Edema associated with low plasma protein level and any gestational hypertension as warning signs of HELLP syndrome

Abstract

Purpose: Because preeclampsia is a multisystem disorder, its definition has recently been revised, including cases with evidence of renal, liver, neurological, or hematological dysfunction. However, the role of edema remains unclear. While the presence of mild edema is common in normal pregnancy, in severe preeclampsia protein transfer from the vascular into the interstitial compartment could lead to low serum protein level and favor the transport of fluid to the interstitial compartment.

Materials and methods, Results: Over a 4-year period, 9749 women have given birth in our university maternity ward. In this period of time, 86 women developed severe preeclampsia. Among them, we retrospectively identified nine patients who first presented with mild de novo hypertension or preeclampsia, extensive edema or excessive gestational weight gain (GWG), and documented low serum protein levels; five patients also reported headache. Serum protein levels ranged from 51 to 56 g/l. We analyzed the progression of the disease in these women, and found that these patients developed criteria for complete or partial hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome in four and five cases, respectively. All patients were delivered quickly of healthy babies, and no other maternal adverse outcomes occurred.

Discussion: As plasma proteins are the primary determinants of plasmatic colloid osmotic pressure (COP), headache in association with edema, low serum protein levels, and even mild hypertension, could reflect cerebral vasogenic edema with the same mechanism as for cerebral edema reported in posterior reversible encephalopathy syndrome and eclampsia. Thus, the sequential association of edema or excessive GWG with markedly low serum protein levels and mild gestational hypertension could signal the imminent development of severe preeclampsia and possibly HELLP syndrome. This sequence should be assessed in additional large-scale prospective studies.

Keywords:

• Edema
• gestational weight gain
• headache
• severe preeclampsia
• HELLP syndrome
• pregnancy-induced hypertension
• low serum protein level

Ethics approval and consent to participate

All pregnant women booked to deliver in our university hospital are informed of the follow-up schedule and that perinatal data (excluding individual details, images or videos) are routinely entered at birth into an electronic record-keeping system for contributions to the mandatory national “Programme de Médicalisation des Systèmes d' Information” (PMSI) database. Written informed consent is obtained from all women, and the database has been declared to the French data protection authority (Commission Nationale de l’Informatique et des Libertés [CNIL]).

This short report is a retrospective description of clinical biological findings obtained from this database during the observed course of events that document an undescribed aspect of the course of the severe preeclampsia. There was no hypothesis testing and no systematic data collection beyond that which was part of routine clinical practice, and the dataset used in the present case series is fully anonymous, containing the minimum level of detail necessary to reproduce clinical items and all numbers reported in the paper, without any identifying features, providing to patients the highest degree of confidentiality.

Disclosure statement

The authors declare that they have no competing interests.

Author contributions

LC: Study conception and design; LC and JB: Analysis and interpretation of data; LC: Drafting of manuscript.

Data availability statement

All data analyzed and used in the study may be shared with other researchers on request provided the data comply with the same standards as the main dataset.