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

Evaluation of maternal liver elasticity by acoustic radiation force impulse elastosonography in hypertensive disorders of pregnancy: a preliminary descriptive study

Purpose: To compare maternal liver elasticity scores by Acoustic Radiation Force Impulse (ARFI) elastosonography in healthy and preeclamptic pregnancies and its association with the severity of the disease.Materials and methods: Forty-two healthy, 33 mild, 33 severe preeclamptic and 28 pregnant women with Hemolysis, Elevated Liver enzymes and Low Platelets (HELLP) syndrome were included into the study. Maternal liver elasticity was measured by ARFI elastosonography at the first day of puerperium. The maternal and neonatal outcomes of the patients were retrieved from the medical records.Results: The ARFI-Mean liver elastosonography scores of controls and mild preeclamptic women were lower than severe preeclamptic and HELLP syndrome women (p: 0.001). The mean ARFI elastosonography score >1.22 m/s indicated the effect of severe preeclampsia on maternal liver elasticity with 72.7% sensitivity and 74.7% specificity (Area under curve [AUC], 0.835, 95% confidence interval [CI], 0.757–0.913). The mean ARFI elastosonography score >1.31 m/s indicated the effect of HELLP syndrome on maternal liver elasticity with 78.6% sensitivity and 75.9% specificity (AUC, 0.794, 95% CI, 0.695–0.892).Conclusions: The maternal liver becomes stiffer in severe preeclampsia and HELLP syndrome measured by ARFI elastosonography. The increased maternal liver ARFI scores may alert the obstetrician about the possible maternal puerperal morbidity.

Hemolysis, elevated liver enzymes, and low platelet syndrome: Outcomes for patients admitted to intensive care at a tertiary referral hospital

ABSTRACTPurpose: The aim was to assess outcomes for pregnancies in which hemolysis, elevated liver enzymes, and low platelet (HELLP) syndrome develops and the patient requires transfer for critical care. Materials and Methods: The cases of women with HELLP syndrome who delivered at our tertiary center or surrounding hospitals and were admitted to the intensive care between January 2007 and July 2012 were retrospectively analyzed. Results were compared for the surviving and non-surviving patients. Results: Among the 77 women with HELLP syndrome, maternal mortality rate was 14% and 24 (30%) of 81 fetuses and newborns died in the perinatal period. The most common maternal complications were disseminated intravascular coagulation (DIC) (n = 22; 29%), acute renal failure (n = 19; 25%), and postpartum hemorrhage (n = 16; 21%). Compared with surviving women, the non-surviving women had higher mean international normalized ratio (INR) (p < 0.0001); higher mean serum levels of aspartate aminotransferase (AST) (p < 0.0001); higher alanine aminotransferase (ALT) (p < 0.0001); higher lactate dehydrogenase (LDH) (p < 0.0001), and higher bilirubin (p = 0.040) levels; and lower platelet count (p = 0.005). Conclusion: DIC is a major risk factor for maternal outcome among patients with HELLP syndrome who require intensive care. Low platelet count; high AST, ALT, LDH, INR; and total bilirubin are associated with high mortality risk in this patient group. In addition, low platelet count; low fibrinogen level; prolonged activated thromboplastin time; high INR; and high total bilirubin, LDH, blood urea nitrogen, and creatinine are associated with high risk for complications in this patient group.

A mobile phone-based approach to detection of hemolysis

Preeclampsia and HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome are pregnancy-related complications with high rates of morbidity and mortality. HELLP syndrome, in particular, can be difficult to diagnose. Recent work suggests that elevated levels of free cell hemoglobin in blood plasma can, as early as the first trimester, potentially serve as a diagnostic biomarker for impending complications. We therefore developed a point-of-care mobile phone–based platform that can quickly characterize a patient's level of hemolysis by measuring the color of blood plasma. The custom hardware and software are designed to be easy to use. A sample of the whole blood (~10µL or less) is first collected into a clear capillary tube or microtube, which is then inserted into a low-cost 3D-printed sample holder attached to the phone. A 5–10min period of quiescence allows for gravitational sedimentation of the red blood cells, leaving a layer of yellowish plasma at the top of the tube. The phone camera then photographs the capillary tube and analyzes the color components of the cell-free plasma layer. The software converts these color values to a concentration of free hemoglobin, based on a built-in calibration curve, and reports the patient's hemolysis level: non-hemolyzed, slightly hemolyzed, mildly hemolyzed, frankly hemolyzed, or grossly hemolyzed.. The accuracy of the method is ~1mgdL−1. This phone-based point-of-care system provides the potentially life-saving advantage of a turnaround time of about 10min (versus 4+hours for conventional laboratory analytical methods) and a cost of approximately one dollar USD (assuming you have the phone and the software are already available).

110 Thrombotic microangiopathy in pregnant kidney transplant recipients: A life-threatening condition for mother and child

Introduction Thrombotic microangiopathy (TMA) represents a spectrum of disorders characterized by thrombosis that affect small arterial vessels. Pregnancy is a potential trigger to acute episodes of TMA, which in turn, although rare, are associated with high maternal and perinatal morbidity and mortality. In renal transplant (RT) setting, fertility is increased by restoration of renal function, meanwhile RT patients are more susceptible to gestational complications, such as TMA syndromes. Objectives The aim of this study was to report our experience with RT recipients who developed TMA in allograft during pregnancy. Methods We describe four cases of pregnant RT recipients with TMA diagnosed by allograft biopsy, due to acute allograft dysfunction, at Hospital do Rim between 2011 and 2015. Their clinical and laboratory data were collected and are highlighted here. Results At conception, the average age was 21 ± 4 years. Their obstetric history revealed previous abortions in two patients and one previous uncomplicated pregnancy in another patient. All patients had chronic hypertension before conception and one patient also had preexisting proteinuria greater than 0.5 g. At the time of the confirmation of pregnancy, 75% of the patients were being maintained on immunosuppressive therapy with prednisone, tacrolimus and azathioprine, while one patient was receiving prednisone, tacrolimus and everolimus. The mean interval time of RT to pregnancy was 25 (9–45) months and the average baseline creatinine was 1.1 (0.9–1.4). The TMA diagnosis was established in the 14th week of gestation on average, and it was associated with thrombocytopenia and microangiopathic hemolytic anemia in only one patient. Moreover, concomitant acute cellular rejection (AR) occurred in one patient, and superimposed urinary tract infection in another. Except for the patient who had AR, in all cases the calcineurin inhibitor was withdrawn. Three patients developed preeclampsia with HELLP (hemolysis, elevated liver enzymes and low platelets) syndrome. The mean gestational term at delivery was 23 ± 2 weeks and these resulted in two abortions and two stillbirths. Over a 6 month follow-up period post pregnancy, there was one case of graft loss and all patients had increased proteinuria and creatinine levels – median creatinine = 4.3 (1.5–11); median proteinuria = 1.1 (0.6–1.9). Conclusions Since HELLP syndrome was very prevalent in these cases we suggest that the TMA diagnosis demands careful surveillance for gestational hypertension complications. Apart from the poor pregnancy outcomes, TMA in pregnant RT patients is associated with deterioration of graft function.

8 The sFlt-1/PLGF ratio can rule out preeclampsia for up to four weeks in women with suspected preeclampsia

Introduction Clinical signs and symptoms of preeclampsia are known to be poorly predictive of who will develop the condition, prompting the investigation of angiogenic biomarkers as potential diagnostic and predictive aids. The Elecsys® immunoassay soluble fms-like tyrosine kinase (sFlt-1)/placental growth factor (PlGF) ratio is Conformite Europeenne-In Vitro Diagnostics approved as a diagnostic aid for preeclampsia, and as an aid in the short-term prediction of preeclampsia (rule out and rule in) in pregnant women with suspected preeclampsia in conjunction with other diagnostic and clinical information. In the Prediction of Short-Term Outcome in Pregnant Women with Suspected Preeclampsia Study (PROGNOSIS), a cut-off value of 38 was derived and validated to rule out preeclampsia and HELLP (hemolysis, elevated liver enzymes and low platelet count) syndrome within one week (Zeisler et al. N Engl J Med 2016;374:13–22). However, the ability of the sFlt-1/PlGF ratio to rule out preeclampsia up to four weeks in women with suspected disease has not been determined. Objectives We aimed to establish the negative predictive values (NPVs) applying the Elecsys® immunoassay sFlt-1/PlGF ratio cut-off value of 38 to rule out preeclampsia within two to four weeks after testing in women with suspected preeclampsia. Methods PROGNOSIS was a prospective, observational, multicenter study, which validated the sFlt-1/PlGF ratio cut-off value of 38 to reliably rule out preeclampsia within one week in women who had clinical signs and symptoms of the syndrome (gestational age 24w+0d–36w+6d). We performed a post-hoc analysis of the data from the validation cohort of 550 participants to determine the NPV of this ratio cut-off value to rule out preeclampsia within two, three and four weeks after testing. Results A total of 550 participants from the PROGNOSIS validation cohort were included in this analysis (median age 31years; median pre-pregnancy body mass index 26.2kg/m 2 ; median systolic blood pressure 128.0mmHg; median gestation week 31w+3d; 79 (14%) were current smokers; 418 (76%) were white/Caucasian). Of these, 98 (18%) developed preeclampsia/HELLP syndrome at some point during their pregnancy: 15 (3%) within one week; 41 (7%) within two weeks; 60 (11%) within three weeks; and 71 (13%) within four weeks. The NPV to rule out preeclampsia in women with sFlt-1/PlGF values of 38 and below within two, three and four weeks of testing was 97.9% (95% confidence interval [CI]: 96.0–99.0), 95.7% (95% CI: 93.3–97.5), and 94.3% (95% CI: 91.7–96.3), respectively (Table). Conclusions This post-hoc analysis of PROGNOSIS shows that sFlt-1/PlGF ratios of 38 and below could rule out preeclampsia for up to four weeks after testing with high NPV in women with suspicion of the syndrome.

Beyond maternal death: improving the quality of maternal care through national studies of ‘near-miss’ maternal morbidity

BackgroundStudies of maternal mortality have been shown to result in important improvements to women’s health. It is now recognised that in countries such as the UK, where maternal deaths are rare, the study of near-miss severe maternal morbidity provides additional information to aid disease prevention, treatment and service provision.ObjectivesTo (1) estimate the incidence of specific near-miss morbidities; (2) assess the contribution of existing risk factors to incidence; (3) describe different interventions and their impact on outcomes and costs; (4) identify any groups in which outcomes differ; (5) investigate factors associated with maternal death; (6) compare an external confidential enquiry or a local review approach for investigating quality of care for affected women; and (7) assess the longer-term impacts.MethodsMixed quantitative and qualitative methods including primary national observational studies, database analyses, surveys and case studies overseen by a user advisory group.SettingMaternity units in all four countries of the UK.ParticipantsWomen with near-miss maternal morbidities, their partners and comparison women without severe morbidity.Main outcome measuresThe incidence, risk factors, management and outcomes of uterine rupture, placenta accreta, haemolysis, elevated liver enzymes and low platelets (HELLP) syndrome, severe sepsis, amniotic fluid embolism and pregnancy at advanced maternal age (≥ 48 years at completion of pregnancy); factors associated with progression from severe morbidity to death; associations between severe maternal morbidity and ethnicity and socioeconomic status; lessons for care identified by local and external review; economic evaluation of interventions for management of postpartum haemorrhage (PPH); women’s experiences of near-miss maternal morbidity; long-term outcomes; and models of maternity care commissioned through experience-led and standard approaches.ResultsWomen and their partners reported long-term impacts of near-miss maternal morbidities on their physical and mental health. Older maternal age and caesarean delivery are associated with severe maternal morbidity in both current and future pregnancies. Antibiotic prescription for pregnant or postpartum women with suspected infection does not necessarily prevent progression to severe sepsis, which may be rapidly progressive. Delay in delivery, of up to 48 hours, may be safely undertaken in women with HELLP syndrome in whom there is no fetal compromise. Uterine compression sutures are a cost-effective second-line therapy for PPH. Medical comorbidities are associated with a fivefold increase in the odds of maternal death from direct pregnancy complications. External reviews identified more specific clinical messages for care than local reviews. Experience-led commissioning may be used as a way to commission maternity services.LimitationsThis programme used observational studies, some with limited sample size, and the possibility of uncontrolled confounding cannot be excluded.ConclusionsImplementation of the findings of this research could prevent both future severe pregnancy complications as well as improving the outcome of pregnancy for women. One of the clearest findings relates to the population of women with other medical and mental health problems in pregnancy and their risk of severe morbidity. Further research into models of pre-pregnancy, pregnancy and postnatal care is clearly needed.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.

Variation of long-chain 3-hydroxyacyl CoA dehydrogenase DNA methylated modification and correlation with gene mRNA expression of early-onset preeclampsia, HELLP syndrome and antiphospholipid syndrome in trophoblast cells of placenta

By detecting the DNA methylation and gene expression of long-chain 3-hydroxyacyl CoA dehydrogenase(LCHAD)in trophoblast cells, analyze the correlation of DNA methylation and gene expression in early-onset preeclampsia(EPE), hemolysis, elevated liver enzymes, and low platelets(HELLP)syndrome and antiphospholipid syndrome(APS), to investigate the molecular basis of long-chain fatty acid oxidation changes in different preeclampsia and pathological pregnancy. Primary human cytotrophoblast cells and HTR8/Svneo cells were treated with serum from patients with EPE(14 cases), HELLP(12 cases), APS(14 cases), and normal pregnant women(NP, 14 cases). The methylation level of LCHAD gene promoter region through the MassARRAY platform and mRNA expression level by real-time fluorescent quantitative PCR technique were conducted. (1)Cytosine-phosphate-guanine(CpG)sites in human LCHAD DNA promoter region: CpG sites were detected in the range of 558 bp before LCHAD gene transcription start site, the detected CpG sites were 11 sites including 8 single sites and 3 complex sites. The position of these sites were at-984,-960,-899,-853,-811,-796,-774,-727,-615,-595,-579 respectively.(2)The sites of-899,-853,-615 and-595 showed increased methylation level in EPE and HELLP groups. The methylation level at-899,-853 and-615 sites in EPE and HELLP groups were significantly higher than those in NP group(P<0.01). The methylation level at-853 site was higher in EPE group than that in HELLP group(P<0.05). The-595 site showed the unmethylated in EPE, HELLP and APS groups. There were significantly difference between the 3 groups and EPE group(P<0.01).(3)The gene expression of LCHAD mRNA in EPE(0.048±0.005), HELLP(0.045±0.006)and APS(0.044±0.004)groups were significantly lower than NP group(0.076±0.009; P<0.01).(4)The correlation of methylation level and gene expression in all groups: the methylation level at-899,-853,-727,-615 and-579 sites were negatively correlated with gene mRNA expression in EPE group(P<0.05). The methylation level at-899,-853 and-615 sites were negatively correlated with gene mRNA expression in HELLP group(P< 0.05). The variation of LCHAD DNA methylation of trophoblast cells are found among EPE, HELLP syndrome and APS. The different correlation of LCHAD DNA methylation and gene expression are different in pathological groups. LCHAD DNA methylation of EPE and HELLP syndrome were significantly increased and negatively correlated with LCHAD gene mRNA expression. These results further revealed the molecular basis of long-chain fatty acid oxidation in different preeclampsia and pathological pregnancy.

Transfusion Related Acute Lung Injury after Cesarean Section in a Patient with HELLP Syndrome.

Transfusion-related acute lung injury (TRALI) is a serious adverse reaction of transfusion, and presents as hypoxemia and non-cardiogenic pulmonary edema within 6 hours of transfusion. A 14-year-old primigravida woman at 34 weeks of gestation presented with upper abdominal pain without dyspnea. Because she showed the syndrome of HELLP (hemolysis, elevated liver enzymes, and low platelet count), an emergency cesarean section delivery was performed, and blood was transfused. In the case of such patients, clinicians should closely observe the patient's condition at least during the 6 hours while the patient receives blood transfusion, and should suspect TRALI if the patient complains of respiratory symptoms such as dyspnea. Furthermore, echocardiography should be performed to distinguish between the different types of transfusion-related adverse reactions.

Babesia microti Infection in Pregnancy Mimicking HELLP Syndrome

Babesiosis during pregnancy is an uncommon cause of hemolysis during pregnancy and may have a similar presentation to hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome. We report a case of a 34- year-old healthy gravida 3 para 1-0-1-1 at 38 weeks of gestation who was transferred to our tertiary care center for induction of labor for suspected HELLP syndrome. Peripheral blood smear from the referring hospital showed intraerythrocytic ring forms consistent with Babesia microti infection. She was treated with clindamycin and quinine and had a vaginal delivery of a healthy infant. This case demonstrates that although uncommon, babesiosis should be on the differential for imitators of HELLP syndrome to optimize treatment and outcomes.

The Use of Plasma Exchange in a Very Early-onset and Life Threatening, Hemolysis, Elevated Liver Enzymes, and Low Platelet (HELLP) Syndrome: A Case Report

Background: HELLP syndrome is a life threatening pregnancy and early postpartum complication. Very early presentation (before the 21st pregnancy week) is rare and represents an extremely difficult situation for patients and physicians. Supportive therapy (magnesium sulfate, antihypertensive drugs and corticosteroids) may be useful to prolong pregnancy; till now the removing of placenta is the only effective therapeutic option. Plasmapheresis may represent a new and efficacious therapeutic option. Case description: The article reports on a case of very-early onset HELLP Syndrome at the 18th (17+5) week of gestation. It was a challenging clinical and therapeutic case. Since the fetus did not show any signs of growth retardation or pathological Doppler findings, indicating a good fetal prognosis, we used plasmapheresis as an ultima ratio to prolong pregnancy. With plasmapheresis, the pregnancy was prolonged for 20 days. Unfortunately the deterioration of the clinical situation required delivery in the 21st (20+4) gestational week. Conclusion: Plasmapheresis allows prolongation of pregnancy with early onset, life threatening HELLPSyndrome.

First trimester prediction of HELLP syndrome.

The aim of this study was to evaluate first-trimester maternal characteristics and biomarkers in pregnancies that subsequently develop HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome. Maternal history, biochemical, and biophysical parameters were compared between women who developed HELLP, preeclampsia (PE) without HELLP and controls. After determination of significant variables through univariate analysis a first-trimester prediction model was obtained by applying logistic regression analysis. Performance of the model was evaluated. Twenty participants with HELLP were compared with 147 patients that developed PE without HELLP and 2810 controls. Women with HELLP were more likely Caucasian, nulliparous and presented a higher mean arterial pressure (MAP) when compared with controls. As opposing to women who developed HELLP, women who developed PE without HELLP were more likely of African-American origin and presented an even higher first-trimester MAP. Enrollment biochemical and biophysical parameters were similar between HELLP and PE or controls. Ethnicity, nulliparity, history of previous PE, history of previous HELLP syndrome, and first-trimester MAP were primary risk factors. A prediction rule for HELLP syndrome had an area under the curve of 0.80, with 75% sensitivity for 79% specificity. The majority of pregnancies that develop HELLP syndrome can be predicted in the first trimester. © 2015 John Wiley & Sons, Ltd.

Immediate Delivery Versus Expectant Monitoring for Hypertensive Disorders of Pregnancy Between 34 and 37 Weeks of Gestation (HYPITAT-II)

Patients with hypertensive disorders of pregnancy usually have the 2 treatment options, either immediate delivery or continuing the pregnancy. Although immediately delivery of the placenta is seen as the more definitive of the 2 treatments, it does carry the potentially higher risks of an earlier birth (preterm if <37 weeks’ gestation), neonatal complications, and need for cesarean delivery. In particular, little is known of immediate delivery’s effect on maternal and neonatal outcomes in women between 34 and 37 weeks’ gestation. Therefore, this study, HYPITAT II, examines a cohort of pregnant women with mild hypertensive disorders at 34 to 37 weeks’ gestation, in order to evaluate the outcomes related to immediate delivery versus expectant monitoring (continuing pregnancy). This was an open-label, randomized controlled trial, in which 703 women with mild gestational hypertension, preeclampsia, deteriorating preexisting hypertension, and/or superimposed preeclampsia were examined at 34 to 36 weeks’ gestation. Patients with severe disease were excluded. Within 24 hours of randomization, patients in the immediate delivery group (n = 353) who had a Bishop score of 6 or greater underwent labor induced by amniotomy with oxytocin augmentation, had a score of less than 6, cervical priming prior to induction of labor, or, if they had a contraindication as determined by the attending obstetrician, cesarean delivery. Expectant monitoring (n = 351) was conducted per standard local protocols. Both maternal and neonatal outcomes were observed until discharge, and then patients were followed up at 6 weeks after birth. Primary maternal outcome was a composite of adverse maternal outcomes (thromboembolic complications, pulmonary edema, HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome, eclampsia, placental abruption, death), whereas secondary maternal outcomes were mode of delivery and cesarean delivery. Primary neonatal outcome was respiratory distress syndrome, whereas secondary outcomes covered a wide range of neonatal complications. The primary neonatal outcome, or respiratory distress syndrome, occurred more frequently in the immediate delivery group than in the expectant monitoring group (5.7% vs 1.7%; relative risk, 3.30; absolute risk, 4.0%; P = 0.005), and in a post hoc analysis, overall risk of neonatal morbidity was higher in the immediate delivery group than in the expectant monitoring group. However, neonates in the expectant monitoring group were at significantly increased risk of admission to the neonatal intensive care unit, infection or sepsis, or transient tachypnea. Although less, the risk of adverse primary maternal outcomes, as a composite, was not statistically significantly different between the 2 groups (1.1% immediate vs 3.1% expectant monitoring; relative risk, 0.36; absolute risk, 2.0; P = 0.067). HELLP syndrome was observed as the most common adverse outcome in both groups. Risk of cesarean delivery between groups also did not differ significantly. None of the adverse maternal outcomes led to neonatal complications. Immediate delivery carries significantly increased risk of adverse neonatal outcomes, such as respiratory distress syndrome. Although women with mild hypertensive disorders at 34 to 37 weeks’ gestation may benefit slightly from immediate delivery, until further studies are conducted to clarify the uncertainty, the authors recommend expectant monitoring as the primary route of treatment for this population and that immediate delivery take place only when needed.

Critical Illness in Pregnancy: Part I: An Approach to a Pregnant Patient in the ICU and Common Obstetric Disorders

Managing critically ill obstetric patients in the ICU is a challenge because of their altered physiology, different normal ranges for laboratory and clinical parameters in pregnancy, and potentially harmful effects of drugs and interventions on the fetus. About 200 to 700 women per 100,000 deliveries require ICU admission. A systematic five-step approach is recommended to enhance maternal and fetal outcomes: (1) differentiate between medical and obstetric disorders with similar manifestations, (2) identify and treat organ dysfunction, (3) assess maternal and fetal risk from continuing pregnancy and decide if delivery/termination of pregnancy will improve outcome, (4) choose an appropriate mode of delivery if necessary, and (5) optimize organ functions for safe delivery. A multidisciplinary team including the intensivist, obstetrician, maternal-fetal medicine specialist, anesthesiologist, neonatologist, nursing specialist, and transfusion medicine expert is key to optimize outcomes. Severe preeclampsia and its complications, HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome, and amniotic fluid embolism, which cause significant organ failure, are reviewed. Obstetric conditions that were not so common in the past are increasingly seen in the ICU. Thrombotic thrombocytopenic purpura of pregnancy is being diagnosed more frequently. Massive hemorrhage from adherent placenta is increasing because of the large number of pregnant women with scars from previous cesarean section. With more complex fetal surgical interventions being performed for congenital disorders, maternal complications are increasing. Ovarian hyperstimulation syndrome is also becoming common because of treatment of infertility with assisted reproduction techniques. Part II will deal with common medical disorders and their management in critically ill pregnant women.

Etiology, clinical profile and prognosis of pregnancy-related acute kidney injury in critically ill obstetric patients

Objective To investigate the etiology, clinical profile and prognosis of pregnancy-related acute kidney injury (PR-AKI) in critically ill obstetric patients. Methods Data of the critically ill obstetric patients admitted to ICU from January 2011 to March 2014 were collected and analyzed retrospectively.PR-AKI patients were screened according to the clinical diagnostic criteria of AKI.The etiological diseases, laboratory indicators, urine output, length of ICU stay, prognosis of PR-AKI were documented and analyzed; and the risk factors of PR-AKI was assessed with logistic regression analysis. Results A total of 124 critically ill obstetric patients were enrolled, and AKI occurred in 46 of them (37.1%) under kidney disease: Improving Global Outeomes Acute kidney injury(KDIGO-AKI) criteria.The main causes of PR-AKI included pre-eclampsia(41.3%, 19/46), hemorrhagic shock(21.7%, 10/46), hemolysis, elevated liver enzymes and low platelet (HELLP) syndrome (17.4%, 8/46), acute fatty liver of pregnancy (AFLP) (15.2%, 7/46). Of the 46 PR-AKI patients, 3 died (6.5%), and the causes of death was cerebral hemorrhage, cerebral venous sinus thrombosis and multiorgan failure (MOF). There were 23 cases in stage 1, 13 cases in stage 2 and 10 cases in stage 3 according to KIDGO-AKI stage criteria.Ten patients received renal replacement treatment: 1 in stage 1, 2 in stage 2 and 7 in stage 3.Complete, partial and no renal recovery was observed in 73.9% (34/46), 17.4%(8/46) and 8.7%(4/46) of the patients, respectively.Complete renal recovery was observed 91.3% (21/23) in stage 1, 9/13 in stage 2, 4/10 in stage 3, respectively.On logistic regression, pregnancy-induced hypertension, hemorrhagic shock and HELLP syndrome were risk factors of PR-AKI. Conclusions The incidence of PR-AKI in critically ill obstetric patients is high.A variety of etiological factors and risk factors are related to PR-AKI.Early detection and effective therapeutic measures are important to PR-AKI.The prognosis of PR-AKI is related with severity of AKI. Key words: Acute kidney injury; Etiology; Pregnancy; Risk factors

Effects of serum from patients with early-onset pre-eclampsia, HELLP syndrome, and antiphospholipid syndrome on fatty acid oxidation in trophoblast cells.

The role of metabolic disorders of long-chain fatty acid oxidation in the development of pre-eclampsia (PE), hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome and antiphospholipid syndrome (APS) is unclear. The aim of this study was to research the effects of three serum on fatty acid oxidation in trophoblast cells. Primary human trophoblast cells and HTR8/SVneo cells were treated with serum from patients with early-onset severe PE (E-PE), E-PE with HELLP (PE-HELLP), APS, and normal pregnant women as controls (NC). Cells treated with free fatty acids (FFAs) of various lengths were used as controls. Triglyceride (TG) and FFA levels of the E-PE and APS groups were significantly higher than the PE-HELLP and NC groups (P < 0.05). Trophoblast cells treated with serum from the E-PE and APS groups showed obvious morphological changes and a large amount of lipid droplet deposition. Cells in the E-PE group had more severe damage of mitochondria ultrastructure, presenting with cell morphological changes, lipid droplet deposition, and mitochondria damage similar to the long-chain FFA group. FFA levels in the PE-HELLP group increased significantly compared with the NC group (P < 0.05), while TG levels did not change significantly (P > 0.05). Trophoblast cells treated with serum from the PE-HELLP group showed cellular morphology and mitochondria changes similar to the E-PE group, but had relatively less lipid droplet deposition. Serum from patients with E-PE, PE-HELLP, and APS with elevated levels of FFA had different effects on trophoblast cells, including cell morphology, lipid droplets deposition, and mitochondrial ultrastructure, suggesting disorders of lipid metabolism and fatty acid oxidation of various degrees and types. Serum from patients with E-PE led to damage similar to that of long-chain FFA in cell morphology, lipid droplet deposition and mitochondrial ultrastructure, indicating the correlation between disorders of long-chain fatty acid oxidation and the development of the disease.

Severe pre-eclampsia complicated by HELLP syndrome alterations in the structure of the umbilical cord (morphometric and immunohistochemical study)

The aim of this study was to evaluate the morphometric and immunohistochemistry in umbilical cords from patients with severe pre-eclampsia with and without haemolysis, elevated liver enzymes and low platelets (HELLP) syndrome. The patient and control groups were similar according to baseline obstetric characteristics. White blood cell count in patients with HELLP syndrome and the control group was significantly increased among patients with HELLP syndrome (p < 0.001). Morphometric examination and endothelial core length were significantly different between the groups. In the umbilical cord cross-section of the HELLP group, endothelial cell degeneration in the vessel wall and basement membrane thickening were observed. In the muscle layer of blood vessels, the following disorders were found: increased collagen fibres in the muscle cell, hyperplasia and separation of muscle fibres as well as edema in the intermediate connective tissue. Immunohistochemical analysis showed that endothelial cells, basal membrane and fibroblast cells in the HELLP group expressed high levels of CD44. Vessel wall and amniotic epithelial basement membrane thickening were observed in the HELLP group. Matrix metalloproteinase 9 (MMP9) was expressed. Fibroblast and smooth muscle cells were fusiform and showed a positive reaction to immunohistochemical staining of α-actin smooth muscle.

Recurrence of hypertensive disorders of pregnancy: an individual patient data metaanalysis

We performed an individual participant data (IPD) metaanalysis to calculate the recurrence risk of hypertensive disorders of pregnancy (HDP) and recurrence of individual hypertensive syndromes. We performed an electronic literature search for cohort studies that reported on women experiencing HDP and who had a subsequent pregnancy. The principal investigators were contacted and informed of our study; we requested their original study data. The data were merged to form one combined database. The results will be presented as percentages with 95% confidence interval (CI) and odds ratios with 95% CI. Of 94 eligible cohort studies, we obtained IPD of 22 studies, including a total of 99,415 women. Pooled data of 64 studies that used published data (IPD where available) showed a recurrence rate of 18.1% (n=152,213; 95% CI, 17.9-18.3%). In the 22 studies that are included in our IPD, the recurrence rate of a HDP was 20.7% (95% CI, 20.4-20.9%). Recurrence manifested as preeclampsia in 13.8% of the studies (95% CI,13.6-14.1%), gestational hypertension in 8.6% of the studies (95% CI, 8.4-8.8%) and hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome in 0.2% of the studies (95% CI, 0.16-0.25%). The delivery of a small-for-gestational-age child accompanied the recurrent HDP in 3.4% of the studies (95% CI, 3.2-3.6%). Concomitant HELLP syndrome or delivery of a small-for-gestational-age child increased the risk of recurrence of HDP. Recurrence increased with decreasing gestational age at delivery in the index pregnancy. If the HDP recurred, in general it was milder, regarding maximum diastolic blood pressure, proteinuria, the use of oral antihypertensive and anticonvulsive medication, the delivery of a small-for-gestational-age child, premature delivery, and perinatal death. Normotensive women experienced chronic hypertension after pregnancy more often after experiencing recurrence (odds ratio, 3.7; 95% CI, 2.3-6.1). Among women that experience hypertension in pregnancy, the recurrence rate in a next pregnancy is relatively low, and the course of disease is milder for most women with recurrent disease. These reassuring data should be used for shared decision-making in women who consider a new pregnancy after a pregnancy that was complicated by hypertension.

Maternal near miss in the intensive care unit: clinical and epidemiological aspects.

ObjectiveTo analyze the epidemiological clinical profile of women with maternal near miss according to the new World Health Organization criteria.MethodsA descriptive crosssectional study was conducted, in which the records of patients admitted to the obstetric intensive care unit of a tertiary hospital in Recife (Brazil) over a period of four years were analyzed. Women who presented at least one near miss criterion were included. The variables studied were age, race/color, civil status, education, place of origin, number of pregnancies and prenatal consultations, complications and procedures performed, mode of delivery, gestational age at delivery, and maternal near miss criteria. The descriptive analysis was performed using the program Epi-Info 3.5.1.ResultsTwo hundred fifty-five cases of maternal near miss were identified, with an overall ratio of maternal near miss of 12.8/1,000 live births. Among these cases, 43.2% of the women had incomplete primary education, 44.7% were primiparous, and 20.5% had undergone a previous cesarean section. Regarding specific diagnoses, there was a predominance of hypertensive disorders (62.7%), many of which were complicated by HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome (41.2%). The laboratory near miss criteria were the most often observed (59.6%), due mainly to the high frequency of acute thrombocytopenia (32.5%).ConclusionsA high frequency of women who had a low level of education and who were primiparous was observed. According to the new criteria proposed by the World Health Organization, hypertensive pregnancy disorders are still the most common among maternal near miss cases. The high frequency of HELLP syndrome was also striking, which contributed to acute thrombocytopenia being the most frequent near miss criterion.

Failure of Intraoperative Red Cell Salvage: A Patient with Sickle Cell Disease and HELLP (Hemolysis, Elevated Liver enzymes and Low Platelets) Syndrome

Cell salvage is a process whereby the bloodshed from the operative field is collected and returned to the patient. It can be especially useful when allogeneic red blood cell (RBC) units are not readily available such as when the recipient has multiple alloantibodies. We report on the anesthesia and transfusion strategies for managing a pregnant patient with sickle cell disease (SCD) with HELLP (Hemolysis, Elevated Liver enzymes and Low Platelets) syndrome. A pregnant patient with twins at 30 weeks of gestation was admitted in an SCD crisis. She subsequently developed HELLP syndrome and required urgent cesarean delivery; however, she had multiple RBC antibodies complicating the immediate provision of crossmatched RBC units. Cell salvage was used to capture the blood shed during her procedure while the blood bank was searching for compatible RBCs units. Despite multiple interventions designed to optimize the cell salvage procedure for the unique challenges of a patient with SCD, the salvaged RBCs hemolyzed and could not be reinfused. Cell salvage in an obstetric patient with SCD in an acute crisis and superimposed HELLP was unable to recover intact and useable RBCs. Further studies into methods of optimizing the procedure for use in this context are warranted. Close communication between the clinical teams treating the patient and the transfusion service is required so that the RBC transfusion requirements can be anticipated; this is especially important when the patient has multiple antibodies.

Total bile acids in the maternal and fetal compartment in relation to placental ABCG2 expression in preeclamptic pregnancies complicated by HELLP syndrome

ObjectiveTo investigate total bile acid (TBA) levels in maternal (MB) and umbilical cord blood (UCB) in normotensive, preeclamptic (PE), and PE pregnancies complicated by hemolysis elevated liver enzymes and low platelets (HELLP) syndrome in the context of ABCG2 placental gene expression levels, a recently reported placental bile acid transporter. MethodsTBA levels were determined in 83 paired MB and UCB samples of normotensive, PE and PE/HELLP pregnancies and in 22 paired arterial and venous UCB samples from uncomplicated term pregnancies. ABCG2 gene expression was measured in 104 human placentas by reverse transcriptase quantitative polymerase chain reaction. ResultsOverall, TBA levels in MB are higher compared to levels in UCB (p<0.0001), but this comparison looses statistical significance for the 11 PE/HELLP cases. TBA levels in maternal blood are increased in PE/HELLP compared to PE pregnancies (p=0.016). TBA levels in arterial and venous UCB from 22 normotensive pregnancies are not statistically different. ABCG2 expression is reduced in pregnancies where preeclampsia is further complicated by HELLP syndrome. ABCG2 expression in human placenta is not correlated with TBA levels in either the maternal or fetal compartment. ConclusionIncreased maternal TBA levels in PE/HELLP pregnancies indicate a relation between bile acids in the maternal circulation and HELLP syndrome. As overall TBA levels in maternal blood are increased compared to UCB, we conclude that the placenta partly protects the fetus from increased maternal TBA levels. This consistent difference in TBA levels between the maternal and fetal compartment is unrelated to the placental expression of ABCG2.