HELLP syndrome, associated with eclampsia, preeclampsia, in one hundred cases, the complications, maternal morbidity and mortality: the near miss and missed obstetric scenarios

Authors

  • Pratibha Devabhaktuni Department of Obstetrics and Gynaecology, Modern Government Maternity Hospital, Osmania Medical College, Hyderabad, Telangana, India; Department of Obstetrics and Gynaecology, CARE Institute of Medical Sciences, Hyderabad, Telangana, India
  • Malathi Ponnuru Department of Obstetrics and Gynaecology, Modern Government Maternity Hospital, Osmania Medical College, Hyderabad, Telangana, India
  • Lahari R. Vangala Department of Obstetrics and Gynaecology, Modern Government Maternity Hospital, Osmania Medical College, Hyderabad, Telangana, India

DOI:

https://doi.org/10.18203/2320-1770.ijrcog20232929

Keywords:

Preeclampsia, Eclampsia, HELLP syndrome, AFLP, Maternal mortality

Abstract

Background: The investigations done, complications observed, mode of delivery, management of complications, the perinatal outcome, the maternal mortality, the lessons learnt have been outlined. The referral to higher tertiary care Institutes has been analysed. The goals of management were, control of hypertension, prevention of convulsions, assessment of the severity of HELLP syndrome, identification of associated complications and chances of fetal salvage, a decision to be made regarding the mode of delivery, keeping the blood products ready, anaesthetist and paediatrician to be informed, consultation of nephrologist, cardiologist, neurophysician, ophthalmologist, gastroenterologist, surgeon as required in the particular case and continued vigilance in the postpartum period.

Methods: This is a prospective observational study of one hundred cases of HELLP syndrome managed at two tertiary care Institutes. Twenty-five cases, managed at CARE Institute of Medical sciences, during the years 2011 to 2013 and 75 cases from the Institute of Obstetrics and Gynaecology at Modern Government Maternity Hospital, MGMH, Osmania Medical College, OMC, between 2021 to 2023, were included in the study.

Results: Labour was induced, in 47.29%, vaginal delivery in 28 cases, 37.83% and lower segment caesarean section (LSCS) was needed in 46, 62.16% in the study. A total of 90.66% of HELLP have occurred in the third trimester of pregnancy. Eclampsia was associated with HELLP syndrome in 39/100=39%. The remaining 61 cases had preeclampsia associated HELLP syndrome. PRAKI in 31/100=31%, DIC in 19%, PRES in 7/100, PPCM 2%, PPH in 18=24%, maternal mortality in 17/100=17%.

Conclusions: Delivery by 37 weeks would have clearly prevented 36% of cases. Delivery by 35 weeks would have prevented 61% of cases of HELLP syndrome.

References

Weinstein L. Syndrome of hemolysis, elevated liver enzymes, and low platelet count: a severe consequence of hypertension in pregnancy. 1982. Am J Obstet Gynecol 2005;193:859.

Audibert F, Friedman SA, Frangieh AY, Sibai BM. Clinical utility of strict diagnostic criteria for the HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome. Am J Obstet Gynecol. 1996;175:460-4.

Sibai BM. Diagnosis, controversies, and management of the syndrome of hemolysis, elevated liver enzymes, and low platelet count. Obstet Gynecol. 2004;103:981-91.

Martin JN Jr, Rinehart BK, May WL, Magann EF, Terrone DA, Blake PG. The spectrum of severe preeclampsia: comparative analysis by HELLP (hemolysis, elevated liver enzyme levels, and low platelet count) syndrome classification. Am J Obstet Gynecol. 1999;180:1373-84.

Special bulletin on maternal mortality in India 2018-20. Sample registration system office of the registrar general, India. 2022.

Isler CM, Rinehart BK, Terrone DA, Martin RW, Magann EF, Martin JN Jr. Maternal mortality associated with HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome. Am J Obstet Gynecol. 1999;181:924-8.

Mihu D, Costin N, Mihu CM, Seicean A, Ciortea R. HELLP syndrome – a multi systemic disorder. J Gastrointestin Liver Dis. 2007;16:419-24.

Devabhaktuni P, Ponnuru M, Vangala LR, Bommakanti L, Nawinne M, Komatlapalli S. HELLP syndrome on the rise: a major cause of maternal deaths. Int J Reprod Contracept Obstet Gynecol. 2022;11:1644-53.

Kaur AP, Kaur N, Dhillon SPS. HELLP syndrome and its implications on maternal and perinatal outcome. Int J Reprod Contracept Obstet Gynecol. 2018;7(3):1007-11.

Ağaçayak E, Bugday R, Peker N, Deger U, Kavak GO, Evsen MS, et al. Factors Affecting ICU Stay and Length of Stay in the ICU in Patients with HELLP Syndrome in a Tertiary Referral Hospital. Int J Hypertens. 2022;3366879.

Osmanagaoglu MA, Osmanagaoglu S, Ulusoy H, Bozkaya H. Maternal outcome in HELLP syndrome requiring intensive care. Am J Obstet Gynecol. 2000;36(183):444-8.

Ellison J, Sattar N, Greer I. HELLP syndrome: mechanisms and management. Hosp Med. 1999;60:243-9.

Arslan E. COVID-19: a cause of HELLP syndrome? A case report. IJWH. 2022;14:617-23.

Lillicrap D. Disseminated intravascular coagulation in patients with 2019-nCoV pneumonia. J Thromb Haemost. 2020;18(04):786-7.

Arslan E. COVID-19: A Cause of HELLP Syndrome? A Case Report. Int J Women’s Health. 2022;14:617:23.

Norooznezhad AH, Nurzadeh M, Darabi MH, Naemi M. Coronavirus disease 2019 (COVID-19) in a pregnant women with treatment resistance thrombocytopenic purpura with and suspicion to HELLP syndrome: a case report. BMC Pregnancy and Childbirth. 2021;21:567.

Mahajan O, Talwar D, Kumar S, Jaiswal A, Madaan S, Khanna S, Shah D. Fatal HELLP syndrome in pregnancy: A sequelae of Long COVID? Med Sci. 2021;25(114):1878-81.

Ronnje L, Länsberg JK, Vikhareva O, Hansson SR, Herbst A, Zaigham M. Complicated COVID 19 in pregnancy: A case report with severe liver and coagulation dysfunction promptly improved by delivery. BMC Pregnancy Childbirth. 2020;20:18.

Koopmans CM, Bijlenga D, Groen H, Vijgen SM, Aarnoudse JG, Bekedam DJ, et al. Induction of labour versus expectant monitoring for gestational hypertension or mild preeclampsia after 36 weeks’ gestation (HYPITAT): a multicentre, open-label randomised controlled trial. HYPITAT study group. Lancet. 2009;374:979-88.

Koopmans CM, Bijlenga D, Groen H, Vijgen SM, Aarnoudse JG, Bekedam DJ, et al. Induction of labour versus expectant monitoring for gestational hypertension or mild pre-eclampsia after 36 weeks’ gestation (HYPITAT): a multicentre, open-label randomised controlled trial. HYPITAT study group. Lancet. 2009;374:979-88.

Alam A, Choi S. Prophylactic use of tranexamic acid for postpartum bleeding outcomes: A systematic review and meta-analysis of randomized controlled trials. Transfus Med Rev. 2015;29:231-41.

WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet. 2017;389(10084):2105-16.

Wang L, Gan Q, Du S, Zhao Y, Sun G, Lin Y, Li R. Acute fatty liver of pregnancy cases in a maternal and child health hospital of China: three case reports. Medicine. 2020;99:29(e21110).

Sitaula S, Agrawal A, Thakur A, Manandhar T, Thapa BD, Dhamala J. Acute Fatty Liver of Pregnancy: A Life Threatening Condition. Nep J Obstet Gynecol. 2020;15(30):79-80.

Byrne JJ, Seasely A, Nelson DB. Comparing acute fatty liver of pregnancy from hemolysis, elevated liver enzymes, and low platelets syndrome. J Matern Fetal Neonatal Med. 2020;1-11.

Gedik E, Yucel N, Sahin T, Koca E, Colak YZ, Togal T. Hemolysis, elevated liver enzymes, and low platelet syndrome: outcomes for patients admitted to intensive care at a tertiary referral hospital. Hypertens Pregnancy. 2017;36:21-9.

Erdemoglu M, Kuyumcuoglu U, Kale A, Akdeniz N. Factors affecting maternal and perinatal outcomes in HELLP syndrome: evaluation of 126 cases. Clin Exp Obstet Gynecol. 2010;37:213-6.

Sibai BM, Ramadan MK, Usta I, Salama M, Mercer BM, Friedman SA. Maternal morbidity and mortality in 442 pregnancies with hemolysis, elevated liver enzymes, and low platelets (HELLP syndrome). Am J Obstet Gynecol. 1993;169:1000-6.

Osmanagaoglu MA, Osmanagaoglu S, Ulusoy H, Bozkaya H. Maternal outcome in HELLP syndrome requiring intensive care. Am J Obstet Gynecol. 2000;36(183):444-8.

Gul A, Aslan H, Cebeci A, Polat I, Ulusoy S, Ceylan Y. Maternal and fetal outcomes in HELLP syndrome complicated with acute renal failure. Ren Fail. 2004;26:557-62.

Novotny S, Lee-Plenty N, Wallace K, Kassahun-Yimer W, Jayaram A, Bofill JA, et al. Acute kidney injury associated with preeclampsia or hemolysis, elevated liver enzymes, and low platelets syndrome. Pregnancy Hypertens. 2020;19:94-9.

Martínez de Ita AL, García Cáceres E, Helguera Martínez AM, Cejudo Carranza E. Acute renal insufficiency in HELLP syndrome. Ginecol Obstet Mex. 1998;66:462-8.

Wang L, Tang D, Zhao H, Lian M. Evaluation of Risk and Prognosis Factors of Acute Kidney Injury in Patients With HELLP Syndrome During Pregnancy. Front Physiol. 2021;12:650826.

Ye W, Shu H, Yu Y, Li H, Chen L, Liu J, et al. Acute kidney injury in patients with HELLP syndrome. Int Urol Nephrol. 2019;51:1199-206.

Huang C, Chen S. Acute kidney injury during pregnancy and puerperium: a retrospective study in a single center. BMC Nephrol. 2017;18:146.

Kaur AP, Kaur N, Dhillon SPS. HELLP syndrome and its implications on maternal and perinatal outcome. Int J Reprod Contracept Obstet Gynecol. 2018;7(3):1007-11.

Bahadur BR, Kodey PD, Mula A. Maternal and fetal outcome in HELLP syndrome. Int J Clin Obstet Gynaecol. 2019;3(4):140-4.

Devabhaktuni P, Ponnuru M, Vangala LR, Bommakanti L, Nawinne M, Komatlapalli S. HELLP syndrome on the rise: a major cause of maternal deaths. Int J Reprod Contracept Obstet Gynecol. 2022;11:1644-53.

Haddad B, Barton JR, Livingston JC, Chahine R, Sibai BM. Risk factors for adverse maternal outcomes among women with HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome. Am J Obstet Gynecol. 2000;183(6):1475-9.

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Published

2023-09-28

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Original Research Articles