Mini Review - (2015) Volume 1, Issue 1
Corticelli A1*, Marianna DE1, Grimaldi M1, Moioli M1, Bosi S1, Rosato F1, Trifiletti V3, Manco E2, E. Cinque2, Saltarini M4
1Department of Obstetrics and Gynaecology - ASL4 Chiavarese, Lavagna, Genoa, Italy
2Department of Anesthesiology, ASL4 Chiavarese, Lavagna, Genoa, Italy
3MD University of Study, Genoa
4Department of Anesthesiology, A.O.S. Maria Della Misericordia, Udine, Italy
*Corresponding Author:
Corticelli A
Department of Obstetrics and Gynaecology - ASL4 Chiavarese, Lavagna, Genoa, Italy
Tel: 328 3165990
Email: cortidoc@gmail.com
Received date: November 03, 2015; Accepted date: December 15, 2015; Published date: December 19, 2015
Copyright: © 2015 Corticelli A, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Keywords
HELLP syndrome; Intensive care unit
Objective
HELLP syndrome is an obstetric complication characterized by heamolysis, elevated liver enzymes and low platelet count. This condition occurs in 0.5%-0.9% of all pregnancies and in 10-20% of patients with preeclampsia (Table 1).
| Headache |
| Nausea or vomiting |
| Changes in vision |
| Racing pulse, mental confusion |
Table 1. Symptoms of HELLP syndrome.
HELLP was named by Weinstein in 1982 and typically occurs between 27 and 37 weeks of pregnancy (70% of all cases) or immediately postpartum in 20% of cases (until 48 hours after childbirth) [1,2]. Although the cause of HELLP remains unknown, age older than 30 years and multiparity are recognized risk factors [2]. Pathophysiology of HELLP syndrome is not well-defined but endothelial dysfunction is considered the main underlying problem: fibrin forms cross linked networks in the small blood vessel, causing microangiopathy and tissutal hypo perfusion, and platelets are consumed.
Materials and Methods
The study group enrolled about 800 pregnant women/year afferring in our hospital in Northern Italy, near Portofino, in a primary delivery center.
The tables represent major clinical characteristics of syndrome and of the study group (Tables 2 and 3).
| Patients | 9 | 100,00% |
| Age | 34 yo | 100,00% |
| SAPSII | 16,1 | |
| Admission criteria to Intensive care Unit | ||
| Monitoring | 2 | 22,20% |
| Intensive treatment | 7 | 77,80% |
Table 2. Patients' characteristics.
| Respiratory failure | 2 | 22,20% |
| Cardiovascular failure | 1 | 11,10% |
| Neurologic dysfunction | 2 | 22,20% |
| Procedures | ||
| Invasive ventilation | 4 | 44,40% |
| Not invasive ventilation | 2 | 22,20% |
| Vasoactive Drugs | 2 | 22,20% |
| Hemofiltration | 1 | |
| Outcome | ||
| Alive | 9 | 100,00% |
| Hospitalization in ICU | 4,0 days | |
| Hospitalization | 9,0 days | |
Table 3. Organs' failure/dysfunction at the time of admission.
A 43 years old patient at 38 weeks' gestation suffering from spontaneous rupture of liver right lobe subcapsular hematoma underwent exploratory laparotomy with periephatic packing with omentum. Then patient was transferred to the referral Centre for transplants of San Martino Hospital (Genoa, Italy) and a liver transplantation was performed after 12 hours [3] (Table 4).
| HELLP class | Tennessee Classification | Mississippi classification |
| 1 | Platelets ≤ 100-100003/L AST ≥70 IU/L LDH≥ 600 IU/L |
Platelets ≤ 50 -100003/L AST or ALT ≥ 70IU/L LDH≥ 600 IU/L |
| 2 | Platelets ≤ 100-10.0003/L ≥ 50-10.0003/L AST or ALT ≥ 70 IU/L LDH ≥ 600 IU/L |
|
| 3 | Platlets≤ 150-10.0003/L ≥ 100-10.0003/L AST or ALT ≥ 40 IU/L LDH ≥ 600 IU/L |
Table 4. Main diagnostic criteria of the HELLP syndrome.
Discussion
Our collected data are similar to those of International literature [4]. HELLP syndrome may present with variability of features and can be subdivided into incomplete and complete form (Table 5).
| Trimester | diagnostic | |
|---|---|---|
| HG | 1,2 | ↑ Bilirubin (×2-4 ULN), ↑ ALT/AST (× 2-4 ULN) |
| ICP | 1,2,3 | ↑ Bilirubin (× 6 ULN), ↑ ALT/AST (× 6 ULN), ↑ bile acids |
| PRE-ECLAMPIA | 2,3 | ↑ Bilirubin (× 2-5 ULN), ↑ ALT/AST (× 10-50 ULN), decrease of platelets |
| HELLP | 2,3 | ↑ ALT/AST (x10-20 ULN)), ↑ LDH, decrease ofplatelets, ↑ uric acid |
| AFLP | 2,3 | ↑ Bilirubin (× 6-8 ULN), ↑ ALT/AST (× 5-10 ULN) – rarely > 20 |
↑: increase. HG:Hyperemesis Gravidarum. ICP = intrahepatic cholestasis of pregnancy. HLLP = heamolysis, elevated liver enzymes, and low platelets. AFLP = acute fatty liver of pregnancy. ALT= alanine aminotransferase.
AST = aspartate aminotransferase. LDH = lactate dehydrogenase. ULN = upper limit normal.
Table 5. Characteristic timings and diagnostic laboratory features of liver diseases related to pregnancy.
The 'Missisipi classification' divided HELLP syndrome into 3 classes of increasing severity (Table 4) based on platelet count and major diagnostic criteria: hemolisis, increasing LDH concentration >600 IU/L and AST>70 IU/L. Use of corticosteroids for patients with HELLP syndrome remains a controversial issue [5]. Serum uric acid concentration is a predictive factor (Table 5) for maternal complications in case of preeclampsia [6] and this data is a strong marker of poor outcome [7,8].
Conclusion
HELLP syndrome is life-treating obstetrical complication with high risk of maternal mortality.
The distinction between hepatic diseases related to pregnancy or not is crucial to improve clinical outcome among women with hepatic dysfunction during gestation [7,8].
Based on our clinical experience, a flow-chart (protocol) for multidisciplinary management of patients with HELLP syndrome was made up in collaboration Anesthesiologists, reducing significantly misdiagnosis and fetal maternal complications.
