OB-GYN-L Messages for January, 1997: Re: atypical HELLP vs. TTP (fwd)

Re: atypical HELLP vs. TTP (fwd)

From: A.P. VAN DER COLF

rvdcolf@iwwn.com.na

Wed Jan 15 05:55:58 1997

1 TI - Corticosteroids for the enhancement of fetal lung maturity: impact on the gravida with preeclampsia and the HELLP syndrome. SO - Aust N Z J Obstet Gynaecol 1993 May;33(2):127-31 AU - Magann EF; Martin RW; Isaacs JD; Blake PG; Morrison JC; Martin JN Jr AD - Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson 39216-4505. MJ - Dexamethasone [therapeutic use]; HELLP Syndrome [drug therapy]; Lung [embryology] MN - Adolescence; Adult; Dexamethasone [pharmacology]; Fetal Organ Maturity [drug effects]; HELLP Syndrome [classification]; Lung [drug effects]; Platelet Count; Pregnancy; Retrospective Studies MT - Female; Human; Support, Non-U.S. Gov't PT - JOURNAL ARTICLE AB - This study was undertaken to determine maternal impact of corticosteroids administered for the promotion of fetal lung maturity in mothers with the HELLP syndrome. Twenty-seven of 427 women with the HELLP syndrome treated between 1980-1991 received a full course of steroids prior to preterm delivery. This group was compared to 27 matched control patients with the HELLP syndrome who received no corticosteroids. Subjects were matched for maternal age, race, sex of the fetus, and severity of the HELLP syndrome. The antepartum platelet count stabilized or increased in 25 of 27 steroid-treated women in contrast to 0 of 15 control women (p 0.00001). In comparison to control patients, LDH serum concentrations in steroid-treated patients stabilized or decreased and the SGOT/AST and SGPT/ALT stabilized or decreased during therapy (p 0.005). The interval from delivery to platelet nadir in patients with Class III HELLP syndrome was shorter in the steroid-treated group (p 0.008) than in untreated patients. EM - 9401 IS - 0004-8666 LA - English UI - 94029794 RN - 50-02-2 (Dexamethasone)

2 TI - Maternal-perinatal outcome associated with the syndrome of hemolysis, elevated liver enzymes, and low platelets in severe preeclampsia-eclampsia. SO - Am J Obstet Gynecol 1986 Sep;155(3):501-9 AU - Sibai BM; Taslimi MM; el-Nazer A; Amon E; Mabie BC; Ryan GM MJ - Hemolysis; Liver Diseases [complications]; Platelet Count; Pre-Eclampsia [complications] MN - Abruptio Placentae [complications]; Adolescence; Adult; Amniocentesis; Anesthesia, Epidural; Delivery; Disseminated Intravascular Coagulation [complications]; Hematocrit; Liver Diseases [diagnosis] [enzymology]; Parity; Perinatology; Pre-Eclampsia [mortality]; Pregnancy; Prognosis; Syndrome; Ultrasonography MT - Female; Human PT - JOURNAL ARTICLE AB - During an 8-year period, 112 severe preeclamptic-eclamptic patients with the above syndrome were studied. The incidence of this syndrome was significantly higher in white patients, in patients with delayed diagnosis of preeclampsia and/or delayed delivery, and in multiparous patients. Twenty-six patients had amniocentesis and 16 received epidural anesthetics. There was one maternal bleeding episode associated with epidural anesthetics. The use of steroids in 17 patients did not improve maternal platelet count. The overall perinatal mortality was 367 per 1000 and neonatal morbidity was significant. There were two maternal deaths and two patients with ruptured liver hematoma, and nine had acute renal failure. Thirty-eight percent had intravascular coagulopathy and 20% had abruptio placentae. On follow-up, 44 patients used oral contraceptives without maternal morbidity and 38 patients had 49 subsequent pregnancies. Only one patient had recurrence of the syndrome in subsequent pregnancies. The presence of a "true" syndrome of hemolysis, elevated liver enzymes, and low platelets (HELLP syndrome) in preeclampsia is associated with poor maternal-perinatal outcome. EM - 8612 IS - 0002-9378 LA - English UI - 86320438

3 TI - Familial thrombotic thrombocytopenic purpura in a Bedouin family. SO - Sangre (Barc) 1992 Apr;37(2):133-5 AU - Dvilansky A; Yermiahu T; Hatskelzon L AD - Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel. MJ - Fetal Growth Retardation [etiology]; Pre-Eclampsia [diagnosis]; Pregnancy Complications, Hematologic [ethnology]; Purpura, Thrombotic Thrombocytopenic [genetics] MN - Adrenal Cortex Hormones [therapeutic use]; Adult; Cesarean Section; Combined Modality Therapy; Consanguinity; Diagnosis, Differential; Ethnic Groups [genetics]; Pedigree; Plasmapheresis; Pregnancy Complications, Hematologic [drug therapy] [therapy]; Pregnancy Complications, Infectious [diagnosis]; Pregnancy; Purpura, Thrombotic Thrombocytopenic [drug therapy] [therapy]; Transients and Migrants; Urinary Tract Infections [diagnosis] MT - Case Report; Female; Human PT - JOURNAL ARTICLE AB - A 24-year-old Beduin pregnant woman in her 22nd week of gestation was treated successfully by plasmaphereses and steroids as soon as the diagnosis of TTP was confirmed by the clinical and laboratory criteria needed. Her sister died due to complications of TTP in pregnancy five years earlier while her other sister recuperated from TTP during pregnancy. However, fetal loss ensued. Thus, family history in pregnant women presenting with toxemia of pregnancy--like--syndrome may be the first clue to familial TTP. EM - 9210 IS - 0036-4355 LA - English UI - 92320432 RN - 0 (Adrenal Cortex Hormones)

4 TI - Postpartum corticosteroids: accelerated recovery from the syndrome of hemolysis, elevated liver enzymes, and low platelets (HELLP). SO - Am J Obstet Gynecol 1994 Oct;171(4):1154-8 AU - Magann EF; Perry KG Jr; Meydrech EF; Harris RL; Chauhan SP; Martin JN Jr AD - Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson 39216-4505. MJ - Dexamethasone [therapeutic use]; HELLP Syndrome [drug therapy]; Puerperal Disorders [drug therapy] MN - Adolescence; Adult; Aspartate Aminotransferase [blood]; Dexamethasone [administration & dosage]; HELLP Syndrome [metabolism]; Lactate Dehydrogenase [blood]; Platelet Count [drug effects]; Pregnancy; Prospective Studies; Puerperal Disorders [metabolism]; Puerperium MT - Female; Human; Support, Non-U.S. Gov't PT - CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL AB - OBJECTIVE: Because most morbidity and mortality associated with atypical preeclampsia and the syndrome of hemolysis, elevated liver enzymes, and low platelets is a postpartum phenomenon, we undertook this investigation to evaluate the use of high-dose corticosteroids to minimize maternal morbidity and accelerate postpartum recovery in patients with this form of severe preeclampsia. STUDY DESIGN: Into this prospective, randomized study 40 parturients with the syndrome were recruited. The syndrome was defined by a clinical presentation consistent with a diagnosis of severe preeclampsia or eclampsia in addition to laboratory evidence of hemolysis, hepatic dysfunction, and thrombocytopenia. Immediately post partum 20 parturients assigned to the treatment group received four doses of intravenous dexamethasone at 12-hour intervals (10 mg, 10 mg, 5 mg, 5 mg) over 36 hours. Patients assigned to the control group received no corticosteroids. All study subjects were intensively monitored by mean arterial pressure and urinary output every 2 hours, hematocrit and platelet count every 6 hours and lactic dehydrogenase, aspartate aminotransferase, and alanine aminotransferase every 12 hours for the first 48 hours post partum. RESULTS: The steroid-treated group with the syndrome of hemolysis, elevated liver enzymes, and low platelets had significant changes over time in mean arterial pressure, urinary output, platelet count, lactic dehydrogenase and aspartate aminotransferase versus the control group with the syndrome. Relative to the control group, the mean arterial pressure became significantly decreased at 22 hours in the steroid-treated group (p 0.03), urinary output increased significantly by 16 hours (p 0.02), the platelet count increased significantly by 24 hours (p 0.05), and both lactic dehydrogenase and aspartate aminotransferase decreased significantly by 36 hours (p 0.04 and p 0.05, respectively). CONCLUSIONS: In association with high-dose corticosteroid administ ration, parturients with the syndrome of hemolysis, elevated liver enzymes, and low platelets recovered from the disease process more rapidly than did control subjects, as measured by urinary output, mean arterial pressure, platelet count, lactic dehydrogenase, and aspartate aminotransferase. In this disease process, which has significant associated morbidity and mortality, especially in patients with advanced cases, high-dose corticosteroid therapy appears to significantly hasten recovery and lessen the severity of the disease post partum. We postulate that use of this therapeutic approach in properly selected patients could result in lessened overall maternal morbidity and mortality, shorter patient stays in recovery and intensive-care areas, and shorter overall hospitalization with reduced medical care costs. EM - 9501 IS - 0002-9378 LA - English UI - 95029623 RN - EC 1.1.1.27 (Lactate Dehydrogenase); EC 2.6.1.1 (Aspartate Aminotransferase); 50-02-2 (Dexamethasone)

5 TI - Antepartum corticosteroids: disease stabilization in patients with the syndrome of hemolysis, elevated liver enzymes, and low platelets (HELLP) [see comments] CM - Comment in: Am J Obstet Gynecol 1995 May; 172(5):1656-7 SO - Am J Obstet Gynecol 1994 Oct;171(4):1148-53 AU - Magann EF; Bass D; Chauhan SP; Sullivan DL; Martin RW; Martin JN Jr AD - Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson 39216-4505. MJ - Dexamethasone [therapeutic use]; HELLP Syndrome [drug therapy] MN - Adolescence; Adult; Alanine Aminotransferase [blood]; Analysis of Variance; Dexamethasone [administration & dosage]; Discriminant Analysis; HELLP Syndrome [blood] [urine]; Lactate Dehydrogenase [blood]; Linear Models; Multivariate Analysis; Platelet Count [drug effects]; Pregnancy Trimester, Second; Pregnancy Trimester, Third; Pregnancy; Prospective Studies MT - Female; Human; Support, Non-U.S. Gov't PT - CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL AB - OBJECTIVE: Our purpose was to evaluate the impact of antepartum administration of corticosteroids on the course of the syndrome of hemolysis, elevated liver enzymes, and low platelets (HELLP) in pregnancies at 24 to 37 weeks' gestation. STUDY DESIGN: This prospective, randomized study was undertaken in 25 antepartum patients with atypical severe preeclampsia expressed as HELLP syndrome. Twelve pregnant women were randomized to receive double-dose dexamethasone (10 mg intravenously every 12 hours) until delivery, and 13 women were randomized to the control arm. Management and delivery decisions for all patients were based on a common protocol, with delivery undertaken for a deteriorating maternal or fetal condition. RESULTS: In the corticosteroid-treated group the maternal platelet count significantly increased (p = 0.006), whereas lactic dehydrogenase and alanine aminotransferase significantly decreased over time (p = 0.03 and p = 0.005) in comparison to the 13 women who did not receive corticosteroids. Maternal urinary output after entry into the study was significantly increased within hours after steroid administration versus the control group (p = 0.0006). The study entry-to-delivery interval (41 +/- 15 hours) was significantly longer in the group of steroid-treated women (p = 0.0068). CONCLUSIONS: Stabilization and significant improvement in the laboratory and clinical parameters associated with HELLP syndrome occurred in women who received high-dose antenatal corticosteroids, as measured by maternal platelet count, urinary output, lactic dehydrogenase, alanine aminotransferase, and postponement of delivery. We believe the findings of this investigation permit us to speculate that this therapeutic approach could enhance maternal-fetal care by postponing delivery of some previable fetuses, reduce the need for maternal transfusion of blood products, reduce neonatal morbidity or mortality from multiple systemic effects, and facilitate a safer transfer of th e ill mother to a tertiary care site for optimal peripartal care. EM - 9501 IS - 0002-9378 LA - English UI - 95029622 RN - EC 1.1.1.27 (Lactate Dehydrogenase); EC 2.6.1.2 (Alanine Aminotransferase

-- ---------- From: Christina Moisidis[SMTP:moisidis@bcm.tmc.edu] Sent: Tuesday, January 14, 1997 6:13 To: Multiple recipients of list Subject: atypical HELLP vs. TTP (fwd)

The question posed is this an atypical HELLP syndrome or a mild TTP? Would you consider starting empiric steroids for TTP/HELLP despite the low grade temperature. Any suggestions?

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