Hemolysis, Elevated Liver Enzymes, And Low Platelets Syndrome Research Articles

Correlation between maternal thyroid function tests and endothelin in preeclampsia-eclampsia

Objective: To investigate the relationship between results of maternal thyroid function tests and endothelin levels in preeclamptic or eclamptic women. Methods: Thyroid hormones, TSH, and endothelin were measured in plasma or serum from 37 proteinuric, preeclamptic or eclamptic women and 20 normotensive, nonlaboring, pregnant women. Subjects were subdivided into four groups according to hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome and birth weights of infants with respect to gestational age. Results: A significant decrease in concentrations of total thyroxine (T4) (13.76 ± 1.84 μg/dL versus 10.00 ± 1.48 μg/dL, P < .05), total triiodothyronine (T3) (180.58 ± 30.84 ng/dL versus 141.16 ± 27.31 ng/dL, P < .01), free T4 (1.45 ± 0.27 ng/dL versus 1.10 ± 0.21 ng/dL, P < .01) and free T3 (3.32 ± 0.56 pg/mL versus 2.41 ± 0.60 pg/mL, P < .01) and a significant increase in TSH (1.55 ± 0.89 μIU/mL versus 2.96 ± 1.07 μIU/mL, P < .05) and endothelin (2.31 ± 0.61 pg/mL versus 6.11 ± 1.41 pg/mL, P < .001) levels were observed in the preeclamptic-eclamptic group compared with the normotensive group. Also, women without HELLP syndrome and without small-for-gestational-age infants had elevated levels of thyroid hormones and decreased levels of TSH and endothelin compared with other subgroups, but stastical significance was reached only in total T4 ( P < .05), TSH ( P < .05), and endothelin ( P < .001). Birth weights of infants born to preeclamptic or eclamptic women correlated positively with total T4 ( P < .01) and total T3 ( P < .01) and negatively with TSH ( P < .01) levels. A more significant negative correlation was found in preeclamptic-eclamptics ( P < .001) between birth weight and endothelin levels than in control subjects ( P < .05). Endothelin levels in preeclamptic or eclamptic women correlated negatively with total T4 ( P < .01), total T3 ( P < .05), free T4 ( P < .05), and free T3 ( P < .05) and positively with TSH levels ( P < .01) compared with control subjects. Conclusion: Moderate decreases in thyroid hormones with concomitant increases in TSH levels in maternal serum correlated with severity of preeclampsia or eclampsia and high levels of endothelin. Changes in results of thyroid function tests induced by preeclampsia or eclampsia might be consequences of the dysfunction in the hypothalamic-pituitary-thyroid axis, secondary to the disease itself.

Correlation Between Maternal Thyroid Function Tests and Endothelin in Preeclampsia-Eclampsia

In Brief Objective To investigate the relationship between results of maternal thyroid function tests and endothelin levels in preeclamptic or eclamptic women. Methods Thyroid hormones, TSH, and endothelin were measured in plasma or serum from 37 proteinuric, preeclamptic or eclamptic women and 20 normotensive, nonlaboring, pregnant women. Subjects were subdivided into four groups according to hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome and birth weights of infants with respect to gestational age. Results A significant decrease in concentrations of total thyroxine (T4) (13.76 ± 1.84 μg/dL versus 10.00 ± 1.48 μg/dL, P < .05), total triiodothyronine (T3) (180.58 ± 30.84 ng/dL versus 141.16 ± 27.31 ng/dL, P < .01), free T4 (1.45 ± 0.27 ng/dL versus 1.10 ± 0.21 ng/dL, P < .01) and free T3 (3.32 ± 0.56 pg/mL versus 2.41 ± 0.60 pg/mL, P < .01) and a significant increase in TSH (1.55 ± 0.89 μIU/mL versus 2.96 ± 1.07 μIU/mL, P < .05) and endothelin (2.31 ± 0.61 pg/mL versus 6.11 ± 1.41 pg/mL, P < .001) levels were observed in the preeclamptic-eclamptic group compared with the normotensive group. Also, women without HELLP syndrome and without small-for-gestational-age infants had elevated levels of thyroid hormones and decreased levels of TSH and endothelin compared with other subgroups, but stastical significance was reached only in total T4 (P < .05), TSH (P < .05), and endothelin (P < .001). Birth weights of infants born to preeclamptic or eclamptic women correlated positively with total T4 (P < .01) and total T3 (P < .01) and negatively with TSH (P < .01) levels. A more significant negative correlation was found in preeclamptic-eclamptics (P < .001) between birth weight and endothelin levels than in control subjects (P < .05). Endothelin levels in preeclamptic or eclamptic women correlated negatively with total T4 (P < .01), total T3 (P < .05), free T4 (P < .05), and free T3 (P < .05) and positively with TSH levels (P < .01) compared with control subjects. Conclusion Moderate decreases in thyroid hormones with concomitant increases in TSH levels in maternal serum correlated with severity of preeclampsia or eclampsia and high levels of endothelin. Changes in results of thyroid function tests induced by preeclampsia or eclampsia might be consequences of the dysfunction in the hypothalamic-pituitary-thyroid axis, secondary to the disease itself. Moderate decreases in thyroid hormone levels with concomitant increases in TSH levels correlate with the severity of preeclampsia-eclampsia and high plasma levels of endothelin.

HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome: The benefit of corticosteroids

Objective: The purpose of this study was to determine the effect of corticosteroids on platelet counts and liver functions in women with pregnancies complicated by the HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome. Study Design: The study group consisted of 93 patients between 24 and 34 weeks’ gestation diagnosed with HELLP syndrome. All were given intramuscular injections of either betamethasone or dexamethasone. The 3 most common regimens used were 12 mg of intramuscular betamethasone administered twice 12 hours apart, 12 mg of intramuscular betamethasone administered twice 24 hours apart, and 6 mg of intramuscular dexamethasone administered 4 times 6 hours apart. Precorticosteroid and postcorticosteroid platelet counts and liver function test results were compared. The differences in improvement in hematologic abnormalities among the 3 corticosteroid regimens were also analyzed. Results: The hematologic abnormalities seen in the 93 patients with HELLP syndrome improved after the administration of corticosteroids. The platelet count increased by 23.3 × 10 3/μL ( P < .001). A statistically significant decrease was seen in liver enzyme levels. The alanine aminotransferase decreased by 31.6 IU/L, the aspartate aminotransferase decreased by 52.1 IU/L, and the alkaline phosphatase decreased by 7.6 IU/L. Of the 3 regimens used, 2 doses of 12 mg of intramuscular betamethasone given every 12 hours improved the liver function to the greatest degree. Conclusions: This study demonstrates that corticosteroids produce a significant improvement in the hematologic abnormalities associated with HELLP syndrome. Two doses of betamethasone given 12 hours apart was the most effective corticosteroid regimen. (Am J Obstet Gynecol 1999;181:304-9.)

31P magnetic resonance spectroscopy of the liver in HELLP syndrome.

Using magnetic resonance spectroscopy (MRS) to measure phosphorus-containing metabolites in the liver, this study aimed to investigate non-invasively whether or not women with haemolysis, elevated liver enzymes and low platelets (HELLP) have detectable abnormalities of hepatic energetics. John Radcliffe Hospital, Oxford. Prospective study. After giving informed consent, patients with HELLP syndrome (n = 7) and controls with severe pre-eclampsia (n = 3), were studied by 31P MRS of the liver as soon as possible after delivery (range 2-4 days) and compared with normal nonpregnant controls (n = 6). Haematological and biochemical tests were performed serially and on the day of the MRS in all pregnant patients. The severity of HELLP varied as follows: peak aspartate aminotransferase (range 129-2574), peak gamma glutamyl transferase (range 28-96), peak lactate dehydrogenase (range 305-2820), nadir platelets (range 25-114), peak international normalised ratio for prothrombin time (before fresh frozen plasma) (range 0.9-1.9). One pregnancy was terminated but all others resulted in live births and all mothers made uneventful, rapid recoveries. MRS-determined relative hepatic concentrations of phosphorus-containing metabolites and absolute concentrations of adenosine triphosphate did not differ significantly between groups. One patient with the most clinically severe HELLP syndrome (by laboratory criteria) exhibited magnetic resonance spectra which showed a relative increase in phosphomonoester and an absolute decrease in hepatic adenosine triphosphate (to 62% of control). Enthusiasm for the conservative management of HELLP syndrome that develops remote from term has been tempered by the inability to identify patients at risk for progression to hepatic necrosis. We found that most patients with HELLP syndrome had normal liver metabolism as assessed by MRS. However, clinically severe HELLP syndrome can be associated with disturbed hepatic metabolism consistent with that seen in hepatic ischaemia and/or granulocytic infiltration of the liver.

A review of HELLP syndrome.

HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome is a variant of severe preeclampsia which is associated with substantial maternal and perinatal morbidity and mortality. As with preeclampsia, the etiology and pathogenesis of HELLP syndrome is not completely understood. An increase in vascular thrombosis and activation of the coagulation system may be important in the clinical presentation of this disorder. Laboratory criteria for the diagnosis of HELLP syndrome have been classically described but lack uniformity among different institutions. Aggressive management of HELLP syndrome with expeditious delivery appears to yield the lowest perinatal mortality rates. Conservative or expectant management has been associated with higher stillbirth rates with antenatal corticosteroids not causing resolution of the laboratory abnormalities. Resolution of laboratory abnormalities in HELLP syndrome runs a protracted course over several days after delivery. Despite nearly two decades since HELLP syndrome has been defined as a clinical entity, treatment for the disorder still remains delivery of the patient.

Neonatal outcome in severe preeclampsia at 24 to 36 weeks' gestation: Does the HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome matter?

Objective: Our purpose was to compare neonatal outcome after preterm delivery of infants whose gestation was complicated by the HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome, partial HELLP syndrome, or severe preeclampsia. Study Design: We reviewed the maternal and neonatal charts from 269 consecutive pregnancies complicated by the HELLP syndrome or severe preeclampsia managed at our perinatal center. The HELLP syndrome was defined by previously published laboratory criteria. Viable pregnancies were divided into 3 groups: HELLP syndrome, partial HELLP syndrome (at least 1, but not all 3, features of the HELLP syndrome), and severe preeclampsia (no features of the HELLP syndrome). Results were compared by means of χ 2 analysis and Student t test where appropriate. Logistic regression was used to evaluate outcome variables at different gestational ages. Results: There were no significant differences in complications among the 3 groups at each gestational age. There was, as expected, a significant decrease in morbidity and mortality rates with advanced gestational age. Conclusions: In severe preeclampsia, neonatal morbidity and death are related to gestational age rather than to the presence or absence of the HELLP syndrome. Whether expectant management is safe for women with the HELLP syndrome requires further study. (Am J Obstet Gynecol 1999;180:221-5.)

Imaging of subcapsular hepatic and renal hematomas in pregnancy complicated by preeclampsia and the HELLP syndrome

The purpose of this report is to provide an illustrative case of spontaneous hepatic and renal hematomas that occurred during a pregnancy complicated by preeclampsia and the HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome. The sonographic and computed tomographic findings included intrahepatic, subcapsular hepatic, and extracapsular perihepatic hematomas in addition to a large subcapsular renal hematoma. Since hepatic and renal hematomas that occur in association with preeclampsia and the HELLP syndrome are rare but potentially life-threatening complications, prompt laboratory and radiologic evaluations are essential and may reduce the associated morbidity and mortality.

Imaging of subcapsular hepatic and renal hematomas in pregnancy complicated by preeclampsia and the HELLP syndrome

The purpose of this report is to provide an illustrative case of spontaneous hepatic and renal hematomas that occurred during a pregnancy complicated by preeclampsia and the HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome. The sonographic and computed tomographic findings included intrahepatic, subcapsular hepatic, and extracapsular perihepatic hematomas in addition to a large subcapsular renal hematoma. Since hepatic and renal hematomas that occur in association with preeclampsia and the HELLP syndrome are rare but potentially life-threatening complications, prompt laboratory and radiologic evaluations are essential and may reduce the associated morbidity and mortality. © 1999 John Wiley & Sons, Inc. J Clin Ultrasound 27:35–40, 1999.

Severe folate deficiency masquerading as the syndrome of hemolysis, elevated liver enzymes, and low platelets

Although folate deficiency is common in pregnancy, progression to megaloblastosis is not. Hemolytic anemia, thrombocytopenia, and coagulopathy due to folate deficiency may mimic the syndrome of hemolysis, elevated liver enzymes, and low platelets (HELLP). Two women presented in the second trimester with abdominal pain and severe thrombocytopenia. These symptoms were misinterpreted in the first woman as the HELLP syndrome, leading to an emergency cesarean delivery. Subsequent investigation revealed folate deficiency; treatment resulted in rapid normalization of all abnormalities. In the second woman, folate deficiency was diagnosed antenatally. Treatment allowed continuation of the pregnancy to term. The serious complications of folate deficiency make a strong case for supplementation in pregnancy. Careful scrutiny of clinical and laboratory findings may help discriminate the HELLP syndrome from its mimics, avoiding preterm delivery.

Neonatal morbidity and mortality associated with maternal haemolysis elevated liver enzymes and low platelets syndrome.

To compare the impact of maternal haemolysis, elevated liver enzymes and low platelets (HELLP) syndrome, uncomplicated hypertension in pregnancy (HIP), and no hypertension (controls) on neonatal morbidity and mortality, 108 infants were matched with respect to gestational age, date of birth, and gender. The HELLP group infants had more grade 3 and 4 respiratory distress syndromes (36%) than the HIP group (19%) or controls (11%). Cardiovascular instability (arterial hypotension, volume resuscitation) was significantly more common in HELLP neonates (20% and 31%) than in HIP infants (9% and 6%) or controls (3% and 9%). Both, HELLP and HIP infants showed a higher incidence of growth retardation than the controls. After 32 weeks of gestation the incidence of severe neonatal morbidity was not different. : Before 32 weeks of gestation both respiratory and cardiovascular morbidity and intra-uterine growth retardation associated with HIP is further aggravated by a maternal HELLP syndrome.

Preeclampsia and liver infarction in early pregnancy associated with the antiphospholipid syndrome

Usually, preeclampsia is a disease of the second half of pregnancy (i.e., beyond 20 weeks' gestation). Early-onset preeclampsia has been reported in association with the antiphospholipid syndrome, however, the cases reported have been at 25-30 weeks' gestation. Three pregnant women presented with clinical and laboratory features of severe preeclampsia and the syndrome of hemolysis, elevated liver enzymes, and low platelets (HELLP) before 20 weeks' gestation. On evaluation, they were found to have antiphospholipid antibodies (anticardiolipin and/or lupus anticoagulant). Two of the patients had abdominal computed tomography scans that showed a low-density area along the hepatic periphery, compatible with hepatic infarction. Spontaneous resolution of all clinical and laboratory manifestations of preeclampsia and HELLP syndrome was observed after fetal death and pregnancy termination. Preeclampsia and HELLP syndrome can present before 20 weeks' gestation in association with the antiphospholipid syndrome and may be associated with hepatic infarction.

Postoperative incision complications after cesarean section in patients with antepartum syndrome of hemolysis, elevated liver enzymes, and low platelets (HELLP): Does delayed primary closure make a difference?

OBJECTIVE: Our purpose was to evaluate wound complications between patients with antepartum HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome with primary closure versus delayed closure and Pfannenstiel versus midline skin incisions. STUDY DESIGN: Medical records of patients with antepartum HELLP syndrome undergoing cesarean section were examined for type and timing of skin closure: Pfannenstiel versus midline skin incision and primary versus delayed closure. The immediate (before hospital discharge) and late (2-week postoperative check) wound complications were analyzed with respect to timing of wound closure and type of skin incision. RESULTS: A total of 104 patients were identified; 75 had a primary skin closure and 29 had a delayed closure 48 to 72 hours postoperatively. Immediate wound complications (wound infection, hematoma), occurred in 18 (26%) patients who had primary closure versus 8 (24%) who had a delayed closure, odds ratio 1.13 (95% confidence interval 0.39 to 3.27). A late wound breakdown was seen in only 1 patient with primary closure but in none with delayed closure. There were no fascial wound dehiscences. No statistical difference in wound complication was found between midline (primary, delayed) and Pfannenstiel (primary, delayed) incisions, odds ratio 0.65 (95% confidence interval 0.23 to 1.88). CONCLUSION: In women with antepartum HELLP syndrome delivered by cesarean section the frequency of wound complications is not influenced by type of skin incision or time of skin closure (primary or delayed). (Am J Obstet Gynecol 1996;175:893-6.)

Dietary consumption and plasma concentrations of vitamin E in pregnancies complicated by preeclampsia

OBJECTIVE: Vitamin E, a potent antioxidant, has been suggested to play a role in preventing preeclampsia. Our aim was to determine whether consumption and plasma levels of vitamin E are lower in preeclamptic than in normal women. STUDY DESIGN: A case-control study design was used. We identified 48 women with preeclampsia (late-pregnancy hypertension, proteinuria, and hyperuricemia). Ninety normal women served as the control group. Vitamin E consumption was estimated by use of a previously validated dietary recall questionnaire administered by a single trained research nurse to 42 of the preeclamptic women and all 90 of the control women. Blood was drawn from all women and stored until assayed at -70° C. Plasma vitamin E concentrations were determined by use of high-pressure liquid chromatography. RESULTS: The mean dietary vitamin E consumption was similar for both the preeclamptic and control groups (11.74 ± 9.39 vs 11.34 ± 7.51 mg/24 hr, p = 0.73). When the analysis also included estimations of vitamin E supplements, the total consumption was found to be higher in those who had preeclampsia than in controls (37.20 ± 20.54 vs 22.3 ± 27.24 mg/24 hr, p = 0.003). The mean plasma vitamin E concentration was significantly higher in preeclamptic than in control patients (1.41 ± 0.39 vs 1.15 ± 0.32 mg/dl, p < 0.001). Among the preeclamptic patients, those with severe disease associated with HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome (n = 11) had the highest plasma vitamin E concentrations. CONCLUSIONS: We found no evidence that low vitamin E consumption is related to the development of preeclampsia. Higher plasma vitamin E concentrations in preeclamptic patients are speculated to represent a response to oxidative stress. (Am J Obstet Gynecol 1996;175:1024-8.)

Clinical utility of strict diagnostic criteria for the HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome

OBJECTIVE: Our purpose was to compare the maternal outcome of pregnancies complicated by HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome, partial HELLP syndrome, or severe preeclampsia. STUDY DESIGN: In a retrospective cohort study we reviewed the maternal charts of 316 women with HELLP syndrome or severe preeclampsia managed at our perinatal center between July 1, 1992, and June 30, 1995. HELLP syndrome was strictly defined by previously published laboratory criteria. Women were divided into three groups: HELLP syndrome ( n = 67), partial HELLP syndrome (one or two but not all three features of HELLP syndrome, n = 71), and severe preeclampsia (no features of HELLP syndrome, n = 178). Results were compared by χ 2 analysis and one-way analysis of variance. RESULTS: Mean gestational ages at delivery in the HELLP, partial HELLP, and severe preeclampsia groups were, respectively, 31.7, 32.7, and 34.5 weeks ( p < 0.001 between HELLP and severe preeclampsia). There was one maternal death from intracerebral hemorrhage in the HELLP group. In women with HELLP syndrome there was a higher incidence of cesarean section ( p < 0.05), disseminated intravascular coagulation ( p < 0.001), and need for transfusion ( p < 0.001) than in the other two groups. CONCLUSIONS: Higher incidences of maternal complications in women with HELLP syndrome stress the importance of strict criteria for the definition of HELLP syndrome. Women with partial HELLP syndrome should be studied and managed separately from women with complete HELLP syndrome. (Am J Obstet Gynecol 1996;175:460-4.)

The maternal and neonatal outcome of triplet gestations

OBJECTIVE: Our purpose was to determine the contemporary maternal and neonatal outcome of triplet gestations. STUDY DESIGN: A retrospective review of 57 triplet deliveries between April 1, 1989, and July 31, 1994, was performed. RESULTS: The mean gestational age at delivery was 33.0 ± 2.7 weeks, and the mean birth weight was 1820 ± 513 gm. The most common maternal complications were preterm labor (86.0%), anemia (58.1%), preeclampsia (33.3%), preterm premature rupture of the membranes (17.5%), postpartum hemorrhage (12.3%), and HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome (10.5%). Neonatal complications included hyaline membrane disease (29.6%), transient tachypnea of the newborn (20.1%), intraventricular hemorrhage (7.7%), and major congenital anomalies (7.1%). The perinatal mortality was 41 per 1000. Birth order had no significant effect on the incidence of neonatal complications. CONCLUSION: Perinatal mortality rates have improved in recent years but remain higher than for singleton gestations. Despite increasing experience with triplets, the rate of maternal complications is high. (A M J O BSTET G YNECOL 1996;174:1551-6.)

The intrapartum platelet count in patients with HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome: Is it predictive of later hemorrhagic complications?

The intrapartum platelet count in patients with HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome: Is it predictive of later hemorrhagic complications?

Postpartum thrombotic thrombocytopenic purpura complicated by Budd-Chiari syndrome

Thrombotic thrombocytopenic purpura is an infrequent but devastating complication of pregnancy, often difficult to differentiate from severe preeclampsia and the syndrome of hemolysis, elevated liver enzymes, and low platelets (HELLP). To our knowledge, the combination of thrombotic thrombocytopenic purpura and hepatic vein thrombosis has not been reported previously in pregnancy. A 33-year-old woman, a multigravida, was delivered at 36 weeks' gestation because of pregnancy-induced hypertension and HELLP syndrome. Postpartum, the patient became obtunded, disoriented, and anuric. Her laboratory values revealed a Coombs-negative, microangiopathic hemolytic anemia, modestly abnormal coagulation studies, and thrombocytopenia. She also had elevated liver enzymes, lactate dehydrogenase, and creatinine. The largest plasma von Willebrand factor multimeric forms were relatively decreased in her ethylenediaminetetra-acetic acid-platelet-poor plasma. A diagnosis of thrombotic thrombocytopenic purpura was made. The patient received plasma exchange, hemodialysis, blood transfusion, and glucocorticoids. She responded to therapy, but was later noted to have increasing hepatosplenomegaly, rising levels of bilirubin, and elevated alkaline phosphatase. A Doppler study and magnetic resonance imaging demonstrated the absence of flow in the middle and left hepatic veins, secondary to thrombosis (Budd-Chiari syndrome). She was maintained on warfarin therapy and was discharged on postpartum day 50. The early recognition of thrombotic thrombocytopenic purpura is crucial for the initiation of appropriate treatment as soon as possible. The avoidance of platelet transfusion and early plasma-exchange therapy may be lifesaving.

Postpartum plasma exchange for atypical preeclampsia-eclampsia as HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome

OBJECTIVE: Our purpose was to investigate the postpartum use of plasma exchange in patients considered to have atypical preeclampsia-eclampsia manifested as persistent HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome with or without evidence of other organ injury. STUDY DESIGN: During a 10-year period, 18 patients with HELLP syndrome were treated post partum with single or multiple plasma exchange with fresh-frozen plasma. Each patient was entered into the clinical trial either because of persistent evidence of atypical preeclampsia-eclampsia as HELLP syndrome > 72 hours after delivery (group 1) or with evidence of worsening HELLP syndrome at any time post partum in association with single- or multiple-organ injury (group 2). All procedures were performed with the IBM 2997 Cell Separator (IBM, Cobe Laboratories, Inc., Lakewood, Colo.) system. Maternal and perinatal outcomes were the main outcomes studied. RESULTS: In the absence of other disease conditions, the 9 patients in group 1 with persistent postpartum HELLP syndrome complicated only by severe clinical expressions of preeclampsia-eclampsia responded rapidly to one or two plasma exchange procedures with few complications and no maternal deaths. In contrast in the 9 patients of group 2 with HELLP syndrome presentations complicated by other organ disease, the response to plasma exchange was variable and there were two deaths in this group. CONCLUSION: The current series of patients details the successful postpartum application of plasma exchange therapy for unremitting HELLP syndrome but reveals that a uniformly positive response to this therapy will not always be observed when there is additional single or multiple organ injury. 1995;172:1107-27.)

The recurrence risk of the syndrome of hemolysis, elevated liver enzymes, and low platelets (HELLP) in subsequent gestations

Objective: Although it is an important clinical issue, accurate prediction of recurrence risk for the syndrome of hemolysis, elevated liver enzymes, and low platelets (HELLP) has been problematic because of limited patient experience. This study was undertaken to determine the likelihood that this form of severe preeclarnpsia-eclampsia or any other hypertensive disorder would occur in a subsequent pregnancy.Study Design: An extensive retrospective analysis of medical records and patient follow-up regarding subsequent pregnancy outcome were undertaken for the 481 patients with HELLP syndrome managed at this tertiary medical center between Jan. 1, 1980, and Oct. 30, 1991. The Mississippi three-class system was used to define severity of disease on the basis of the lowest observed perinatal platelet count (class 1 ≤ 50,000/μl, class 2>50,000/μl to ≤ 100,000//μl, and class 3>100,000//μl to ≤ 150,000/μl).Results: Subsequent gestations (n = 195) occurred in 122 of 481 patients. Evaluable data were available for analysis in 161 of 195 possible pregnancies. Seventy-eight (48%) pregnancies were complicated by some type of hypertensive disorder, 44 (27%) of which had class 1, 2, or 3 HELLP syndrome. Non-HELLP preeclampsia-eclampsia was detected in 25 subsequent gestations (15%). Thus the total frequency of preeclampsia was 69 in 161 (43%). If the data for class 3 HELLP are completely excluded from the analysis, 81 subsequent evaluable and viable gestations were identified, 19 pregnancies with preeclampsia-eclampsia (23%) and 15 patients with HELLP syndrome (19%), for a total recurrence rate of 42%. Subsequent HELLP gestations were frequently delivered abdominally (64%) on average 2 weeks later than the index pregnancy (32.6 ± 5.0 weeks versus 34.7 ± 5.3 weeks). Delivery at < 32 weeks conferred a high risk (61 %) for a similar preterm delivery in a subsequent gestation.Conclusion: The risk of recurrence of the HELLP syndrome in our population is 19% to 27%. When data from all pregnancies with all farms of preeclarnpsia are considered, the risk of recurrence for any type of preeclampsia-eclampsia is 42% to 43%. A previous preterm delivery is a very high risk factor for recurrence of prematurity with preeclampsia-eclampsia.

Antepartum corticosteroids: Disease stabilization in patients with the syndrome of hemolysis, elevated liver enzymes, and low platelets (HELLP)

Our purpose was to evaluate the impact of antepartum administration of corticosteroids on the course of the syndrome of hemolysis, elevated liver enzymes, and low platelets (HELLP) in pregnancies at 24 to 37 weeks' gestation. This prospective, randomized study was undertaken in 25 antepartum patients with atypical severe preeclampsia expressed as HELLP syndrome. Twelve pregnant women were randomized to receive double-dose dexamethasone (10 mg intravenously every 12 hours) until delivery, and 13 women were randomized to the control arm. Management and delivery decisions for all patients were based on a common protocol, with delivery undertaken for a deteriorating maternal or fetal condition. In the corticosteroid-treated group the maternal platelet count significantly increased (p = 0.006), whereas lactic dehydrogenase and alanine aminotransferase significantly decreased over time (p = 0.03 and p = 0.005) in comparison to the 13 women who did not receive corticosteroids. Maternal urinary output after entry into the study was significantly increased within hours after steroid administration versus the control group (p = 0.0006). The study entry-to-delivery interval (41 +/- 15 hours) was significantly longer in the group of steroid-treated women (p = 0.0068). Stabilization and significant improvement in the laboratory and clinical parameters associated with HELLP syndrome occurred in women who received high-dose antenatal corticosteroids, as measured by maternal platelet count, urinary output, lactic dehydrogenase, alanine aminotransferase, and postponement of delivery. We believe the findings of this investigation permit us to speculate that this therapeutic approach could enhance maternal-fetal care by postponing delivery of some previable fetuses, reduce the need for maternal transfusion of blood products, reduce neonatal morbidity or mortality from multiple systemic effects, and facilitate a safer transfer of the ill mother to a tertiary care site for optimal peripartal care.