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VOL. 16, NO. 4, OCTOBER 2008192 Thai J Obstet Gynaecol Khumsat R et al. Incidence and risk factors of HELLP syndrome in Thaipregnant women with severe pre-eclampsia

Thai Journal of Obstetrics and Gynaecology

October 2008, Vol. 16, pp. 192-19861-167

OBSTETRICSIncidence and Risk Factors of HELLP Syndrome in ThaiPregnant Women with Severe Pre-eclampsia

RatcharatKhumsatMD,ThanyaratWongwananurakMD,DittakarnBoriboonhirunsarnMD,M.P.H.,Ph.D.Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand

ABSTRACT

Objectives TodeterminetheincidenceandriskfactorsofHELLPsyndromeinpregnantThai

womenwithseverepre-eclampsiaandtocomparepregnancyoutcome.Design Cross-sectionalstudy.Subject Atotalof255pregnantwomenwithseverepre-eclampsia,>28weeksofgestation,

whodeliveredatSirirajHospitalbetweenJanuary2005andJune2007.Materials and MethodsThemedicalrecordswerereviewedtodeterminetheincidenceofHELLP

syndrome. Characteristics regarding current pregnancy anddelivery andmaternalandneonataloutcomeswereextracted.

Results TheincidenceofHELLPsyndromewas12.5%.WomenwithHELLPsyndromeweresignificantlyolder,morelikelytobemultiparousanddeliveredatlowergestationalage(p

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VOL. 16, NO. 4, OCTOBER 2008 193Khumsat R et al. Incidence and risk factors of HELLP syndrome in Thaipregnant women with severe pre-eclampsia

riskforrenalfailure,consumptivecoagulopathy,

abruptioplacentae,pulmonaryandcerebraledema,

subcapsular l iver hematoma and hypovolumic

shock.

Maternalcomplicat ionswerereportedabout

1.1-24.2%(5,6)andperinataloutcomessuchasbirth

asphyxia,IUGRandfetaldeathwerereportedabout

7.7-60%(7,8)resultedinpretermdelivery.Genetics(9)

and other factors such as maternal age, parity,

race(10)mayaffectseverityofdiseaseindividually.

Thedefinitetherapyforseverepre-eclampsia

oreclampsia with orwithout HELLP syndrome is

removalofallgestationalproductsfromtheuterus.

The use of antepartum corticosteroids, rescue

surfactant,neonatalintensivecareunittechnology

and the maternal transport of premature and

immaturepregnanciestotertiarycarefacilitieshave

collectivelyincreasedthesurvivabilityoftheinfants.

Thepurposeof thisreportwastodetermine

incidenceofHELLPsyndrome,toassessriskfactors

o f H EL LP s yn dr om e i n p at ie nt s w it h s ev er e

pre-clampsiaandtocomparematernalandperinatal

outcomesbetweenwomenwithseverepre-eclampsia

andwomenwithHELLPsyndrome.Thedatafrom

thisstudyusetoevaluationriskfactorsofHELLP

syndromeforearlydiagnosis,earlymanagement

a nd p re ve nt io n o f t he p ro gr es si on o f s ev er e

pre-eclampsiatoHELLPsyndrome.

Materials and Methods

AretrospectivestudywasconductedatSiriraj

Hospitalwith theapprovalofthe institutionalethic

committee.Atotalof255pregnantwomenwhowere

diagnosedseverepre-eclampsia,gestationalage28

weeks ormorewhodelivered inthis hospitalwere

enrolled.

HELLPsyndromewasdefinedbythepresence

ofallofthethreefollowingcriteria(11):hemolysis

(characteristicperipheralbloodsmear,serumlactate

dehydrogenase 600U/l, total serum bilirubin

1.2 mg/ml), elevated liver enzymes (serum

aspartate aminotransferase 70 U/l) and low platelet

count (

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VOL. 16, NO. 4, OCTOBER 2008194 Thai J Obstet Gynaecol

(directbilirubin),AST(serumaspartatetransminase,

ALT(serumalaninetransminase),creatinineand

coagulogramweresignificantlyincreasedinwomen

withHELLPsyndrome;howevergestationalagewas

significantlowerinwomenwithHELLPsyndromein

varyingdegree(allp-valueswere

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VOL. 16, NO. 4, OCTOBER 2008 195Khumsat R et al. Incidence and risk factors of HELLP syndrome in Thaipregnant women with severe pre-eclampsia

DB (mg/dl) 0.10.2 0.91.9

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VOL. 16, NO. 4, OCTOBER 2008196 Thai J Obstet Gynaecol

Discussions

Although the term HELLP syndrome was

definedbyWeinstein (1)buttheincidenceandtherisk

factorofHELLP syndromewerenotstudied inour

hospital.

In this study, the incidence of HELLP

syndromewas12.5%amongseverepre-eclampsia.

The reported rates of HELLP syndrome were

di fferent between studies. The retrospective

population based cohort study of558pregnancies

w it h s ev er e p re -e cl am ps ia s ho we d t ha t 1 2%

hadHELLPsyndrome. (12)Anotherreportof615

Indian pregnant women found the incidence of

HELLPsyndromewas23.68%amonghypertensive

disorderduringpregnancy.(13)Thedifferencesmight

beduetothedifferencesinpatientscharacteristics

a nd cond ition s in e ach p opu latio n an d th e

differencesindiagnosticcriteria.Thisstudyusedthe

standardized strict laboratorycriteria which were

definedbySibia.(11)

Pr ev io us s tu dy f ou nd t ha t t he r is k f ac to r o f

HELLP syndrome was multipara compared with

severepre-eclampsiagroup (14)andinWhiteand

Chinese populations have HELLPsyndromemore

thanEastIndianpopulation (15)duetoappropriate

ANC, early detection of severe pre-eclampsia

andgoodmedical records.Smoking inpregnant

womenwasreducedtheincidenceofseverepre-

eclampsia.(16)

Ourstudyfoundthatthepossibil ityofHELLP

syndromeincreasedifthepregnant women were

olderandpretermgestation.Laboratoryfindings

showedthatLDH,uricacid,totalbilirubin,direct

bilirubin,SGOT,SGPT,creatinineandcoagulogram

inpregnantwerehigherthanseverepre-eclampsia

group,whilehematocritandplateletcountwereless

thanseverepre-eclampsiagroup.

M at er na l c om pl ic at io ns i n p re gn an t w om en

withHELLPsyndromeincludedacuterenalfailure,

disseminatedintravascularcoagulopathy,pulmonary

edema, marked ascites, pleural effusion, adult

respiratory distress syndrome and abruption of

placenta.(17)Thisstudy,wefoundacuterenalfailure

in6cases(0.18%)anddisseminatedintravascular

coagulopathyin2cases(0.06%)oftotalcasesof

HELLPsyndrome.Insomestudy,eclampsiawas

foundmorefrequentlyinHELLPsyndromegroup.(18)

This study demonstrated that maternal

placentalabruptionincreasedsignificantlyamong

HELLPsyndromegroup,butthematernaleclampsia

andmodesofdeliverywerenotdifferentbetweentwo

groups.Thecesareansectionratesintwogroups

wereveryhigh,becausewhenthediseasewas

diagnosedweoptedfortheterminationofpregnancy

toavoidworseningcomplicationsofseverepre-

eclampsia.

Perinataloutcomeassociatedwithplacental

abruption,intrauterineasphyxiaandprematurity.(17)

Ourstudydemonstratedthatneonatalmorbidities

increasedsignificantlyamongHELLPsyndrome

group,includinglowApgarscoresat1and5minutes

and majorit ies of such morbidities were due to

prematurity.

HELLPsyndromewasrapidlyprogressivewith

morematernalandperinatalmorbidityandmortality,

sometimeswerenotcompletecriteriaofHELLP

syndromebutsignificantlyincreasedrateofcesarean

delivery,eclampsiaandpretermdelivery.(18)

Thelimitationofthisstudyweresmallsample

sizeforHELLPsyndromegroupbecausewehave

clinicalpracticeguidelineforpropermanagementof

severepre-eclampsiasothatpatientswithsevere

pre-eclampsiausuallydidnotprogresstoHELLP

syndrome,lostsomedatafrommedicalrecordsand

the last, some pregnantwomen didnotdeliveryin

ourhospitalbecause somecaseshadbeenreferto

otherhospitals.

Severepre-eclampsiaandHELLPsyndrome

mustbediagnosedassoonaspossible,soastoget

thegoodmaternalandperinataloutcomes.So,this

isrecommendedthatallpregnantorpost-delivery

womenwithslightorseverebloodpressureelevation

shouldbeinvestigatedinordertomakeanearly

diagnosis of severe pre-eclampsia or HELLP

syndrome.

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VOL. 16, NO. 4, OCTOBER 2008 197Khumsat R et al. Incidence and risk factors of HELLP syndrome in Thaipregnant women with severe pre-eclampsia

In conclusion, the incidence of HELLP

syndromeinSirirajHospitalwas12.5%.Thefactors

thatassociatedwithHELLPsyndromeincludedmore

maternalage,pretermgestationalage.Maternaland

neonatalmorbiditiesincreasedamongthatHELLP

syndrome.Therefore,earlydiagnosisandproper

m an ag em en t c ou ld b e a tt em pt ed t o i mp ro ve

maternalandperinataloutcomes.

References1. WeinsteinL.Syndromeofhemolysis,elevateliver

en zy me s, a nd l ow p lat el et co un t: a s ev ereconsequenceofhypertension.AmJObstetGynecol1982;142:159-67.

2. WalkerJJ.Pre-eclampsia.Lancet2000;356:1260-5.3. MartinJN,BlakePG,PerryKG,McCaulJF,HessLW,

MartinRW.ThenaturalhistoryofHELLPsyndrome:

patternsofdiseaseprogressionandregression.AmJObstetGynecol1991;164:1500-13.

4. BartonJR,SibaiBM.CareofpregnancycomplicatedbyHELLPsyndrome.ObstetGynecolClinNorthAm1991;18:165-79.

5. SibaiBM.Maternalmorbidityandmortalityin442pregnancywithhemolysis,elevatedliverenzymes,andlowplatelets(HELLPsyndrome)AmJObstetGynecol1993;169:1000-6.

6. ArougF,BoujariaR,NouiraS,AbrougS,SouissiM,NaijarMF,etal.HELLPsyndrome:incidenceandmeternal-fetaloutcome-aprospectivestudy.IntensityCareMed1992;18:274-7.

7. Harms K, Rath W, Hert ing E, Kuhn W. Maternal

hemolysis,elevatedliverenzymes,lowplateletandneonataloutcome.AmJPerinatol1995;18:274-7.

8. EeltinkCM,VanLingenRA,AaroundseJG,DerksJB,OkkenA.Maternalhemolysis,elevatedliverenzymesandlowplateletsyndrome: specificproblems.EurJPediatr1993;152:160-3.

9. IbdahJA,BennettMJ,RinadoP,ZhaoY,GisonB,SimsH,etal.Afetalfattyacidoxidationdisorderasacauseofdiseasesinpregnantwomen.NEngJMed1999;340:1723-31.

10. M ar ti n J N J r, R in eh ar t B K, M ay W L, M ag an nEF,TerroneDA,BlakePG.Thespectrumofseverepre-elampsia:compareanalysisbyHELLPsyndromeclassification.AmJObstetGynecol1999;180:1373-

84.11. Audibert F,FreidmanAS, FrangiehAY,SibiaBM.

Clinical utility if strict diagnostic criteria for theHELLP(hemolysis,elevatedliverenzymes,andlowp la te let s)s yn dro me. Am J O bs te t Gy ne col1996;175:460-4.

12. Vigil-DeGraciaP.,Pregnancy complicatedbypre-eclampsia-eclampsiawithHELLPsyndrome.IntJGynaecolObstet2001;72:17-23.

13. ChhabraS,QureshiA,DattaN.Perinataloutcomewith HELLP/ partial HELLP complicating hypertensivedisorderofpregnancy.JObstetGynecol2006;26:531-3.

14. Williams KP,WilsonS.Theimpactof parityonthe

i nc id en ce o f H EL LP s yn dr om e a nd s ma ll f orgestationalinfantsinhypertensivepregnantwomen.JObstetGyneCan2002Jun:24:485-9.

15. Will iams KP, Wilson S. Ethnic variation in theincidenceofHELLPsyndromeinahypertensivepregnancypopulation.JPerinatMed1997;25:498-501.

16. Leeners B, Neumaier-Wagner P, Kuse S, RathW.Smokingandtheriskofdevelopinghypertensivediseasesinpregnancy:whatistheeffecton HELLPsyndrome?ActaObstetGynecolScand2007;86:506-7.

17. BenLetaifaD,BenHamadaS,SalemN,BenJaziaK,SalamaA,ManaliL,etal.Maternalandperinatal

morbidity and mortali ty associate with HELLPsyndrome.AnnFrAnesthReanim2000;19:712-8.

18. AbbadeJF,PeraoliJC,CostaRA,CalderonIdeM,Borges VT, Rudge MV. Partial HELLP Syndrome:maternalandperinataloutcome.SaoPauloMedJ2002;120:180-4.

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HELLP syndrome

, ,

: HELLP syndrome : : 255 28 . : HELLPsyndrome : HELLP syndrome 12.5% HELLP syndrome Apgar : HELLP syndrome 12.5%