reduce fetal morbidities like prematurity, neonatal intensive care unit admission etc. and maternal morbidities like prolonged hospitalisation, AKI, DIC , pulmonary edema, multi organ dysfunction syndrome etc. and mortality.

Ex Vivo Test for Measuring Complement Attack on Endothelial Cells: From Research to Bedside

As part of the innate immune system, the complement system plays a key role in defense against pathogens and in host cell homeostasis. This enzymatic cascade is rapidly triggered in the presence of activating surfaces. Physiologically, it is tightly regulated on host cells to avoid uncontrolled activation and self-damage. In cases of abnormal complement dysregulation/overactivation, the endothelium is one of the primary targets. Complement has gained momentum as a research interest in the last decade because its dysregulation has been implicated in the pathophysiology of many human diseases. Thus, it appears to be a promising candidate for therapeutic intervention. However, detecting abnormal complement activation is challenging. In many pathological conditions, complement activation occurs locally in tissues. Standard routine exploration of the plasma concentration of the complement components shows values in the normal range. The available tests to demonstrate such dysregulation with diagnostic, prognostic, and therapeutic implications are limited. There is a real need to develop tools to demonstrate the implications of complement in diseases and to explore the complex interplay between complement activation and regulation on human cells. The analysis of complement deposits on cultured endothelial cells incubated with pathologic human serum holds promise as a reference assay. This ex vivo assay most closely resembles the physiological context. It has been used to explore complement activation from sera of patients with atypical hemolytic uremic syndrome, malignant hypertension, elevated liver enzymes low platelet syndrome, sickle cell disease, pre-eclampsia, and others. In some cases, it is used to adjust the therapeutic regimen with a complement-blocking drug. Nevertheless, an international standard is lacking, and the mechanism by which complement is activated in this assay is not fully understood. Moreover, primary cell culture remains difficult to perform, which probably explains why no standardized or commercialized assay has been proposed. Here, we review the diseases for which endothelial assays have been applied. We also compare this test with others currently available to explore complement overactivation. Finally, we discuss the unanswered questions and challenges to overcome for validating the assays as a tool in routine clinical practice.

Critical Care Problem in a Case of Intracerebral Hemorrhage Due to Eclampsia and Its Ethics and Medicolegal Consideration

BACKGROUND: Eclampsia accompanied by hemolysis elevated liver enzymes low platelet (HELLP) syndrome is an emergency condition during late trimester pregnancy characterized by hypertension, seizures, and coma. Obstetric history is known that the patient does not conducted antenatal care regularly to the doctor so that the patient does not know she has eclampsia. One of which complications due to eclampsia is intracerebral hemorrhage which is a major cause of death and morbidity in pregnant woman. This case report discusses how ethical and medicolegal decision-making for procedures to withholding or withdrawing life support for the critical care problem. The ethical dilemma faced by neuroanesthesia and critical care (NACC) consultants is whether to continue to treat patients in the intensive care unit (ICU) even though the results will be in vain or to restrict critical care because they concluded that the condition of the patient has a terminal stage. CASE REPORT: A reported case of a 23-year-old woman, pregnant, and had a caesarian section for the indication of eclampsia accompanied by HELLP syndrome in rural hospital. Because the patient’s condition worsened, she was referred to Zainoel Abidin hospital due to decrease in consciousness and a computed tomography scan of the head showed extensive bleeding. The results of the neuroanesthesia and neurosurgery team’s assessment stated that there was no indication of surgery on the patient because extensive bleeding had occurred accompanied by brain edema. The patient then undergoes treatment in the ICU to improve the patient’s critical condition. In an effort to overcome this problem, the NACC consultant consults with an ethics and medicolegal consultant as a representation of the medical committee and ethical committee to determine the withholding or withdrawing of life support therapy to the patient. CONCLUSION: Life support therapies that can be withhold or withdraw are simply an extraordinary treatment that provides no benefit. The basic principles of ethics in making decisions to do withholding and withdrawing life support in these patients are beneficence and non-maleficence, while the medicolegal principle in these patients lies in the patient’s condition being medically incurable (terminal state) and medical treatment is useless (futile treatment).

The Impact of Preeclampsia on Work-Related Psychosocial Aspects and Need for Recovery

Women with a history of preeclampsia and/or Hemolysis Elevated Liver enzymes Low Platelets (HELLP) syndrome report impaired cognitive functioning, such as concentration problems and decreased memory function. The presence of subjective cognitive impairment, depressive symptoms and cognitive deficits may affect working abilities.

Leptospirosis in pregnancy: A systematic review.

Leptospirosis is a leading zoonotic disease worldwide with more than 1 million cases in the general population per year. With leptospirosis being an emerging infectious disease and as the world's environment changes with more floods and environmental disasters, the burden of leptospirosis is expected to increase. The objectives of the systematic review were to explore how leptospirosis affects pregnancy, its burden in this population, its effects on maternal and fetal outcomes and the evidence base surrounding treatment options. We performed a systematic review of published and unpublished literature using automated and manual methods to screen nine electronic databases since inception, with no language restriction. Two reviewers independently screened articles, completed the data extraction and assessment of risk of bias. Due to significant heterogeneity and paucity of data, we were unable to carry out a meta-analysis, but we conducted a pooled analysis of individual patient data from the case reports and case series to examine the patient and disease characteristics, diagnostic methods, differential diagnoses, antibiotic treatments, and outcomes of leptospirosis in pregnancy. The protocol for this review was registered on the International Prospective Register of Systematic Reviews, PROSPERO: CRD42020151501. We identified 419 records, of which we included eight observational studies, 21 case reports, three case series and identified four relevant ongoing studies. Overall the studies were with moderate bias and of 'fair' quality. We estimated the incidence of leptospirosis in pregnancy to be 1.3 per 10,000 in women presenting with fever or with jaundice, but this is likely to be higher in endemic areas. Adverse fetal outcomes were found to be more common in pregnant patients who presented in the second trimester compared with patients who presented in the third trimester. There is overlap between how leptospirosis presents in pregnancy and in the general population. There is also overlap between the signs, symptoms and biochemical disturbances associated with leptospirosis in pregnancy and the presentation of pregnancy associated conditions, such as Pre-Eclampsia (PET), Acute Fatty Liver of Pregnancy (AFLP) and HELLP Syndrome (Haemolysis Elevated Liver enzymes Low Platelets). In 94% of identified cases with available data, there was an indicator in the patient history regarding exposure that could have helped include leptospirosis in the clinician's differential diagnosis. We also identified a range of suitable antibiotic therapies for treating leptospirosis in pregnancy, most commonly used were penicillins. This is the first systematic review of leptospirosis in pregnancy and it clearly shows the need to improve early diagnosis and treatment by asking early, treating early, and reporting well. Ask early-broaden differential diagnoses and ask early for potential leptospirosis exposures and risk factors. Treat early-increase index of suspicion in pregnant patients with fever in endemic areas and combine with rapid field diagnosis and early treatment. Report well-need for more good quality epidemiological studies on leptospirosis in pregnancy and better quality reporting of cases in literature.

Is There a Role for Indoxyl Sulfate in Contributing to Impaired Cognition and Anxiety Following a Hypertensive Pregnancy?

Objective Women with hypertensive conditions of pregnancy are at an increased risk of developing Acute Kidney Injury (AKI) which can lead to the progression of chronic kidney disease (CKD). Patients with CKD have impairments in cognition and increases in anxiety and depression. Indoxyl Sulfate (I.S.), a uremic toxin associated with CKD progression, has been reported to contribute to spatial memory impairment. We hypothesized that impairments in learning and memory and anxiety among rats with a previous hypertensive pregnancy (Hemolysis elevated liver enzyme low platelet – HELLP Syndrome) and AKI are accompanied by increased levels of I.S. Study Design On gestational day (GD) 12, sFlt-1 and sEng were infused via mini-osmotic pumps into the abdomen of timed-pregnant Sprague Dawley rats to induce HELLP. A subset of rats underwent either bilateral renal ischemia-reperfusion surgery for 45 minutes on GD18 to induce AKI or a SHAM surgery. Rats were either euthanized on GD19 to assess I.S. levels during pregnancy or at post-partum week (PPW) 15. Between PPW 11-13 rats underwent Barnes Maze and anxiety testing. I.S. concentrations were measured in the circulation and brainstem of rats. Tissue concentrations were normalized to total protein and group comparisons analyzed via statistical analysis where p<0.05 was considered significant. N=9-14 rats/group. Results HELLP and AKI rats displayed hypertension (p<0.05) and kidney injury (p<0.05) relative to NP rats at both time periods. There was a significant group (p=0.04) effect in Barnes maze with NP rats finishing the test significantly faster relative to all other groups by the 5th day of testing (p<0.03). There was a significant difference between groups in anxiety where HELLP+AKI rats spent significantly less time in the open area of the zero maze compared to NP+AKI rats (p=0.02). When the groups were compared there were no changes in circulating I.S. at GD19 (p=0.06) or at PPW15 (p=0.78). Brainstem levels of I.S. during pregnancy were increased in response to AKI and were significantly increased in NP+AKI vs. HELLP rats (p=0.02). However, by PPW15 brainstem levels of I.S. were trending towards an increase among HELLP+AKI rats vs. NP+AKI rats (p=0.06). Conclusion The results from this study suggest that AKI during pregnancy contributes to behavioral deficits, hypertension and imbalances in brainstem I.S. concentrations. We are currently examining other regions of the brain and increasing the N in the I.S. studies (currently n=3-5/group). As I.S. could possibly be one the mechanisms causing impairments in learning and memory after a hypertensive pregnancy complicated by AKI, additional studies to determine if blockade of I.S. results in improvements in cognition and anxiety are planned.

Differences in Post-Delivery Blood Pressures Between Women Who Will Develop Postpartum Preeclampsia and Controls [12M

INTRODUCTION: Postpartum preeclampsia (with first clinical manifestation after delivery) is poorly understood but has the potential for catastrophic consequences for patients. Predictive variables in the postpartum period may improve outcomes. The purpose of this study was to determine if there is a difference in blood pressure in the immediate postpartum period (delivery to discharge) in women readmitted with postpartum preeclampsia and controls. METHODS: Deliveries in a 5-year interval (2014-2019) at a university hospital were included in this retrospective cohort study (n=3,621 unique patients). IRB committee waiver was obtained for the study. Exclusion criteria were diagnosis of preeclampsia, eclampsia, or Hemolysis Elevated Liver Enzymes Low Platelets (HELLP) prior to delivery. Cases included readmissions for preeclampsia, eclampsia, or HELLP diagnosed after delivery (n=26). Controls were randomized from remaining patients (3:1 controls to cases, inflated by 10% to account for prevalence of exclusion criteria) (n=78). Each subject’s highest systolic (SBP) and diastolic blood pressure (DBP) from delivery until discharge was recorded. Two sample t-tests were used, significance set at 0.05. RESULTS: The mean peak SBP for cases was significantly higher than controls at 147.4 mmHg (SD 13.4 mmHg) compared to 133.3 mmHg (SD 12.0 mmHg) (P&lt;.001). Mean peak DBP for cases was also higher than controls at 91.6 mmHg (SD 8.7 mmHg) compared to 82.9 mmHg (SD 8.0) (P&lt;.001). CONCLUSION: Blood pressure in the immediate postpartum period was higher in women readmitted for postpartum preeclampsia compared to controls. This information may be a first step in developing a predictive model to better understand and predict postpartum preeclampsia.

Placental sFLT1 is associated with complement activation and syncytiotrophoblast damage in preeclampsia

ABSTRACTThe immune complement system protects against pathogens; however, excess activation results in disease like hemolytic uremic syndrome, a clinical imitator of preeclampsia. Vascular endothelial factor (VEGF) protects against aberrant complement activation and is inhibited by soluble fms-like tyrosine kinase-1 (sFLT1) in other organs. We hypothesize that sFLT1 promotes complement-mediated placental damage through VEGF inhibition in preeclampsia.Objective: Quantify placental complement activity and sFLT1 expression in preeclampsia, and the subgroup of preeclampsia with hemolysis elevated liver enzymes low platelets (HELLP) syndrome.Methods: Placental complement activation marker C4d, membrane attack complex (MAC), and sFLT1 expression was quantified using immunofluores cence microscopy. Results: Placentas from 18 controls, 25 preeclampsia, including 6 cases of HELLP syndrome were identified. Placental C4d expression was greater in PE (median 6.4 [IQR: 5.1, 8.3]) compared to controls (4.4 [3.6, 5.5]; p = 0.003). MAC expression was also increased in preeclampsia compared to controls (6.5 [5.8, 8.7]; 5.4 [2.9, 5.9], p = 0.001). Placental sFLT1 expression was also higher in preeclampsia (p <0.0001). C4d and MAC were strongly correlated with sFLT1 levels in the placenta (R = 0.72; p < 0.0001 and R = 0.59; p = 0.01, respectively). Complement and sFLT1 expression was elevated in HELLP compared to preeclampsia without laboratory abnormalities, but this difference did not reach statistical significance. Conclusion: Increased placental complement activation and damage was seen in preeclampsia and correlates with sFLT1 expression. Our findings support the importance of the complement pathway in preeclampsia.

Diagnosis of Hemolysis–Elevated Liver Enzymes–Low Platelet Count (HELLP) Syndrome in Rural Hospitals

Rural hospitals have unique challenges, including low volume of high-risk patients and minimal staffing. It is imperative that each emergency has an interdisciplinary approach focusing on the patient, with each team member aware of the plan. HELLP syndrome (hemolysis–elevated liver enzymes–low platelet count) can be difficult to diagnosis. Its symptoms are often mistaken for gastritis, flu, acute hepatitis, gall bladder disease, or other conditions, especially if the patient does not have high blood pressure. The patient is a 20-year-old gravida 1 para 0 woman who presented to labor and delivery ambulatory services after awakening with severe nausea, vomiting, and diarrhea. The patient complained of severe abdominal cramps. Pain level was rated 7 out of 10. She was afebrile, but had chills and shakes. Up to that point, she had an uncomplicated pregnancy. Vitals showed that she had elevated blood pressure of 169/92 mmHg. Staff was unable to obtain fetal heart tones. Because the patient was vomiting, it was difficult to obtain blood pressure readings. Diagnosis: 27-weeks intrauterine fetal death with acute gastroenteritis secondary to food poisoning. Laboratory results showed the following: white blood cell count of 24.5/cells/L, platelet count of 133/mcL, alanine aminotransferase level of 19 U/L, and aspartate aminotransferase level of 45U/L. Blood was retaken 2 hours later and showed a dramatic decrease in platelets, from 133 to 79. The patient’s liver enzymes were elevated. Diagnosis: HELLP syndrome. Supportive interventions included magnesium sulfate, labetalol, and blood products. Total blood products infused in the obstetrics unit equaled six units of packed red blood cells, two units of platelets, two units of cryoprecipitate, and five units of plasma. The patient transferred from the obstetrics unit to the intensive care unit (ICU) for hemodynamic monitoring. The interdisciplinary team included obstetric nurses who monitored the patient in the ICU in collaboration with the critical care team. Nurses should be aware of the signs and symptoms of HELLP, including looking for early warning signs and knowing critical laboratory values for pregnant women. Communication is key for all team members. When a patient is transferred to another unit and service line, it is imperative to have an interdisciplinary and multiservice line approach to care.

Epigastric Pain as a Potential Indicator of Hemolysis–Elevated Liver Enzymes–Low Platelet Count (HELLP) Syndrome in Pregnant Women

Epigastric pain is a common pregnancy symptom. True clinical symptoms are less evident and more challenging during pregnancy. The incidence of HELLP (hemolysis–elevated liver enzymes–low platelet count) is rare but life threatening. Liver rupture is rare and associated with a maternal mortality rate of 16.4% and a perinatal mortality rate of 31.3%. Early diagnosis and treatment have a profound effect on patients’ prognosis. Obstetric nurses should have a heightened awareness of HELLP syndrome in patients presenting with epigastric pain. Expedited interventions geared toward rapid diagnosis and treatment should be implemented to help decrease maternal and neonatal morbidity and mortality. A gravida 2 para 0 term patient presented to triage complaining of severe epigastric pain and uterine contraction for the previous 3 hours. Her cervix was closed; the fetal heart rate was tachycardic at 170 beats per minute (Category II). Intravenous therapy was begun, and a preeclampsia laboratory panel was obtained. The lab results were suggestive of HELLP syndrome. An abdominal ultrasound was performed; findings included a large subcapsular liver hematoma with right upper quadrant and perisplenic fluid. The obstetrician consulted with the trauma surgeon, and the decision was made to do an emergency cesarean and exploratory laparotomy. The patient gave birth to a viable newborn. The trauma surgeon proceeded with a laparotomy and found a large, right-lobe, subcapsular hematoma; disruption of Glisson’s capsule; and active hemorrhage from the liver. The liver was sutured; Class 3 hemorrhagic shock and disseminated intravascular coagulation were noted. The patient required multiple blood transfusions and interventions to resolve blood loss. She required two subsequent trips to the operating room and was intubated for 5 days. She recovered and was discharged home after 12 days in the hospital. Epigastric pain occurring in pregnant and postpartum patients requires diligent assessment. Epigastric pain is the most common symptom of HELLP syndrome, and it can precede abnormal bloodwork changes by several hours. Because of the life-threatening potential of HELLP syndrome, epigastric pain should always be considered a serious symptom.

The Laborhood

The purpose of the laborhood was to create a process for daily huddles that included all necessary team members and was practical and efficient to review daily patient care. Create a multidisciplinary huddle that occurs twice daily and is attended by the labor and delivery unit charge nurse, mother–baby charge nurse, NICU charge nurse, perinatal risk nurse, respiratory therapist, neonatologist, anesthesiologist, and the obstetrician covering the labor and delivery unit. The huddle should start on time and its duration is 5 min. The huddle was created by an interdisciplinary team. The huddle was initially done at 8 a.m. and 8 p.m. After a trial of the huddles, changes were made. The huddle time was changed to 7:45 a.m. and 7:45 p.m. after input from the providers. The form used to run the huddle has been changed numerous times after receiving input from huddle members. A high-risk patient—a woman with cardiac disease (who did not disclose this during any prenatal visits)—arrived when she was in labor. She was discussed at the huddle and a plan of care was formed, including telemetry monitoring. Patients with HELLP syndrome (hemolysis–elevated liver enzymes–low platelets counts) can be discussed and a plan for anesthesia developed. The huddle form is now placed in a location where all can see, so staff can look at the huddle and see an overview of the unit. If the anesthesiologist is in the operating room and cannot attend the huddle, he/she will come to the labor and delivery unit when done and review the form with the charge nurse. The staffs’ perception of delivering safe care is measured through our annual culture of safety survey where all criteria increased after laborhood implementation. Nurses have input into the care of their patients. They must have a way to voice their concerns to a multidisciplinary team. This multidisciplinary huddle is a good forum to discuss patients. The nurse can attend the huddle, or the nurse can discuss concerns with the charge nurse, who will bring the information to the huddle. Communication is key to improved outcomes. This huddle is a good form of communication for the care of obstetric patients.

A Regression Model for Prediction of Cesarean-Associated Blood Transfusion.

To develop a model to predict cesarean-associated red blood cell transfusion. Secondary analysis of all cesarean deliveries in the Maternal-Fetal Medicine Units Network Cesarean Registry. Using a split-sample technique, the derivation group was used to identify associated factors and build predictive models, and the validation group was used to estimate classification errors and determine test characteristics. Using factors available at the time of cesarean, we developed a multivariable logistic regression prediction model. A total of 59,468 women were split evenly and randomly into the derivation and validation groups. The overall rate of transfusion was 2.7%. The area under the receiver operating characteristic curve for the derivation and validation groups were 0.82 (95% confidence interval [CI]: 0.80-0.84) and 0.84 (95% CI: 0.82-0.85), respectively (p = 0.16). The strongest predictors of transfusion were placenta previa (odds ratio [OR]: 7.06, 95% CI: 5.19-9.61) and eclampsia/Hemolysis Elevated Liver Enzymes Low Platelets syndrome (OR: 5.67, 95% CI: 3.77-8.51). In the validation group, the model had a sensitivity, specificity, positive, and negative predictive values of 55.8, 91.5, 16.2, and 98.6%, respectively. Overall, 90.5% of patients were correctly classified. A regression model incorporating variables available at the time of cesarean accurately predicts the need for intra- or postoperative transfusion.

Peripheral Anti-Angiogenic Imbalance during Pregnancy Impairs Myogenic Tone and Increases Cerebral Edema in a Rodent Model of HELLP Syndrome.

Using an animal model of hemolysis elevated liver enzymes low platelets (HELLP) that has systemic inflammation and neuroinflammation we wanted to determine if blood brain barrier (BBB) permeability, cerebral edema, vascular tone, and occludin expression were altered in pregnant rats. Anti-angiogenic proteins sFlt-1 and sEng (4.7 and 7 µg/kg/day, respectively) were chronically infused into normal pregnant (NP) rats beginning on gestational day 12 via a mini-osmotic pump. On gestational day 19, blood pressure was measured via a carotid catheter and brains were collected. BBB permeability was assessed in select brain regions from rats infused with 0.5 mg/mL Texas Red Dextran and phenylephrine. Occludin, sFlt-1, and sEng were analyzed via western blot or ELISA. Infusion of sFlt-1 and sEng into NP rats increased hemolysis and liver enzymes, and decreased platelets and led to hypertension. HELLP rats had significant impairment in the myogenic response and increased BBB permeability in the posterior cortex and brainstem. Brain water content in the posterior cortex was increased and sEng protein expression in the brainstem was significantly increased in HELLP rats. The results from this study suggest that a peripheral anti-angiogenic imbalance during pregnancy is associated with decreased myogenic tone, vasogenic edema, and an increase in BBB permeability, but not anti-angiogenic imbalance in the brain.

Beyond HELLP: Peripartum Catastrophic Thromboembolism due to Hereditary Diffuse Gastric Cancer

Peripartum thrombocytopenia and thrombotic events are usually attributable to diseases like Hemolysis Elevated Liver Enzymes Low Platelets (HELLP) and thrombotic thrombocytopenic purpura (TTP). Malignancy is a rare cause and gastric cancer even more unusual. We report the case of a 28-year-old female with undiagnosed hereditary diffuse gastric cancer (HDGC) in the peripartum period initially presenting with nausea and blurry vision at 35 weeks’ gestation. Following cesarean section 1 week later, she developed thrombocytopenia and elevated blood pressure; HELLP was diagnosed. Development of acute kidney injury, decreasing platelet count and anemia lead to consideration of TTP. Despite plasmapheresis she had no improvement, developed respiratory failure and had acute large vessel arterial and venous thrombosis with multiple cerebral, renal, splenic and lower extremity arterial infarctions. Deep venous thrombosis of lower limbs was also seen. She was placed on corticosteroids and anticoagulation. Following extensive workup, vegetations on mitral valve were seen on echocardiography and she was started on antibiotics for endocarditis. She deteriorated into refractory shock, multiple organ failure and died on postpartum day 8. Autopsy done revealed diffuse submucosal gastric adenocarcinoma (linitus plastica). Metastases were present on small bowel, fallopian tubes, ovary and the placenta. Mitral valve had marantic vegetations. Tumor cells showed CDH1 gene mutation. Such a diagnosis in pregnancy is very challenging due to overlapping symptoms leading to misdiagnosis. Here, thromboembolism was malignancy-related and rapid spread probably hormone-associated. The purpose of this report is to highlight the need to warrant investigation for cancer, among workup for other common conditions, for atypical thromboembolism in pregnancy. J Clin Gynecol Obstet. 2018;7(3-4):81-83 doi: https://doi.org/10.14740/jcgo512w

Attenuation of oxidative stress and hypertension in an animal model of HELLP syndrome

HELLP (hemolysis elevated liver enzyme low platelet) syndrome is associated with hypertension, inflammation, oxidative stress and endothelial activation. The objective of this study was to determine if oxygen scavenging or endothelin A receptor antagonism improved hypertension and oxidative stress. sFlt-1 and sEndoglin were infused via mini-osmotic pump into normal pregnant rats (NP) on gestational day 12 to create HELLP syndrome. On gestational day 18 arterial catheters were inserted and on gestational day 19 mean arterial pressure was analyzed in rats; serum, urine and tissues were collected for molecular analysis. HELLP rats had significantly increased MAP compared to control normal pregnant rats (P < 0.0005). Endothelin A receptor antagonism via ABT-627 and Tempol, superoxide dismutase mimetic, were administered to a subset of normal pregnant and HELLP rats beginning on gestational day 13 and attenuated mean arterial pressure in HELLP rats (P < 0.05; P < 0.005). There were no statistically significant differences in mean arterial pressure between NP+ETA Receptor or NP+Tempol treated rats and NP rats (P = 0.22). Endothelin A receptor blockade significantly decreased HELLP induced isoprostane excretion (P < 0.0005), placental and hepatic reactive oxygen species (P < 0.05; P < 0.0005) and increased placental total antioxidant capacity (P < 0.005) compared to untreated HELLP rats. Similar results in isoprostane (P < 0.005), hepatic reactive oxygen species (P < 0.05) and placental total antioxidant capacity (P < 0.05) were seen in HELLP rats treated with Tempol or Endothelin A receptor antagonist vs. untreated HELLP rats. These data demonstrated a role for oxidative stress in contributing to the hypertension, placental and liver damage that is seen in HELLP syndrome.

Maternal and Perinatal Outcome of Hypertensive Disorders of Pregnancy In a Tertiary Hospital of Kathmandu

Background: Hypertensive disorders of pregnancy are considered to be a major worldwide health problem causing an increased risk of perinatal and maternal morbidity and mortality. Hypertensive disorders are the most common medical disorders encountered during pregnancy.Objective: This study aimed to assess the maternal and perinatal outcome of hypertensive disorders in pregnancy.Methods: A hospital based prospective study was conducted in Obstetrics ward of Kathmandu Medical College Teaching Hospital. Total one hundred pregnant women admitted in antenatal ward with the diagnosis of hypertensive disorders in pregnancy were included in the study. A structured questionnaire was designed and data collection was done through one- to- one interview technique during the period of December 2015 to January 2017. The collected data were analyzed by using Statistical Package for Social Science version 20.Results: Among 100 hypertensive disorders; 80% respondents had gestational hypertension, 16% had preeclampsia and two percent had eclampsia. Of total, 52% respondents had normal vaginal delivery followed by 46% caesarian section. One respondent had ante-partum hemorrhage, 11% had post-partum hemorrhage and one had developed hemolysis, elevated liver enzymes low platelets counts syndrome. Fortunately, no maternal mortality was occurred. Regarding perinatal outcome, 17% babies were born preterm, 13% babies had low birth weight and seven percent babies had birth asphyxia. Total fi ve were stillbirths and one percent had early neonatal death.Conclusion: Maternal outcome was good except few morbidities but perinatal outcome was found to be adverse. Proper management of hypertensive disorders is required to reduce perinatal morbidities and mortalities.Journal of Kathmandu Medical College,Vol. 6, No. 4, Issue 22, Oct.-Dec., 2017, Page: 145-149