Christopher A. Sullivan

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 preeclampsia-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 < or = 50,000/microliters, class 2 > 50,000/microliters to < or = 100,000/microliters, and class 3 > 100,000/microliters to < or = 150,000/microliters). 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 forms of preeclampsia 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.

A pilot study of intravenous ondansetron for hyperemesis gravidarum.

OBJECTIVE We attempted to determine whether the antiemetic ondansetron would be more effective than promethazine in treating hyperemesis gravidarum. STUDY DESIGN Patients with hyperemesis gravidarum who required hospital admission were randomized to receive either intravenous ondansetron (n = 15) or intravenous promethazine (n = 15) in a double-blind manner. Severity of disease was determined by electrolyte status, weight loss, ketonuria, and prior use of outpatient antiemetics. Outcome variables included degree of nausea, weight gain during treatment, days of hospitalization, and number of medication doses. RESULTS In this preliminary investigation ondansetron offered no advantage when compared with promethazine in the relief of nausea, weight gain, days of hospitalization (4.5 +/- 2.3 vs 4.5 +/- 1.5), and total doses of medication per hospitalization (2.1 +/- 1.2 vs 1.9 +/- 1.3). CONCLUSION This preliminary trial of ondansetron demonstrated no benefit over promethazine in patients hospitalized for hyperemesis gravidarum.

Management of the obstetric patient with thrombocytopenia.

Thrombocytopenia that complicates pregnancy can occur secondary to known maternal disease processes or may arise again during, and as a result of, gestation. A combination of maternal history, clinical presentation, and laboratory investigation usually leads the obstetrician to the proper diagnosis of the condition and, when necessary, dictates appropriate fetal intervention. Although the differential diagnosis of thrombocytopenia can be a frustrating and difficult exercise, especially in an emergent intrapartum environment, clinical persistence coupled with hematology consultation when appropriate usually will reward the provider and patient with the best chance to achieve optimal maternal-fetal outcome.

Corticosteroid-induced arrest of HELLP syndrome progression in a marginally-viable pregnancy

Corticosteroid therapy in preterm pregnancy complicated by severe pre-eclampsia as HELLP syndrome temporarily stabilizes the HELLP syndrome. One such patient complicated by extreme prematurity was treated with long-term high-dose corticosteroid therapy. The HELLP syndrome was temporarily stabilized and additional in utero fetal maturation was gained.

Estimate of birthweight among post-term pregnancy: Clinical versus sonographic

The objective was to compare the relative accuracy of clinical versus sonographic estimate of birthweight among post-term pregnancies (gestational age ≥41 weeks). Prospectively over a 2-year period, 84 parturients, with reliable dating criteria, underwent clinical and sonographic estimate (abdominal circumference and femur length) of birthweight. All examinations were performed during the intrapartum period in the labor and delivery suite by one of three obstetricians managing the patient. Among post-term pregnancies, the clinical estimate of birthweight had a significantly lower mean absolute error (322 ± 263 g) and mean absolute percentage error (8.9% ± 7.1%) than sonographic mensuration (547 ± 426 g, 14.8% ± 11.0%, respectively; P < 0.001). Moreover, in post-term pregnancies, clinical estimate was within ±10% of the actual birthweight (65.4%) significantly more frequently than with sonographic (42.8%) mensuration (P = 0.005). Among 20 post-term macrosomic newborns (birthweight ≥4,000 g) clinical estima...

Wound Complications Followingcesarean Delivery of Patients with Hellp Syndrome: Pfannenstiel Versus Vertical Skin Incision

Objective: We sought to determine whether vertical or Pfannenstiel skin incision was associated with fewer hemorrhagic and postoperative wound complications following cesarean delivery in patients with HELLP syndrome.Methods: As part of an extensive retrospective analysis of medical records for all patients with HELLP syndrome who delivered between January 1,1980 and June 30,1993, we investigated those delivering abdominally either using a midline or Pfannenstiel skin incision and primary skin closure.Main Outcome Measure: The principal outcome measure was wound complication as hematoma or dehiscence.Results: A total of 215 patients were identified; 185 patients received midline vertical skin incisions and 30 had Pfannenstiel incisions. In the midline group, there were 17 wound separations (17/185, 9%) and 5 other types of wound complication (total 22/185, 12%). Significantly more wound complications, as wound separation, occurred in 8 of the 30 (27%) patients with Pfannenstiel incisions (p = 0.01). The o...