Muna Tahlak, MD, FACOG Latifa Hospital. Objectives Update on the disease focus on diagnosis Complications timing and mode of delivery mortality and morbidity.
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Slide 1
Muna Tahlak, MD, FACOG Latifa Hospital
Slide 2
Objectives Update on the disease focus on diagnosis
Complications timing and mode of delivery mortality and morbidity
controversial aspects of corticosteroid use
Slide 3
Latifa Hospital is a tertiary center on average 6000 deliveries
per year >80% high risk obstetric care 465 pregnant women had
hypertensive disorder (8%)
Slide 4
Causes of maternal death in developed countries Other direct
causes of deaths21.3 Hypertensive disorders16.1 Embolism 14.9
Haemorrhage13.4 Abortion8.2 Ectopic pregnancy4.9 Unclassified
deaths 4.8 Sepsis/infection2.1 WHO data on maternal mortality
Slide 5
Team Work
Slide 6
HELLP Syndrome Weinstein regarded signs and symptoms to
constitute an entity separate from severe preeclampsia and in 1982
named the condition HELLP H = Haemolysis EL = Elevated Liver
enzymes LP = Low Platelets currently regarded as a variant of
severe preeclampsia or a complication.
Slide 7
The HELLP syndrome occurs in about 0.5 to 0.9% of all
pregnancies and in 10 to 20% of cases with severe preeclampsia
Slide 8
70% of the cases develops before delivery with a peak frequency
between the 27th and 37th gestational weeks 10% occur before the
27th week 20% beyond the 37th gestational week
Slide 9
HELLP syndrome usually develops within the first 48 hours in
women who have had proteinuria and hypertension prior to
delivery
Slide 10
hypertension and proteinuria absent in 1020% of the cases
Slide 11
Symptoms right upper abdominal quadrant epigastric pain nausea
and vomiting 3060% of women have headache 20% visual symptoms
partial HELLP syndrome fewer symptoms less complications
Slide 12
Reported frequency of signs and symptoms of HELLP syndrome
Sign/symptomFrequency, percent Proteinuria86 to 100 Hypertension82
to 88 Right upper quadrant/epigastrict pain40 to 90 Nausea,
vomiting29 to 84 Headache33 to 61 Visual changes10 to 20
Jaundice5
Slide 13
Slide 14
Haemolysis, one of the major characteristics of the disorder,
is due to a microangiopathic haemolytic anaemia
Slide 15
Normal peripheral blood smear
Slide 16
Microangiopathic smear
Slide 17
H(hemolysis) high LDH concentration unconjugated bilirubin low
or undetectable haptoglobin concentration is a more specific
indicator. Low haptoglobin concentration (< 1 g/L < 0.4
g/L)
Slide 18
Elevated Liver enzymes(EL) Elevation of liver enzymes may
reflect the haemolytic process as well as liver involvement.
Haemolysis contributes to the elevated levels of LDH enhanced
asparate aminotransferase (AST) and alanine aminotransferase (ALAT)
levels are mostly due to liver injury
Slide 19
Low platelet(LP) Thrombocytopenia < 15010 9 /L) caused by
gestational thrombocytopenia (GT) (59%) immune thrombocytopenic
purpura (ITP) (11%) preeclampsia (10%) HELLP syndrome (12%). PLTs
< 10010 9 /L are relatively rare in preeclampsia and gestational
thrombocytopenia, frequent in ITP and obligatory in the HELLP
syndrome (according to the Sibai definition)
Slide 20
Diagnosis Many different criteria Biochemical markers Clinical
Preeclampsia ELLP
Slide 21
Diagnostic criteria two major definitions for diagnosing the
HELLP syndrome
Slide 22
Professor Baha Sibai Professor and Chairman of the Department
of Obstetrics and Gynecology at the University of Cincinnati
College of Medicine leading authority in the care and treatment of
women with preeclampsia and eclampsia, has published more than 500
peer-reviewed articles
Slide 23 600 units/L (U/L)">
Tennessee Classification System Platelets 10010 9 /L AST 70
IU/L LDH 600 IU/L Sibai has proposed strict criteria for "true" or
"complete" HELLP syndrome Intravascular haemolysis is diagnosed by
abnormal peripheral blood smear, increased serum bilirubin ( 20.5
mol/L or 1.2 mg/100 mL) and elevated LDH levels (> 600 units/L
(U/L)
Mississippi classification Class 2 Platelets 10010 9 /L 5010 9
/L AST or ALT 70 IU/L LDH 600 IU/L
Slide 26
Mississippi classification Class 3 Platelets 15010 9 /L 10010 9
/L AST or ALT 40 IU/L LDH 600 IU/L
Slide 27
Differential diagnosis viral hepatitis cholangitis and other
acute disease ITP acute fatty liver of pregnancy (AFLP) haemolytic
uremic syndrome (HUS) thrombotic thrombocytopenic purpura (TTP)
systemic lupus erythematosus (SLE)
Slide 28
Complications reported in the HELLP syndrome Maternal
complicationsOccurrence (%) Eclampsia49 Abruptio placentae920
DIC556 Acute renal failure736 Severe ascites411 Cerebral oedema18
Pulmonary oedema310
Slide 29
Complications reported in the HELLP syndrome Maternal
complicationsOccurrence (%) Subcapsular liver hematomaBetween 0.9%
and 200 cases or about 1.8% Cerebral infarctionFew case reports
Cerebral Haemorrhage1.540 Maternal death125 Wound
hematoma/infection 2 714 Retinal detachment1
Slide 30
Maternal Mortality Stroke45% Cardiac Arrest40% DIC39% ARDS27%
Renal failure27% Sepsis24% Hepatic Rupture20% Hypoxic
encephalopathy15% Contributing factors to deaths in 54 women with
HELLP syndrome From Isler and co-authors,1999
Management of pregnant women with HELLP syndrome Immediate
delivery > 34 weeks' gestation or later Nonreassuring tests of
fetal status Presence of severe maternal disease: multiorgan
dysfunction, DIC, liver infarction or hemorrhage, renal failure, or
abruptio placenta
Slide 33
27 to 34 weeks of gestation Delivery within 48 hours evaluation
stabilization steroid treatment for fetal lung maturity
Slide 34
Steroid use no clear evidence of any effect of corticosteroids
on substantive clinical outcomes. insufficient evidence for the
routine use The use of corticosteroids only to increase rate of
recovery in platelet count if considered clinically worthwhile.
Cochrane Review of 11 trials comparing corticosteroids with
placebo/no treatment
Slide 35
before 24 weeks' gestation, termination of pregnancy should be
strongly considered
Slide 36
Method of Delivery Vaginal Cesarean section
Slide 37
Anesthesia Choice According to ACOG Regional anesthesia is
preferred for women with preeclapmsia and eclampsia General
anesthesia carries more risk than regional
Slide 38
Anesthesia Choice What platelet count is adequate for regional
anesthesia? No absolute answer Platelet counts >100,000/ul are
acceptable to most anesthesiologists Platelet counts in
50,000-100,000 range are potential candidates according to
ACOG
Slide 39
Risk of spinal or epidural hematoma Paralysis
Slide 40
Frederick P. Zuspan, M.D. 1922- 2009 An internationally
recognized authority in the field of maternal-fetal medicine An
expert on preeclampsia In the 1960s, Zuspan pioneered the use
intravenous magnesium sulfate to prevent convulsions in women with
preeclampsia. His treatment protocol was adopted internationally
and is still used to treat preeclampsia nearly 50 years later
Slide 41
there's an empty plaque at Chicago's famous Lying-in Hospital
waiting for the engraved name of the person who discoveres the
cause.
Slide 42
Summary HELLP syndrome is unique to pregnancy HELLP syndrome
develops in approximately 1 of 1000 pregnancies overall and 10 to
20 percent of pregnancies with severe preeclampsia/eclampsia
Delivery and supportive management is cure Multidisciplinary
approach Tertiary center
Slide 43
Summary outcome for mothers with HELLP syndrome is generally
good, but serious complications can occur Recommendations are
against giving dexamethasone for treatment