Kenneth G. Perry

The natural history of HELLP syndrome: patterns of disease progression and regression.

Despite much recent interest in HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count), there is little published information about the natural history of this unique form of severe preeclampsia-eclampsia. The time course and pattern of laboratory abnormalities for 158 patients with HELLP syndrome managed in a single tertiary referral center between 1980 and 1989 were studied retrospectively. Despite considerable patient variation, most gravid women with HELLP syndrome had decreasing platelet counts until 24 to 48 hours after delivery. Conversely, lactate dehydrogenase concentrations usually peaked 24 to 48 hours post partum. In all patients who recovered, a platelet count greater than 1,000,000/mm3 was spontaneously achieved by the sixth postpartum day or within 72 hours of platelet nadir. An upward trend in platelet count and a downward trend in lactate dehydrogenase concentrations should be apparent in patients without complications by the fourth postpartum day. These data provide baseline information against which the course of individual patients can be compared and the infrequent, atypical case identified for interventive therapy.

pregnancy Complicated by Preeclampsia-eclampsia With the Syndrome of Hemolysis, Elevated Liver Enzymes, and Low Platelet Count : how Rapid is Postpartum Recovery?

The rapidity of postpartum disease recovery for severe preeclampsia associated with hemolysis, elevated liver enzymes, and low platelet count (HELLP syndrome) has not been well studied. Between January 1980 and March 1989, 158 pregnancies with preeclampsia-eclampsia complicated by HELLP syndrome were managed at the University of Mississippi Medical Center. The 70 patients with platelet nadir below 50,000/microL (class 1 HELLP syndrome) required as long as 11 days for all members to achieve a platelet recovery concentration of more than 100,000/microL, whereas all 88 gravidas with platelet nadir between 50,000-100,000/microL (class 2 HELLP syndrome) exceeded this platelet concentration by the sixth postpartum day, a statistically significant difference (P less than .0001). The interval between delivery and the onset of diuresis (mean +/- SD) was significantly longer in class 1 than in class 2 patients with milder disease (22.7 +/- 18.9 compared with 15.9 +/- 11.1 hours). Significantly more postpartum days were required in class 1 than in class 2 HELLP parturients for the lactic dehydrogenase (LDH) concentration to decrease below 500 IU/L (4.2 +/- 4.9 compared with 3.2 +/- 2.7 days). No women in the class 2 group required plasma exchange therapy to effect disease arrest and reversal, but 11 of 58 severely ill women in class 1 were treated with this modality. We conclude that the platelet count and LDH serum concentration, as indicators of HELLP severity and recovery, are clinically useful tools and that a more protracted postpartum recovery period should be expected for progressively severe expressions of HELLP syndrome.

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.

Postpartum corticosteroids: accelerated recovery from the syndrome of hemolysis, elevated liver enzymes, and low platelets (HELLP).

OBJECTIVE Because most morbidity and mortality associated with atypical preeclampsia and the syndrome of hemolysis, elevated liver enzymes, and low platelets is a postpartum phenomenon, we undertook this investigation to evaluate the use of high-dose corticosteroids to minimize maternal morbidity and accelerate postpartum recovery in patients with this form of severe preeclampsia. STUDY DESIGN Into this prospective, randomized study 40 parturients with the syndrome were recruited. The syndrome was defined by a clinical presentation consistent with a diagnosis of severe preeclampsia or eclampsia in addition to laboratory evidence of hemolysis, hepatic dysfunction, and thrombocytopenia. Immediately post partum 20 parturients assigned to the treatment group received four doses of intravenous dexamethasone at 12-hour intervals (10 mg, 10 mg, 5 mg, 5 mg) over 36 hours. Patients assigned to the control group received no corticosteroids. All study subjects were intensively monitored by mean arterial pressure and urinary output every 2 hours, hematocrit and platelet count every 6 hours and lactic dehydrogenase, aspartate aminotransferase, and alanine aminotransferase every 12 hours for the first 48 hours post partum. RESULTS The steroid-treated group with the syndrome of hemolysis, elevated liver enzymes, and low platelets had significant changes over time in mean arterial pressure, urinary output, platelet count, lactic dehydrogenase and aspartate aminotransferase versus the control group with the syndrome. Relative to the control group, the mean arterial pressure became significantly decreased at 22 hours in the steroid-treated group (p < 0.03), urinary output increased significantly by 16 hours (p < 0.02), the platelet count increased significantly by 24 hours (p < 0.05), and both lactic dehydrogenase and aspartate aminotransferase decreased significantly by 36 hours (p < 0.04 and p < 0.05, respectively). CONCLUSIONS In association with high-dose corticosteroid administration, parturients with the syndrome of hemolysis, elevated liver enzymes, and low platelets recovered from the disease process more rapidly than did control subjects, as measured by urinary output, mean arterial pressure, platelet count, lactic dehydrogenase, and aspartate aminotransferase. In this disease process, which has significant associated morbidity and mortality, especially in patients with advanced cases, high-dose corticosteroid therapy appears to significantly hasten recovery and lessen the severity of the disease post partum. We postulate that use of this therapeutic approach in properly selected patients could result in lessened overall maternal morbidity and mortality, shorter patient stays in recovery and intensive-care areas, and shorter overall hospitalization with reduced medical care costs.

Better maternal outcomes are achieved with dexamethasone therapy for postpartum HELLP (hemolysis, elevated liver enzymes, and thrombocytopenia) syndrome ☆ ☆☆ ★ ★★

OBJECTIVE Our purpose was to determine whether the routine initiation of dexamethasone therapy in patients with postpartum HELLP (hemolysis, elevated liver enzymes, and thrombocytopenia) syndrome produces specific and general therapeutic benefits. STUDY DESIGN In this retrospective, analytic study the puerperal courses of 43 women with postpartum HELLP syndrome who were treated with dexamethasone were compared with those of 237 similar patients who did not receive corticosteroids. Dexamethasone 10 mg intravenously at 12-hour intervals was given until disease remission was noted in treated patients, at which time up to two additional 5 mg intravenous doses were given at 12-hour intervals. RESULTS The two patient groups were similar in regard to mode of delivery, gestational age, parity, and frequency of eclampsia. Compared with control subjects, dexamethasone-treated postpartum patients were more ill with significantly higher (p < 0.05) admission mean arterial blood pressure, higher serum uric acid level, and severe proteinuria. Dexamethasone administration was associated with a more rapid normalization of platelet counts and lactic dehydrogenase values. Most impressive was a clinically significant reduction of indicated transfusion and respiratory therapy, invasive hemodynamic monitoring, infectious or bleeding-related morbidity, and length of postpartum hospital course. CONCLUSIONS Patients who received dexamethasone for postpartum-onset HELLP syndrome experienced a shorter disease course, faster recovery, less morbidity, and less need for other interventionist therapy compared with patients with HELLP syndrome who did not receive dexamethasone.

Trauma in pregnancy: The role of interpersonal violence

OBJECTIVE Our purpose was to determine what role interpersonal violence as intentional injury plays in the pregnant trauma victim. STUDY DESIGN We performed a retrospective review of medical records. RESULTS During a 9-year period in a single university medical and trauma center, 203 pregnant women were treated for a physically traumatic event. Sixty-four women (31.5%) were victims of intentional injury, in most cases by the husband or boyfriend. Although the mean Injury Severity Score was higher in women with fetal death than in women with successful pregnancy outcomes (7.25 vs 1.74, respectively; p < 0.01), 5 of the 8 women with fetal losses incurred these despite an apparent absence of physical injury (maternal Injury Severity Score = 0). CONCLUSIONS Interpersonal violence during pregnancy is a frequent and increasingly common cause of maternal injury. The inconsistent relationship between Injury Severity Score and serious fetal injury or death is underscored by the loss of 5 fetuses despite an Injury Severity Score of 0.

Abnormal Hemostasis and Coagulopathy in Preeclampsia and Eclampsia

Preeclampsia and eclampsia appear to be a state of increased coagulopathy as evidenced by an increase in fibrin formation, activation of the fibrinolytic system, platelet activation and a decrease in platelet count. Routine tests used to assess decompensated disseminated intravascular coagulopathy are of limited value in the preeclamptic and eclamptic population. More sophisticated tests such as determinations of antithrombin III, thrombin-antithrombin III complex, D-dimer, factor VIII antigen/activity ratio, and beta-thromboglobulin, however, show a compensated coagulopathy in the preeclamptic patient. These hemostatic changes, probably the result of endothelial damage, are implicated in the pathogenesis of this disease. A better understanding about the abnormalities of hemostasis and coagulation in the preeclamptic and eclamptic patient may allow the clinician to provide improved management and possibly peripartum therapy.

Operative vaginal delivery : A survey of fellows of ACOG

Objective To document operative vaginal delivery rates of ACOG Fellows and to stratify practice patterns with regard to mid-pelvic delivery and deep transverse arrest by the time elapsed since residency. Methods A survey was mailed to a random sample of 1600 ACOG Fellows. Of the 597 respondents (37%), 558 who still practice obstetrics formed the study group. Selection bias regarding recipients of the survey was reduced by random-ization by an uninvolved third party. The length of time since residency was categorized as 10 years or fewer (“recent,” 31%), 11–20 years (“intermediate,” 43%), and more than 20 years (“remote,” 26%). Results The majority of respondents (338 of 558, 61%) reported an operative vaginal delivery rate of 15% or less. One hundred forty-two (25%) use only forceps, whereas 78 (14%) use vacuum extraction exclusively. More than half have abandoned mid-pelvic operative vaginal deliveries, and of the 41% who still perform these operations, about half use forceps. In cases of deep transverse arrest, about 25% perform cesarean delivery, whereas 26% and 42% use forceps or vacuum, respectively. Resident training and practice in vacuum delivery were more common in the recently trained groups (recent > intermediate > remote; P < .001). There were no differences among the groups with respect to attempting mid-pelvic operative vaginal delivery (P = .29), but the remote group was more likely to use forceps, whereas the recent group was more likely to use vacuum (P = .039). A large disparity existed among the groups regarding the management of deep transverse arrest, with vacuum use associated with group assignment (P < .001). Conclusions The majority of respondents have an operative vaginal delivery rate of no more than 15%. Most respondents have abandoned mid-pelvic operative vaginal delivery. Practice patterns reflect differences in residency training; the more recently trained Fellows more often were taught and use vacuum for delivery.

Adjunctive antibiotic treatment of women with preterm rupture of membranes or preterm labor.

Subclinical infection is associated with pre‐term rupture of the membranes (PROM) and preterm labor (PTL) in many cases. It was hypothesized that antibiotic treatment might delay delivery and/or decrease infectious morbidity in those with PROM or PTL. Patients from 19 to 34 weeks with PROM and no labor or PTL with intact membranes (but not both) were separately randomized to receive ampicillin versus placebo in addition to usual therapy. There were 36 women with PTL (21 ampicillin/15 placebo) and 84 with preterm PROM (41 ampicillin/43 placebo). Demographically, the treatment and placebo groups were similar. Outcome variables analyzed included delivery delay after treatment, maternal chorioamnionitis/endometritis, Apgar score, neonatal infection, or respiratory distress, and hospital stay. There were no significant differences between the ampicillin and placebo groups in those with PTL or preterm PROM as it concerned outcome parameters. Adjunctive ampicillin used for treatment of idiopathic PTL or preterm PROM was not beneficial in this study.

The interrelationship of eclampsia, HELLP syndrome, and prematurity: cofactors for significant maternal and perinatal risk

Objective To determine if there are differences between mothers and fetuses in eclamptic pregnancies with or without concurrent HELLP syndrome.