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

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

Acute fatty liver disease of pregnancy-report of two cases from tertiary care centre, Hyderabad

A referral case from Kollampally, Narayanpet, primi past EDD by 2 days, thrombocytopenia and elevated bilirubin levels. EDC-18.09.22, scan EDC- 26.09.22 She had a vaginal septum and a poor Bishop score. During caesarean section, there was atonic post-partum haemorrhage, (PPH). When PPH could not be controlled with medical management, Haymans stitches were applied to control the bleeding. Total she received seventeen units of blood products, (4 FFPS, 1 SDP, 2 PRBC, 10 CRYO). She succumbed on the fourth POD. Fulminant hepatic failure, hepatic encephalopathy, grade 111, oliguric, AKI, thrombocytopenia, coagulopathy, with sepsis. The second case, a 24 years primi, 38 weeks 4 days, jaundice of three days duration, with HELLP? AFLP, thrombocytopenia with poor Bishop score. This case was a referral from SVS medical college, Mahaboob Nagar (MBNR) on 25.10.22, 7.23pm. An emergency LSCS was performed on 26.10. 22, 2.15 am. Blood products 25 units, (1 PRBC, 8 FFP, 6 RDP, 10 Cryo) units transfused. Intra operative blood loss was 1250 ml. Atonic PPH was managed adopting both medical and surgical, methods. An alive male 3200 gm was delivered. Measures taken to control PPH were, misoprostol 800 mcg PR, inj.oxytocin 20 units i.v drip, uterine massage, Inj. Carboprost was given. Modified B Lynch uterine compression sutures were applied. Bilateral uterine artery ligation was done. Abdominal drain kept. AKI, sepsis and increasing bilirubin levels were noted. At OGH two sessions of haemodialysis were done. Patient expired on 28.10.22. Persistent hypoglycemia, elevated bilirubin, low fibrinogen, prolonged PT and INR pointed to a diagnosis of AFLP. 

HELLP syndrome on the rise: a major cause of maternal deaths

Background: In the recent years, 2021 to 2022, there has been a sudden rise in the number of HELLP syndrome cases admitted to Modern Government Maternity Hospital, (MGMH) / Osmania Medical College. There were maternal deaths due to complications secondary to HELLP syndrome. Complications like placental abruption, DIC, PPH, PRAKI, pulmonary edema, were responsible for maternal deaths. The need for blood products has increased enormously. In our earlier study of eclampsia and imminent eclampsia from the same Institute, during 2004 to 2007, we did not find HELLP syndrome to be a major cause of maternal deaths. Hence, we proceeded with in depth study of the complications, morbidity and mortality and some management issues related to HELLP syndrome. All 70 cases of HELLP in this study had associated Preeclampsia/eclampsia.Methods: This is a prospective analytical observational study of 70 cases of HELLP syndrome.Results: Recurrent preeclampsia was noted in 6÷45=13.33%. Cases of hypothyroidism were observed in 6÷45=13.33%. There were four sets of twins, 8.88%. Placental abruption was noted in 10/70 women with HELLP, 14.28%, DIC occurred in 15÷70=21.42%, PPH occurred in 11÷45 cases, 24.44%, PRAKI was recorded in 16/70 patients, 22.85%, Pulmonary edema occurred in 5/70, 7.14%, PPCM in cases with HELLP syndrome were 2÷70=2.85%, Abdominal delivery was needed in 53÷70=75.71%, Maternal mortality in the present study was10÷70=14.28%, The perinatal mortality was 21.33%. Blood products were needed in 22/45 cases, (9.136) units on the average.Conclusions: Dissemination of knowledge that immediate delivery should be planned in all cases of HELLP, irrespective of gestational age is the need of the hour. Postponing delivery would lead to complications