The HELLP syndrome: Clinical issues and management. A Review

<p>Abstract</p> <p>Background</p> <p>The HELLP syndrome is a serious complication in pregnancy characterized by haemolysis, elevated liver enzymes and low platelet count occurring in 0.5 to 0.9% of all pregnancies and in 10–20% of cases with severe preeclampsia. The present review highlights occurrence, diagnosis, complications, surveillance, corticosteroid treatment, mode of delivery and risk of recurrence.</p> <p>Methods</p> <p>Clinical reports and reviews published between 2000 and 2008 were screened using Pub Med and Cochrane databases.</p> <p>Results and conclusion</p> <p>About 70% of the cases develop before delivery, the majority between the 27th and 37th gestational weeks; the remainder within 48 hours after delivery. The HELLP syndrome may be complete or incomplete. In the Tennessee Classification System diagnostic criteria for HELLP are haemolysis with increased LDH (> 600 U/L), AST (≥ 70 U/L), and platelets < 100·10⁹/L. The Mississippi Triple-class HELLP System further classifies the disorder by the nadir platelet counts. The syndrome is a progressive condition and serious complications are frequent. Conservative treatment (≥ 48 hours) is controversial but may be considered in selected cases < 34 weeks' gestation. Delivery is indicated if the HELLP syndrome occurs after the 34th gestational week or the foetal and/or maternal conditions deteriorate. Vaginal delivery is preferable. If the cervix is unfavourable, it is reasonable to induce cervical ripening and then labour. In gestational ages between 24 and 34 weeks most authors prefer a single course of corticosteroid therapy for foetal lung maturation, either 2 doses of 12 mg betamethasone 24 hours apart or 6 mg or dexamethasone 12 hours apart before delivery. Standard corticosteroid treatment is, however, of uncertain clinical value in the maternal HELLP syndrome. High-dose treatment and repeated doses should be avoided for fear of long-term adverse effects on the foetal brain. Before 34 weeks' gestation, delivery should be performed if the maternal condition worsens or signs of intrauterine foetal distress occur. Blood pressure should be kept below 155/105 mmHg. Close surveillance of the mother should be continued for at least 48 hours after delivery.</p

The myometrial contractility during late pregnancy in dairy cows, in vitro

This study aimed to investigate the in vitro contractility of the myometrium and its relationship to the blood concentrations of estradiol-17β (E2β), progesterone (P4), 15-keto-13,14-dihydro-PGF2α (PGFM) and ionised calcium (Ca2+) prior to tissue harvest in 12 healthy Holstein-Friesian cows in late pregnancy. Three circular (CM) and 3 longitudinal myometrial (LM) strips were dissected during a caesarean section and mounted in an organ bath containing modified Krebs solution (KS). The spontaneous contractility was recorded during five 30-min time periods (T1 to T5), after which the strips were exposed to increasing concentrations of oxytocin (OT; 10-10-10-7M), a natural PGF2α-analogue (PGF; 10-7-10-4M) and KS (Cont) for four 30-min time periods (T6 to T9). The variables area under the curve (AUC), mean (MA) and maximal amplitude (maxA) were calculated for each T. The blood P4, E2ß, Ca2+ and PGFM values averaged 4.0±1.7ng/mL, 482.3±63.7 pg/mL, 0.8±0.3 mmol/L and 125.3±63.7pg/mL. The LM strips had greater AUC, MA, and maxA than CM, and OT caused greater AUC and MA in both muscle layers than PGF or control treatment (OT>PGF>Cont). Estradiol-17β correlated with AUC and MA of LM at T1 to T5 (r=0.69; P≤0.05). In conclusion, LM and CM strips have different contractile performance but show enhanced activity when stimulated with OT and less activity after PGF stimulation if compared with Cont. Blood concentrations of E2β may be useful as an indicator of uterine contractile performance in late pregnant cattle