Results of the Pregnancies with HELLP Syndrome

Abstract

In this study, clinical features, developing complications, and results of thirty-six patients, which were followed up in our Obstetrics and Gynecology and Nephrology departments between 1997 and 2001, with the diagnosis of HELLP syndrome were searched retrospectively. The mean age of the cases followed up with diagnosis of HELLP syndrome were 30.2 ± 5.9 (17–46) years. HELLP syndrome was diagnosed on average in the 32.6 ± 4.8th (23–41) week of gestations. Seventy percent of the cases were with severe preeclampsia and 30% of the cases were with mild preeclampsia. Eleven cases (30%) were nullipara and twenty-five cases (70%) multipara. The average of arterial systolic blood pressure of the cases were 161.6 ± 26 mmHg, and that of diastolic blood pressure was 98.5 ± 16.8 mmHg. In thirteen cases (36%) acute renal failure (ARF), six cases (17%) placenta detachment, two cases disseminate intravascular coagulation (DIC), one case Adult Respiratory Distress Syndrome (ARDS) were developed. In seven cases (19%) intrauterine dead fetuses were detected. In twenty-three cases by cesarian section (64%), in thirteen cases by induction (36%) the pregnancies were terminated in 72 h after diagnosing HELLP syndrome. Birth weights of eleven babies (30%) were below 1500 g. Five of the eleven babies were dead in the neonatal period. Six of the thirteen patients who had ARF were given hemodialysis. Two patients died because of the development of ARF + DIC and ARDS. No predicting factors for the development of HELLP syndrome could be detected, but severe preeclampsia. Therefore we think that preeclamptic pregnancies must be followed up very closely and if HELLP syndrome develops, termination of the pregnancy would be proper as soon as possible.

• Pregnancy
• HELLP syndrome
• Acute renal failure

Introduction

HELLP syndrome, which is known as hemolysis elevated liver enzymes and low platelet count, has been defined as a complication of preeclampsia and eclampsia for many years. However it can develop without preeclampsia or eclampsia.[[1]], [[2]], [[3]]

The incidence of HELLP syndrome in preeclamptic and eclamptic pregnancies ranges between 2% and 19.3%.[[4]], [[5]] It can be seen both in prenatal and in postnatal periods. In one third of the cases it develops in the postnatal period. However it is reported that pulmonary edema and renal failure are seen more commonly in the case with HELLP syndrome, which develop in the postnatal period.[[3]]

The patients with HELLP syndrome may come to the hospital with various symptoms and signs but none of those are specific for HELLP syndrome and they may be with severe preeclampsia and eclampsia. In the patients with HELLP syndrome complications such as disseminate intravascular coagulation (DIC), ablatio placenta, acute renal failure (ARF), pulmonary edema, subcapsularly hematoma of liver and retinal detachment may develop.[[3]], [[6]] It is reported that the frequency rate of maternal and neonatal mortality is increased.[[1]], [[7]], [[8]]

In these clinical study features, developing complications and results of thirty-six patients, which were followed up in our Obstetrics and Gynecology and Nephrology departments between 1997 and 2001, with the diagnosis of HELLP syndrome were searched retrospectively.

Materials and Methods

Thirty-six patients, who were followed up in our Obstetrics and Gynecology and Nephrology departments with the diagnosis of HELLP syndrome between 1997 and 2001, were included in the study. The presences of hemolysis (indirect bilirubin >1.2 mg/dL, LDH >600 U/L), elevated liver enzymes (AST >70 U/L) and thrombocytopenia (<100,000/mm³) were accepted as HELLP syndrome.[[1]]

Age, number of parities, gestational age, a past history of preeclampsia, and chronic hypertension were noted for all pregnancies.

The symptoms and signs (headache, pain in right hypochondrium, nausea- vomiting, edema, hypertension, icterus, and convulsion) and developing complications (DIC, ablatio placenta, ARF, pulmonary edema, subcapsularly hematoma of liver, retinal detachment) were recorded in patients with HELLP syndrome.

Patients who had a progressive increase in the levels of serum creatinine and oligo-anuria lasting more than three days were defined to have acute renal failure (ARF). In the diagnosis of ARF medical history, physical examination findings, urine analysis, ultrasonography, and concomitant blood and urine analysis were performed.

In the patients who had HELLP syndrome developing in the 34th week of the pregnancy, if signs of the fetal lung maturity and maternal complications were present the pregnancy was terminated by induction or cesarian section. If the mother had developed no complications and maturity of fetal lungs were incomplete, the pregnancy was terminated with application of corticosteroid and waiting for the maturation of fetal lungs as long as 48 h.

Mann Whitney U and ki square tests were used for comparing the findings of the groups.

Results

The mean age of the cases followed up with diagnosis of HELLP syndrome were 30.2 ± 5.9 (17–46) years.

HELLP syndrome was diagnosed on the 32.6 ± 4.8th (23–41) gestational week. Seventy percent of the cases were with severe preeclampsia and 30% of the cases were with mild preeclampsia. Eleven cases (30%) were nullipara and twenty-five cases (70%) multipara.

The average of arterial systolic blood pressure of the cases were 161.6 ± 26 mmHg, and that of diastolic blood pressure was 98.5 ± 16.8 mmHg. In seven patients (19.4%) mild and in twenty-five patients (69.4%) severe hypertension was detected.

In thirteen cases (36%) ARF, in six cases (17%) placental detachment, in two cases DIC and in one case Adult Respiratory Distress Syndrome (ARDS) developed. In seven cases (19%) intrauterine dead fetuses were present. In five cases (14%) neonatal mortality and in two cases (5.5%) maternal mortality occurred. These last two patients died because of the development of ARF + DIC and ARDS. In one patient irreversible renal failure developed. In twenty-three cases by cesarian section (64%), in thirteen cases by induction (36%) the pregnancies were terminated in 72-h after diagnosing HELLP syndrome.

Birth weights of eleven babies (30%) were below 1500 g while the average of birth weights was 1687 ± 728 (500–3000) g. Five of the eleven babies were dead in the neonatal period.

The average duration of oligo-anuria in patients with ARF was 5.3 ± 2.2[[2]], [[3]], [[4]], [[5]], [[6]], [[7]], [[8]], [[9]], [[10]] days. Six of the thirteen patients who had ARF were given hemodialysis. One of these cases had DIC, one had placental detachment and three of them had intrauterine dead fetus (23%).

No significant differences between the ARF developing and ARF nondeveloping groups were detected for the following items: Age, arterial blood pressure, parity, gestational age, levels of AST, LDH, and the count of platelet.

Table 1. Clinical features of patients with HELLP syndrome

Clinical features	Results
Condition of consciousness	9 (25%)
Confusion	5 (14%)
Stupor	2 (5.5%)
Coma	2 (5.5%)
Edema	26 (72%)
Nausea-vomiting	16 (44%)
Icterus	10 (28%)
Hypochondriac-epigastric pain	12 (33%)
Hypertension	32 (88.9%)
Convulsion	7 (19%)

Table 2. Laboratory findings of patients with HELLP syndrome

Laboratory findings	Results
Urea (mg/dL)	77.9±63.2 (20–329)
Creatinine (mg/dL)	2.09±2.14 (0.6–9.1)
Uric acids (mg/dL)	8.5±2.9 (2.4–14.8)
T. bilirubin (mg/dL)	5.1±3.8 (1.2–13.1)
ALT (U/L)	296±288 (25–1523)
AST (U/L)	570±535 (70–2100)
LDH (U/L)	2703±1976 (600–10170)
Platelet count (×10^9 L)	60.5±23.6 (24–100)

Discussion

Maternal and perinatal complications are frequently seen in patients with in HELLP syndrome. Therefore these patients must be followed up and managed in critical care units.[[1]]

Martinez et al. reported that in thirty-four (20%) of the 173 patients with HELLP syndrome, which they followed up between 1995 and 1996 ARF developed. They reported that most of the patients had urine output over 800 mL/day and only ten (5.7%) of the pregnancies required dialysis. Maternal mortality rate was detected as 12%. The mortalities were because of ARDS and cerebral hemorrhage.[[9]] This study detected that both the rate of development of ARF (36%) and requirement of dialysis (16.6%) was higher than Martinez et al. However the maternal mortality rate was lower (5.5%).

Table 3. The results of patients with HELLP syndrome who had ARF and who did not

Clinic and laboratory findings	ARF developing	ARF nondeveloping	P
Age (year)	31.0±6.7	29.8±5.4	NSa
Gestational age (week)	33.5±4.1	32.1±5.2	NSa
Numbers of pregnancies	3.5±2.7	3.5±2.0	NSa
Fetal weight (g)	1532±434	1736±801	NSa
Systolic blood pressure (mmHg)	165.4±28.1	159.5±25.5	NSa
Diastolic blood pressure (mmHg)	96.5±19.5	99.5±15.5	NSa
Urea (mg/dL)	138.8±71.7	43.5±11.1	0.0001
Creatinine (mg/dL)	4.2±2.4	0.9±0.1	0.0001
Uric acid (mg/dL)	10.8±2.1	7.3±2.5	0.001
T. bilurubin (mg/dL)	5.7±4.7	4.6±2.8	NSa
Direct bilirubin (mg/dL)	5.4±4.0	2.8±1.7	NSa
ALT (U/L)	325.6±413.4	280.6±206.6	NSa
AST (U/L)	547.8±698	582.7±446	NSa
LDH (U/L)	2918±2108	2590±1942	NSa
Platelet count (×10^9L)	61,16±28, 34	60,11±21,21	NSa
Fibrinogen (mg/dL)	274.4±119	322±166	NSa

NS^a: No significance.

Selçuk et al., conducted a study which they compared the frequency of ARF related to pregnancy and the results of patients both with HELLP syndrome and without HELLP syndrome between the years 1989 and 1999 and detected that in fourteen (35.9%) of the thirty-nine patients related to pregnancies the etiology was detected to be HELLP syndrome. They reported that HELLP syndrome had developed in the postpartum period in 71% of the patients. They also reported that the mean age was 30 years (17–41), the mean of the parity were three (1–13), systolic and diastolic arterial blood pressures were 170 (110–190) and 105 (80–120) mmHg respectively. In patients with HELLP syndrome, ten (71.4%) cases had hypertension, seven cases had loss of consciousness, five cases had icterus (35.7%) and four cases had (28.5%) convulsion. They detected that the duration of oligo-anuria was longer in patients with HELLP syndrome. In only seven of the patients with HELLP syndrome the renal failure was detected to be irreversible. In patients with ARF related to pregnancy who had HELLP syndrome the frequency of mortality was not found different (28.5% and 31.8% respectively).[[4]] Similarly, in our study only one of the thirteen patients who had developed ARF had irreversible renal failure. In our study the rate of maternal mortality was lower.

Haddad et al. detected headache 28%, nausea-vomiting 42%, epigastric or upper abdominal pain 67% in their study which they evaluated the results and risk factors of 183 pregnancies with HELLP syndrome. They reported that in 22% of the cases HELLP syndrome developed in the postpartum period and in 38% of the cases maternal complications occurred. ARF (5%), ablatio placenta (90%), DIC (8%), pulmonary edema (10%) was detected. On the other hand two patients (1%) had died because of intracranial hemorrhage and ARDS. Only eleven (6%) of the 183 pregnancies were detected to have eclampsia with HELLP syndrome at the same time.[[10]]

On the contrary in those studies we detected higher rates of ARF development and maternal mortality. In our study all patients with HELLP syndrome had either preeclampsia or eclampsia (19%) but lower rates had been detected. Maternal mortality and ARF development rates' being higher may be relevant to this condition. In our study uremia, changes of consciousness related to cerebral hemorrhage or convulsions were detected in 25% of the patients. Most of the patients had been detected to have hypertension.

As a result, 70% of the patients with HELLP syndrome had severe preeclampsia. Important complications such as ARF (36%), detached placenta (17%), DIC (5.5%), and intrauterine dead fetus were detected. Intrauterine growth retardation (IUGR), neonatal and maternal mortality rates were very high.

No predicting factors for the development of HELLP syndrome could be detected, except for severe preeclampsia. Therefore we think that preeclamptic pregnancies must be followed up very closely and if HELLP syndrome develops, termination of the pregnancy would be proper as soon as possible.