Hemolysis, Elevated Liver Enzymes, Low Platelets Syndrome Research Articles

Factors Associated with Refractory Severe Hypertension in Patients with Preeclampsia.

This study aimed to identify factors associated with refractory severe hypertension that does not resolve after an initial dose of antihypertensive medication in patients with preeclampsia. This was a retrospective study of all pregnant and postpartum individuals with a diagnosis of preeclampsia, superimposed preeclampsia, HELLP (hemolysis, elevated liver enzymes, low platelet) syndrome, or eclampsia who delivered at 22 weeks or greater at a single academic institution from 2010 to 2020. Inclusion criteria were patients with preeclampsia who developed severe hypertension (systolic pressure ≥160 mm Hg or diastolic pressure ≥110 mm Hg) and received antihypertensive medications for acute severe hypertension. We defined refractory severe hypertension as a systolic blood pressure of ≥160 mm Hg or a diastolic blood pressure of ≥110 mm Hg that did not improve after receiving the initial treatment. To evaluate for factors associated with refractory severe hypertension, we developed multivariable modified Poisson regression using all variables with p-value <0.1 on bivariable analysis and calculated adjusted relative risks (aRRs) with 95% confidence intervals (95% CIs). Of 850, 386 (45.4%) had refractory severe hypertension and 464 (54.6%) responded to the initial antihypertensive medications. Factors associated with refractory severe hypertension included higher body mass index (BMI), chronic hypertension, and higher systolic pressure. Every 5 kg/m2 increase in BMI was associated with a 7% increased risk of refractory severe hypertension (aRR = 1.07; 95% CI: 1.02-1.12). Every 10 mm Hg increase in systolic blood pressure was associated with a 10% increased risk of refractory severe hypertension (aRR = 1.10; 95% CI: 1.04-1.17). Chronic hypertension was associated with a 25% increased risk of refractory severe hypertension (aRR = 1.25; 95% CI: 1.01-1.56) in the diastolic pressure model. Refractory severe hypertension was associated with elevated BMI, chronic hypertension, and higher systolic blood pressure. · Risk factors for refractory severe hypertension are not well-known.. · Almost half of the patients had refractory severe hypertension.. · Higher BMI, chronic hypertension, and higher systolic pressure were the risk factors.. · These patients would require closer follow-up and prompt response to vital signs..

First-trimester uterine artery Doppler and hypertensive disorders in twin pregnancies: Use of twin versus singleton references.

To determine the association of first-trimester uterine artery Doppler with hypertensive disorders of pregnancy in twin pregnancies. This was a retrospective cohort study of twin pregnancies followed at the University Hospital Center of Central Lisbon, Portugal, between January 2010 and December 2022. First-trimester uterine artery pulsatility index (UtA-PI) was determined and compared between twin pregnancies (n = 454) and singleton pregnancies (n = 908), matched to maternal and pregnancy characteristics. Maternal characteristics and mean UtA-PI were analyzed for gestational age, birth weight, gestational hypertension, early- and late-onset pre-eclampsia, HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome, and preterm birth. Univariable and multivariable logistic regression models were used. The mean first-trimester UtA-PI was significantly lower in dichorionic twins than in singletons (P < 0.001). To study hypertensive disorders of pregnancy in twins, 390 pregnancies were included: 311 (79.7%) dichorionic and 79 (20.3%) monochorionic twins. The observed rates of early- and late-onset pre-eclampsia, gestational hypertension, and HELLP syndrome were 1.0%, 4.4%, 7.4%, and 1.5%, respectively. We achieved a 100% detection rate for early-onset pre-eclampsia using the UtA-PI 90th centile for twins. However, when singleton references were considered, the detection rate decreased to 50%. UtA-PI at or above the 95th centile was associated with increased odds for preterm birth before 32 weeks (adjusted odds ratio 4.1, 95% confidence interval 1.0-16.7, P = 0.043). Unless other major risk factors for hypertensive disorders are present, women with low UtA-PI will probably not benefit from aspirin prophylaxis. Close monitoring of all twin pregnancies for hypertensive disorders is still recommended.

Unique presentation of previable HELLP syndrome

Introduction: Hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome is a serious complication of pregnancy characterized by hemolysis, elevated liver enzymes, and low platelets. This condition typically affects pregnant women in the third trimester or postpartum states, with only a handful of reported cases in previable pregnancies. The symptoms of HELLP syndrome can mimic those of other critical conditions during pregnancy, such as acute fatty liver of pregnancy (AFLP), thrombotic thrombocytopenic purpura (TTP), hemolytic-uremic syndrome (HUS), systemic lupus erythematosus (SLE), and antiphospholipid syndrome (APS), making early diagnosis crucial to prevent maternal and fetal harm. Case Report: We report the case of a 23-year-old nulliparous woman who developed HELLP syndrome at 21 weeks gestation. We highlight the importance of recognizing early onset HELLP syndrome and differentiating it from other potential diagnoses to ensure prompt and appropriate treatment. Conclusion: This case of previable HELLP syndrome in a nulliparous patient without other risk factors highlights the importance of early detection and intervention as life saving measures. By understanding the clinical and laboratory findings specific to HELLP syndrome, healthcare providers can improve maternal and fetal outcomes in cases of this rare and serious complication of pregnancy.

Etiology of intracerebral hemorrhage during pregnancy or puerperium: A nationwide study.

Intracerebral hemorrhage during pregnancy or puerperium (pICH) is one of the leading causes of maternal death worldwide. However, limited epidemiological data exist on the etiology and outcomes of pICH, which is required to guide prevention and treatment. A retrospective nationwide cohort study and a nested case-control study was performed in Finland 1987-2016. We identified women with incident pICH by linking the Medical Birth Register (MBR) and the Hospital Discharge Register (HDR). The clinical details were collected from patient records. Three matched controls with a pregnancy without ICH were selected for each case from the MBR. In total, 49 pICH cases were identified. Half of these cases occurred during pregnancy, and the other half during peripartum and puerperium. Based on the SMASH-U (structural vascular lesion, medication, amyloid angiopathy, systemic disease, hypertension, undetermined) classification, 35.4% of the patients had a systemic disease, most commonly preeclampsia, eclampsia, or HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome; 31.3% had a structural vascular lesion; 31.3% had an undetermined etiology; and one patient (2.1%) had hypertension. The most important risk factor was hypertensive disorders of pregnancy (HDP; odds ratio = 3.83, 95% confidence interval = 1.60-9.15), occurring in 31% of the cases. Maternal mortality was 12.5%, and 20.9% of the surviving women had significant disability (modified Rankin Scale = 3-5) 3 months after the pICH. Women with systemic disease had the worst outcomes. Even in a country with a comprehensive pregnancy surveillance system, the maternal mortality rate for pICH is high, and the sequelae are severe. Early recognition and treatment of the key risk factor, HDP, is crucial to help prevent this serious pregnancy complication.

Risk factors for severe postpartum hemorrhage requiring blood transfusion after cesarean delivery for twin pregnancy: a nationwide cohort study.

Postpartum hemorrhage (PPH) is a leading cause of maternal morbidity and mortality. Twin pregnancy and cesarean delivery are well-known risk factors for PPH. However, few studies have investigated PPH risk factors in mothers who have undergone cesarean delivery for twin pregnancies. Therefore, this study investigated the risk factors associated with severe PPH after cesarean delivery for twin pregnancies. We searched and reviewed the Korean Health Insurance Review and Assessment Service's claims data from July 2008 to June 2021 using the code corresponding to cesarean delivery for twin pregnancy. Severe PPH was defined as hemorrhage requiring red blood cell (RBC) transfusion during the peripartum period. The risk factors associated with severe PPH were identified among the procedure and diagnosis code variables and analyzed using univariate and multivariate logistic regressions. We analyzed 31,074 cesarean deliveries for twin pregnancies, and 4,892 patients who underwent cesarean deliveries for twin pregnancies and received RBC transfusions for severe PPH were included. According to the multivariate analysis, placental disorders (odds ratio, 4.50; 95% confidence interval, 4.09-4.95; P < 0.001), general anesthesia (2.33, 2.18-2.49; P < 0.001), preeclampsia (2.20, 1.99-2.43; P < 0.001), hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome (2.12, 1.22-3.68; P = 0.008), induction failure (1.37, 1.07-1.76; P = 0.014), and hypertension (1.31, 1.18-1.44; P < 0.001) predicted severe PPH. Placental disorders, hypertensive disorders such as preeclampsia and HELLP syndrome, and induction failure increased the risk of severe PPH after cesarean delivery for twin pregnancy.

Association between SARS-CoV-2 infection and newly diagnosed hypertension during pregnancy: prospective, population based cohort study

ObjectiveTo study the association between SARS-CoV-2 infection and newly diagnosed hypertension during pregnancy.DesignProspective, population based cohort study.SettingAll singleton pregnancies after 22 completed gestational weeks registered in the Swedish Pregnancy Register...

Maternal and perinatal outcome of women with early-onset severe pre-eclampsia before 28 weeks: Is expectant management beneficial in a low-resource country? A prospective observational study.

To study the maternal and perinatal outcomes in women with severe pre-eclampsia before 28 weeks of pregnancy. A descriptive study from a tertiary care center. All consecutive women with severe pre-eclampsia withonset before 28 weeks of pregnancy were included. The details were collected in a predesigned structured proforma prospectively. The study cohort included 145 women with a mean maternal age of 26.97 ± 5.36 years (range 19-47 years). The mean duration of prolongation of pregnancy was 13.04 ± 10.57 days (range 1-51 days). A total of 29.7% (n = 43) of women had at least one major adverse maternal outcome, and the most common was HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome (n = 24,16.6%), followed by eclampsia (n = 12,8.3%). The stillbirth rate was high (n = 103,68.7%), and most occurred in the antepartum period. Of 47 (31.3%) neonates born alive, only eight (17.02%;8/47) survived up to 28 days of life. Fetal growth restriction with Doppler abnormalities and neonatal sepsis were the most common reasons for perinatal mortality. Expectant management should not be considered routinely when the onset of severe pre-eclampsia is before 25+6 weeks of pregnancy. Between 26 and 27+6 weeks it can be offered under close monitoring and the perinatal survival depends on the neonatal services available in their facility.

MATERNAL AND FOETAL OUTCOMES IN PREGNANCY WITH GESTATIONAL THROMBOCYTOPENIA: A PROSPECTIVE OBSERVATIONAL STUDY

Thrombocytopeniaissecond to anaemia as the most common hematological abnormality during pregnancy. Accurate etiological diagnosis is essential for optimal therapeutic management and thus can prevent maternal and fetal morbidity and mortality. Aim &amp;Objective:To study the clinical profile, maternal and perinatal outcomes in thrombocytopenic antenatal patients. Design:This Prospective observational study design was carried out in the department of obstetrics and gynecology at Chalmeda Anand Rao Institute of Medical sciences Karimnagar, over a period of 18 months from October 2020 to April 2022. Materials And Methods:All the pregnant women who attended antenatal OPD at Chalmeda Anand Rao Institute of Medical Sciences were tested for thrombocytopenia. 70 pregnant women with thrombocytopenia, platelet count lessthan 150x 109 /L and 70 pregnant women with normal platelet count were recruited into the study and the maternal &amp; Fetal outcomes of both groups were studied and compared. Results: Gestational thrombocytopenia is the most common etiology (57.1%). Incidence of thrombocytopenia due to severe preeclampsia and Hemolysis, Elevated Liver enzymes, Low Platelet (HELLP) syndrome in the study group was 28.5% and 8.5% of them had medical cause like malarial or dengue fever. Major causes were gestational thrombocytopenia (GT), Idiopathic Thrombocytopenic Purpura (ITP), Preeclampsia, HELLP syndrome, Malaria, and Dengue. Maternal complications due to bleeding tendencies like placental abruption, Postpartumhemorrhage were evident in the study population. Fetal complications were significantly higher in the study group. Early neonatal thrombocytopenia depended on etiology rather than severity of maternal thrombocytopenia. Conclusions:Outcome of pregnancy with moderate to severe thrombocytopenia dependsmainly on the etiology of thrombocytopenia. Adverse outcomes are especially seen with pregnancy complicated by preeclampsia and HELLP syndrome. Fetomaternal outcome is favorable in gestational thrombocytopenia. Thus, accurate etiological diagnosis is essential for optimal therapeutic management.

An Unusual Cause of Acute Kidney Injury in Pregnancy: Beware of HELLP Look-Alikes

The differential diagnosis between new occurrence or revelation of chronic kidney diseases in pregnancy and hypertensive disorders of pregnancy is not easy, and the presence of a hypertensive disorder superimposed on a glomerular disease is even more challenging, as this case exemplifies. A 29-year-old woman was referred with HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome at the end of her pregnancy. Immediately after cesarean delivery, she developed anuria, unexplained by blood loss or hypotension, and in the absence of known nephrotoxic drugs. While the laboratory features of HELLP rapidly resolved, AKI persisted, and the finding of high-level proteinuria was the hint leading to diagnosis of a glomerular disease (focal segmental glomerulosclerosis, FSGS), later proven by kidney biopsy. This case, reporting on the rare association between HELLP and FSGS, offers the opportunity to discuss the role of proteinuria, hypertension, and in the differential diagnosis of pregnancy-related acute kidney injury (pAKI).

Abstract 13924: Impact of a Pandemic on Women Diagnosed With Peripartum Cardiomyopathy

Background: Peripartum cardiomyopathy (PPCM) is a dilated form of cardiomyopathy that occurs during the last month of pregnancy or up to five months postpartum. Approximately 1,100 women develop PPCM in the United States each year. The aim of our study is to compare the incidence of PPCM prior to the start of the Coronavirus Disease 2019 (COVID) pandemic to afterwards and to determine the impact of COVID on hospitalized patients with PPCM. Methods: This was a retrospective study of 2,286 patients with a diagnosis of PPCM who were admitted to a private hospital system across the United States between the year 2017 and year 2021. There was 1,790 patients in the pre-COVID cohort, and 496 patients in the COVID era cohort. Demographics of patients were collected, with t-test and chi square p-values utilization for statistical description. Results: The mean age of women was 32.13 years. In the COVID era cohort, the percentage of Hispanic patients was significantly higher than the pre-COVID era (16.84% vs. 12.34%, p=0.012). In the COVID era, patients were more likely to have preeclampsia (20.16% vs. 13.52%, p&lt;0.001), HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome (2.62% vs. 0.61%, p&lt;0.001), respiratory failure (19.56% vs. 10.57%, p&lt;0.001), and myocardial infarction (3.63% vs. 1.90%, p=0.022). There was no significant difference in troponin and d-dimer values between the two era cohorts. The average length of stay, percentage of patients admitted to the intensive care unit (ICU), and death did not significantly differ between the pre-COVID and COVID era cohorts. Conclusion: In our study, although there was no significant difference in length of stay, ICU admission, or death in the COVID era cohort, myocardial infarction, preeclampsia, HELLP syndrome, and respiratory failure were each more prevalent in women with PPCM during the COVID era. These findings might indicate suboptimal access to outpatient and inpatient medical care during the COVID pandemic, which could have led to these more serious diagnoses.

Predictors of ICU admission in patients with peripartum cardiomyopathy

Abstract Background Peripartum cardiomyopathy (PPCM) is a dilated cardiomyopathy that affects women in the peripartum period. The incidence of PPCM in the United States is 1,100 women per year. We studied the admission of women diagnosed with PPCM to the intensive care unit (ICU) with the goal of identifying factors that increase risk for adverse outcomes. Methods This was a retrospective study of 2,286 patients with a diagnosis of PPCM admitted to a private hospital system across the United States between the years 2017 and 2021. Logistical regression analysis was utilized to identify specific patient characteristics and risk factors that were associated with admission to the ICU. Results The average age of patients was 32.13 years. The patient cohort was 39.76% black, 39.15% white, and 13.12% Hispanic. The average length of stay was 3.35 days. Preeclampsia was present in 342 (14.96%) patients, cerebral infarction in 31 (1.36%) patients, eclampsia in 48 (2.10%) patients, myocardial infarction (MI) in 52 (2.27%) patients, and HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome in 24 (1.05%) patients. There was a total of 504 (22.05%) patients admitted to the ICU. Preeclampsia (adjusted odds ratio [adj. OR] 1.588, 95% confidence interval [CI] 1.215–2.074, p&amp;lt;0.001), eclampsia (adj. OR 3.131, 95% CI 1.718–5.708, p&amp;lt;0.001), cerebral infarction (adj. OR 4.381, 95% CI 2.028–9.463, p&amp;lt;0.001), age (adj. OR 0.967, 95% CI 0.953–0.982, p&amp;lt;0.001), MI (adj. OR 2.961, 95% CI 1.608–5.455, p&amp;lt;0.001), and HELLP syndrome (adj. OR 4.655, 95% CI 1.926–11.256, p&amp;lt;0.001) were all associated with increased odds of requiring ICU level of care. However, hypertension, d-dimer level, troponin level, active tobacco smoking, alcohol use, and diabetes mellitus were not associated with increased likelihood of admission to the ICU. Conclusion In our study of 2,286 women with PPCM, we found statistically significant predictors of ICU admission included age, HELLP syndrome, eclampsia, preeclampsia, MI, and cerebral infarction. This data may be useful for the early identification and triaging of patients with PPCM that require higher level of care. These results can be utilized in developing a risk score to assist in this goal. Funding Acknowledgement Type of funding sources: Private hospital(s). Main funding source(s): HCA-Riverside Community Hospital

Diagnosis and management of thrombocytopenia in pregnancy.

Thrombocytopenia, defined as platelet count <150×109/L, is frequently observed by physicians during pregnancy, with an incidence of approximately 10% of all pregnancies. Most of the cases of thrombocytopenia in pregnancy are due to gestational thrombocytopenia, which does not confer an increased risk of maternal bleeding. However, because other causes can be associated with life-threatening events, such as severe bleeding, that can affect to maternal and fetal outcomes, differentiating other cause of thrombocytopenia, which includes preeclampsia, HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome, acute fatty liver of pregnancy, immune thrombocytopenia, hereditary thrombocytopenia, antiphospholipid syndrome, thrombotic thrombocytopenic purpura, and atypical hemolytic uremic syndrome, is important. Understanding the mechanisms and recognition of symptoms and signs are important to decide an adequate line of investigation. In this review, the approach to diagnosis and the management of the thrombocytopenia commonly observed in pregnancy are presented.

Evidence of Anxiety, Depression and Learning Impairments following Prenatal Hypertension.

Background: Hypertensive disorders of pregnancy, such as Preeclampsia (PreE) and HELLP (hemolysis, elevated liver enzyme, low platelet) syndrome, affects approximately 5–10% of pregnancies and increases the risk of women developing disorders, such as anxiety or depression, in the postpartum period. Using preclinical rodent models, we set out to determine whether rats with a history of PreE or HELLP had evidence of anxiety, depression or cognitive impairment and whether immune suppression during pregnancy prevented these changes in mood and/or cognition. Methods: Timed-pregnant rats were infused with sFlt-1 and/or sEng to induce PreE or HELLP beginning on gestational day 12. After delivery, a battery of validated behavioral assays was used to assess post-partum depression, anxiety and learning. Results: There was no negative effect on maternal pup interaction due to PreE or HELLP; however, hypertensive dams spent more time immobile in the forced swim test (p < 0.0001). Hypertensive dams also spent less time in the open area of the open field (p = 0.001). There were no significant changes in recognition memory (p = 0.08); however, spatial learning was impaired in hypertensive dams (p = 0.003). Immobility time in the forced swim test was positively correlated with increased circulating S100B (p = 0.04), while increased time spent in the outer zones of the open field was negatively correlated with BDNF levels (p < 0.0001). Conclusion: The results from this study suggest that hypertensive pregnancy disorders are associated with depression, anxiety and learning impairments in the post-partum period.

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).

Therapeutic plasma exchange in HELLP syndrome: A life savior.

BACKGROUND:HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome occurs in about 0.5%–0.9% of all pregnancies, but its prevalence is higher in patients with severe preeclampsia, accounting for a substantial maternal and perinatal morbidity and mortality. According to the latest American Society for Apheresis guidelines, Therapeutic plasma exchange (TPE) performed for postpartum cases and antepartum HELLP syndrome cases fall in Categories III and IV, respectively.MATERIALS AND METHODS:Retrospective analysis was done at our tertiary care center from January 2014 to June 2019 for patients diagnosed with HELLP syndrome. Clinical data for age, gestational age at the time of diagnosis, type of delivery, outcome of pregnancy, history of preeclampsia /eclampsia, hemoglobin levels, AST, ALT, LDH, platelet counts, prothrombin time, activated partial thromboplastin time, international normalised ratio, complete blood count, was obtained from patients' electronic medical records. The TPE was initiated within 24 hrs of diagnosis. All TPE was done on Spectra Optia apheresis system (Terumo BCT, Inc, USA). Statistical testing was conducted with the statistical package for the social science system version SPSS 20.0 and R-3.2.0. Continuous variables were expressed as mean±SD and were compared between Pre and Post TPE records of patients by using the paired T test.RESULTS:Nine patients fulfilled the criteria of HELLP syndrome. Seven (77.8%) were diagnosed in the postpartum period and 2 (22.2%) during the second trimester. Out of the total nine patients, two patients (22.2%) recovered completely and were discharged on day 15 ± 7 days, whereas 4 (44.4%) patients were discharged on day 21 ± 7 days with the advice of hemodialysis. Two (22.2%) patients had an intrauterine death and were discharged 3–4 days after the demise. In all these patients (except one), the TPE was initiated within 24 h of the diagnosis. A significant increase in platelet count and decrease in the lactate dehydrogenase levels (P < 0.05) was observed post TPE.CONCLUSION:Our data showed that TPE improved the treatment outcome in patients with HELLP syndrome despite being a Category III and IV indication among postpartum and antenatal females, respectively. However, a timely diagnosis and management are of paramount importance for a favorable outcome. TPE needs to be performed within 24 h of the diagnosis postdelivery when the patient is not responsive to the usual therapies, especially in class I HELLP syndrome.

EFFICACY OF MAGNESIUM SULPHATE ON MATERNAL MORBIDITY AND MORTALITY IN ECLAMPSIA

Objective: To study efficacy of Magnesium Sulphate in reducing maternal morbidity and mortality in patients presenting with eclampsia.&#x0D; Study Design: Prospective observational study.&#x0D; Place and Duration of Study: Gynae/Obs Department, Combined Military Hospital Bannu, from Jan 2018 Sep 2019.&#x0D; Methodology: A total of 134 patients fulfilling inclusion criteria were included in the study. Patient management was multidisciplinary. Convulsions were controlled by 4gram magnesium sulphate intravenously over 20 minutes as a loading dose, followed by 1gram per hour of maintenance infusion. Blood pressure was controlled with injection Labetalol 10 milligram followed by injection Hydralazine repeated after every 20 minutes till the blood pressure was controlled.&#x0D; Results: A total of 134 patients had eclampsia constituting 6.8% of obstetric admissions. Case fatality was 14 (10.4%) while 120 (89.55%) of the cases responded well to treatment and survived the event. Mean age of patients was 22 years. Thirty patients 22.4% were booked and 104 patients 77.6% were un-booked. Mostly patients 122 (91%) came from rural area and only 12 (9%) were from urban areas with booked pregnancies having regular antenatal visits. One hundred and twenty six (94%) patients with eclampsia presented in antenatal period and only 8 (6%) presented in post natal period. Mode of delivery was cesarean section in 87 (64.9%) and 47 (35.1%) delivered vaginally. Frequency of patient requiring ventilator support, acute renal failure,disseminated intravascular coagulation, adult respiratory distress syndrome, HELLP (hemolysis, elevated liver enzymes, low platelet) syndrome was 11 (8.2%), 46 (34.3%), 43 (32.1%), 35 (26.1%), 7 (5.2%) respectively..........

Can First-trimester AST to Platelet Ratio Index Scores Predict HELLP Syndrome?

To determine whether the ratio of the first-trimester aspartate aminotransferase (AST) to platelet ratio index (APRI) score will be useful as a new determinant of hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome that may develop in the later stages of pregnancy Study Design: Descriptive-analytical study. Perinatology Clinic of Etlik Zübeyde Hanım Maternity and Women's Health Teaching and Research Hospital, Ankara, Turkey. The data of patients diagnosed as having HELLP syndrome between 2018 and 2020 were analyzed retrospectively. Forty-two pregnant women with HELLP syndrome as the study group and 74 pregnant women with no morbidities as the control group were included in the study. First-trimester APRI scores were compared for both the groups. A characteristic curve (ROC) analysis of the study was performed to determine the APRI score levels predicting HELLP syndrome. One hundred and sixteen women with HELLP syndrome had significantly lower fibrinogen levels and platelet (PLT) levels than women without HELLP syndrome (p<0.001). Women with HELLP syndrome had significantly higher ALT, AST, creatinine, and INR levels. These differences were significantly different (p<0.001). Women who developed HELLP syndrome in the third trimester of pregnancy had significantly higher first-trimester APRI scores (0.64±0.10) than the control group (0.40±0.12, p<0.001). In the ROC analysis, 0.55 as a cut-off value for first-trimester APRI scores had a sensitivity of 88.1 % and a specificity of 94.6 % for predicting HELLP syndrome developing in the third trimester of pregnancy. There was an association of first-trimester APRI scores with the prediction of HELLP syndrome, possibly developing in the later weeks of pregnancy. Predicting HELLP syndrome in the early period can assist in proper management and taking necessary precautions. Key Words: HELLP syndrome prediction, First-trimester APRI, APRI scores in pregnancy, APRI score.

Fenotyp akútneho hepatálneho zlyhania pri inaparentnom malobunkovom karcinóme pľúc

Acute liver failure is defined by the manifestation of liver failure from 7th to 21st day in a previously healthy liver. The most frequent causes are viral hepatitis B, A, E, drug or toxin-induced hepatotoxicity (Amanita phalloides), rarely Wilson’s disease, autoimmune hepatitis, HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome, or vascular causes (Budd-Chiari syndrome, hypoxic hepatitis). We present a 71-year- -old female patient with metabolic syndrome admitted to hospital with cholestasis, progression of weakness, abdominal pain, and breathlessness. Because of suspected pleuropneumonia, the treatment with ceftriaxone/metronidazole was initiated. Due to cholestasis progression and suspicion of drug-induced liver toxicity, the treatment was stopped on 5th day. Imaging methods (ultrasonography, CT, magnetic resonance imaging) found multiple small liver lesions, suspected metastatic involvement, which was not confirmed by positron emission tomography – computed tomography. Due to the rapid progression of the patient’s condition with the onset of icterus, ascites, encephalopathy, a liver bio­psy was not done. The patient died on the 17th day of hospitalization. The primary tumour was not detected during her life, and not by pathological section. The diffuse metastasis of small cell lung cancer (SCLC) in the liver was found by histological post mortem examination. The case report suggests high invasiveness of SCLC with a possibility of unusual manifestation in a form of acute hepatic failure.

MAJOR OBSTETRICAL COMPLICATIONS IN AN ELDERLY PRIMIPAROUS WITH A MULTITUDE OF PRE-EXISTING PATHOLOGIES

The number of primiparous pregnant women, over the age of 35, has increased considerably in the past few years, because of the elevated level of education and also because the multitude of contraceptive methods. Such a patient suits the category of elderly primiparous and it represents a real obstetrical challenge, due to the numerous complications related to pregnancy and the immediate postpartum, as well as those related to the neonatal prognosis. We present a 35 old years patient, second gestation, primiparous, a partially monitored pregnancy, known with essential hypertension grade III ESC / ESA, insufficiently controlled therapeutically, with target organ damage (exudative retinal detachment, hypertensive choroidopathy), morbid obesity and also with the suspicion of a renal tumor. The rate of complications occurring in the case of an elderly primiparous was increased in the present case. Obstetrical complications occurred: preeclampsia, HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome, placental abnormalities (placenta accreta), intrauterine growth restriction, chronic fetal distress and finally fetal death in utero. The evolution of the patient in postpartum was burdened by the decompensation of the pre-existing pathology. In conclusion, elderly primiparous is susceptible to obstetrical complications during pregnancy and childbirth, such as premature birth, fetal acute distress, which may result in fetal death, placental abruption, placental abnormalities, preeclampsia, eclampsia, therefore following up the pregnancy requires increased attention and is also a real challenge for the obstetrician.

Acute kidney injury during pregnancy leads to increased sFlt-1 and sEng and decreased renal T regulatory cells in pregnant rats with HELLP syndrome

BackgroundThe incidence of acute kidney injury (AKI) during pregnancy precedes a high maternal mortality rate of 20–40%. AKI during pregnancy has multiple etiologies; however, the more common are maternal hypertensive disorders, which include preeclampsia and HELLP (hemolysis, elevated liver enzyme, low platelet) syndrome. Therefore, we sought to assess the impact of AKI on blood pressure, kidney injury, and anti-angiogenic factors during pregnancies with and without HELLP syndrome.MethodsOn gestational day (GD) 12, mini-osmotic pumps were inserted into a subset of normal pregnant (NP) rats infusing 4.7 μg/kg soluble fms-like tyrosine kinase-1 (sFlt-1) and 7 μg/kg soluble endoglin (sEng) to induce HELLP syndrome. On GD18, the renal pedicles were occluded for 45 min to induce AKI via bilateral ischemia reperfusion in a subset of NP (n = 18) or HELLP (n = 20) rats. Control NP (n = 20) and HELLP (n = 20) rats underwent a SHAM surgery on GD18. Plasma, urine, and maternal organs were saved for further analysis. Renal injury was assessed via renal histopathology, glomerular filtration rate (GFR), T cell infiltration, and assessment of kidney injury molecule-1 (KIM-1) and neutrophil gelatinase-associated lipocalin (NGAL). Data was measured via two-way analysis of variance with Tukey’s test for post hoc analysis.ResultsBlood pressures were increased in HELLP+AKI rats (p = 0.0001); both NP+AKI and HELLP+AKI rats had increased lactate dehydrogenase (p < 0.0001) and aspartate aminotransferase levels (p < 0.0001), and decreased platelet levels (p < 0.001) vs. NP rats. HELLP+AKI (p = 0.002) and HELLP rats (p = 0.0002) had evidence of renal fibrosis vs. NP rats. GFR was decreased in HELLP+AKI (p = 0.01) rats vs. NP rats. Urinary KIM-1 was increased in NP+AKI rats vs. NP (p = 0.003) and HELLP rats (p = 0.01). HELLP+AKI rats had increased urinary KIM-1 vs. NP (p = 0.0008) and HELLP rats (p = 0.004) and increased NGAL vs. HELLP rats (p = 0.002). HELLP+AKI rats had increased sFlt-1 (p = 0.009) vs. NP rats. NP+AKI (p = 0.02) and HELLP+AKI (p = 0.007) rats had increased sEng vs. NP rats. CD3+CD4+ T cells were significantly increased in HELLP+AKI rats vs. NP (p = 0.0002) and NP+AKI (p = 0.05) rats. T regulatory cells were significantly decreased in HELLP+AKI (p = 0.03) and NP+AKI (p = 0.02) rats vs. NP rats; there were no changes between groups in T helper 17 cells (p = 0.34).ConclusionThe findings in this study suggest that AKI during pregnancy contributes to increased blood pressure and biochemical markers for HELLP syndrome, creates an anti-angiogenic imbalance, and exacerbates kidney injury as shown on histopathology, GFR, and kidney injury markers.