¹Associate Professor, ²Professor & HOD, Department of OBGY, Bharati Hospital and Medical College, Sangli, Maharashtra, INDIA.

Email: drvmjadhav@gmail.com, bmpatil56@gmail.com

Table 1: HELLP syndrome: Mississippi triple-class system.¹

(AST: aspartate aminotransferase, ALT: alanine aminotransferase, LDH: lactate dehydrogenase.)

Written informed consent was taken prior to the start of the study from each patient. Pregnant women satisfying study criteria underwent detailed history taking (chief complaints, obstetric history, etc.), clinical examination and hematological/biochemical investigations. Labour was monitored as per standard operative procedures of department. All new-born babies were immediately attended by neonatologists and if required admitted in NICU. Patients were subjected to repeat biochemical investigations; hemoglobin level and platelet count in the postpartum period after 48 hours. Maternal outcome was measured in terms of age of mother, parity, socioeconomic status, period of gestation, severity of preeclampsia, eclampsia, class of HELLP syndrome, mode of delivery, need for blood products, maternal complications like pulmonary edema, acute renal failure, abruption placenta, disseminated intravascular coagulation, postpartum haemorrhage and maternal mortality. Perinatal outcome was measured in terms of prematurity, dysmaturity, intrauterine fetal demise, birth asphyxia, APGAR score, neonatal jaundice, hypoglycemia, hypocalcemia, sepsis, NICU admission and early neonatal death. After complete stabilisation patients were discharged. Follow up was kept for 28 days. All details were entered in Microsoft excel sheet and sstatistical analysis was done using descriptive statistics.

RESULTS

In present study total 51 patients satisfying study criteria were studied. Most common maternal age group was 20-25 years (47.1 %), mean maternal age was 24.1 ± 4.2 years. Most common gestational age group was 34-47 weeks (47.1 %), mean gestational age was 34.71 ± 2.89 weeks, range was 29- 38 weeks. High risk factors were pre-eclampsia (76.5 %), Previous history of HELLP (13.7 %) and eclampsia (3.9 %). In most of patients Antepartum onset of HELLLP syndrome (54.9 %) was noted. Vaginal delivery (56.9 %) was common mode of delivery.

Table 2: Demographic and clinical characteristics

In present study malaise (90.2%), proteinuria (86.3 %), right upper quadrant/epigastric pain (84.3 %), right upper quadrant/epigastric tenderness (82.4 %), hypertension (80.4 %), nausea/vomiting (74.5 %) and headache (64.7 %) were common signs and symptoms noted in patients of HELLP syndrome

Table 3: Sign and symptoms of HELLP syndrome.

As per Mississippi triple-class system 70.59% patients had partial HELLP, 29.41% had complete HELLP. 3.92%, 9.8 % and 15.69 % patients had HELLP class I, II and III respectively. Placental abruption (35.29 %) was most common complication noted, followed by postpartum hemorrhage (29.41 %), acute kidney injury (13.73 %), pulmonary oedema (7.84 %), DIC (7.84 %), multiorgan dysfunction (7.84 %) and eclampsia (3.92 %). Maternal death was noted in 2 (3.92 %) patients.

Table 4: Maternal complications

In present study, most babies had 1.5-2.4 kgs (47.1 %) birth weight. APGAR ≤ 7 at 1 min was noted in 37.3 % neonates while APGAR ≤ 7 at 5 min was noted in 21.6 neonates. 15 neonates (29.4 %) required neonatal resuscitation. Common neonatal high-risk factors were prematurity (74.5 %), IUGR (35.3 %), Respiratory distress (60.8 %), Neonatal jaundice (11.8 %). During early neonatal period 29 neonates (56.9 %) required admission to NICU. Total neonatal deaths were 22 (43.1 %), 9 were intrauterine deaths (17.6 %) and 13 were early neonatal death (25.5 %).

Table 5: Perinatal outcome

DISCUSSION

Hypertensive disorders are among the most common medical disorders during pregnancy and continue to be the major cause of maternal and perinatal morbidity and mortality. HELLP syndrome is often associated with preeclampsia, as up to 20% of women with severe preeclampsia develop HELLP syndrome.⁹ The clinical presentation of hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is one of the more severe forms of preeclampsia because it has been associated with increased rates of maternal morbidity and mortality.¹⁰ HELLP syndrome is characterized by thrombocytopenia and microangiopathic hemolytic anemia leading to end-organ injury and is considered to be the classic thrombotic microangiopathy (TMA) of pregnancy. In HELLP syndrome, the main presenting symptoms are right upper quadrant pain and generalized malaise in up to 90% of cases and nausea and vomiting in 50% of cases.¹¹ The clinical course of HELLP syndrome often is characterized by progressive and sometimes sudden deterioration in maternal and fetal condition and women with HELLP syndrome should be delivered regardless of their gestational age.¹¹ Shelat PM et al.,¹² noted that HELLP syndrome was more common in younger age group (45%) and in primigravida (52.5%). Most of the patients presented at >36 weeks of gestation (40%) and most of the patients delivered by caesarean section (67.5%). Maternal complications were acute renal failure (27.5%), DIC (22.5%), maternal mortality (7.5%). Neonatal complications associated were intrauterine death (27.5%), prematurity (25%) and intrauterine growth retardation (15%). Similar findings were noted in present study. In study by Rakshit A et al.,¹³ prevalence of HELLP syndrome and partial HELLP syndrome were found to be 7.3% and 5.3% respectively in preeclampsia. The systolic blood pressure, gestational age at admission and during delivery, hematological and biochemical variables, rate of spontaneous vaginal delivery and type of anaesthesia were significantly different in HELLP syndrome and partial HELLP syndrome than in the preeclampsia group. There were statistically significant difference in perinatal outcome like birth weight, intrauterine death, neonatal death, and admission in NICU. They concluded that termination of pregnancy is the definitive treatment for HELLP syndrome and it should be treated only in a tertiary care center, as it needs a multidisciplinary team approach work by the obstetrician, paediatrician, physician, transfusion medicine specialist, anaesthesiologist etc. Chidanandaiah SK et al.,¹⁴ noted, incidence of HELLP syndrome during 1 year period as 1.14% of total deliveries and 3.82% of pregnancy induced hypertension (PIH). Majority (50%) patients belong to age group of 21-25 years, mean age was 22.5 years, most of them were primigravida (55%) and majority (52.5%) was in 36-40 weeks gestation and mean gestational age was 33.6 weeks. Headache (56.25%) was the most common imminent symptom. Most of symptoms were nonspecific like malaise (50%), edema (45%), vomiting (20%) and epigastric pain (7.5%). Out of 80 patients of HELLP syndrome 19 delivered by LSCS and 61 delivered vaginally. Ascites (26.25%), PPH (25%) and placental abruption (22.5%) were the most common maternal complications in HELLP syndrome followed by acute renal failure (18.75%), pulmonary edema (12.5%), DIC (6.25%) and cerebrovascular accidents (6.25%). Maternal mortality was 11.25% and perinatal mortality was 41.25%. In a retrospective study, Divya MB et al.,¹⁵ analyzed fetomaternal outcome in women diagnosed with HELLP syndrome over 2 year study period. Among 7,566 deliveries, 63 women (0.83%) had HELLP syndrome. Mean age was 29.5 years. 47.6% (n=30) women developed HELLP syndrome at gestational age less than 34 weeks. Maternal complications were abruption (27.78%), acute kidney injury (16.67%), DIC (16.67%), sepsis (11.11%) and postpartum hemorrhage (11.11%). In this study, HELLP syndrome led to one maternal death (1.58%). The perinatal mortality was 25.75%. Novotny S et al., recently reported an association between PR-AKI and obstetric complications, indicating that 24% and 22% of women with PRAKI complicated with HELLP syndrome had placental abruption and obstetric hemorrhage, respectively compared to the 13 and 11% of HELLP patients without PR-AKI. Early detection, prompt referral, better transport facility, appropriate and timely intervention, availability of life saving facilities like mechanical ventilators, dialysis equipment and blood products like FFP, Platelets, Packed cell transfusion at tertiary care centers will significantly reduce the maternal and fetal morbidity and mortality.

CONCLUSION

HELLP syndrome is associated with poor outcome for the mother and fetus. Timely diagnosis and management of HELLP syndrome by induction and delivery by vaginal route or by cesarean section is beneficial and prevents complications in mother and fetus.

REFERENCES

1. Martin, J.N., Jr.; Brewer, J.M.;Wallace, K.; Sunesara, I.; Canizaro, A.; Blake, P.G.; LaMarca, B.; Owens, M.Y. Hellp syndrome and composite major maternal morbidity: Importance of Mississippi classification system. J. Matern. Fetal Neonatal Med. 2013, 26, 1201–1206.
2. Baxter, J.K.; Weinstein, L. HELLP syndrome: The state of the art. Obstet. Gynecol. Surv. 2004, 59, 838–845.
3. Zhou Y, McMaster M, Woo K, Janatpour M, Perry J, Karpanen T, et al. Vascular endothelial growth factor ligands and receptors that regulate human cytotrophoblast survival are dysregulated in severe preeclampsia and hemolysis, elevated liver enzymes and low platelets syndrome. Am J Pathol. 2002;160:1405-23.
4. Strand S, Strand D. Placenta-derived CD59 ligand causes liver damage in haemolysis, elevated liver enzymes and low platelet count syndrome. Gastroenterol. 2004;126:849-58.
5. Fang C, Richards A, Liszewski MK, Kavanagh D, Atkinson JP. Advances in understanding in pathogenesis of aHUS and HELLP. BJH British J Hematol. 2008;143:336-48.
6. Steven Gabbe G, Jennifer Niebyl R. Joe Leigh Simpson Obstetrics-Normal and Problem Pregnancies 5th edition, 2007, 874-882.
7. Campos A, Goncalves A, Massa A, Amaral P, Silva P. HELLP syndrome a severe form of preeclampsia American journal of experimental and clinical research.2016;3(3):170-174.
8. Kim HY, Sohn YS, Lim JH, et al. Neonatal outcome after preterm delivery in HELLP syndrome. Yonsei Med J 2006;47(3):393–398.
9. Drakeley AJ, Le Roux PA, Anthony J, Penny J. Acute renal failure complicating severe preeclampsia requiring admission to an obstetric intensive care unit. Am J Obstet Gynecol. (2002) 186:253–6.
10. Barton JR, Sibai BM. Diagnosis and management of hemolysis, elevated liver enzymes, and low platelets syndrome. Clin Perinatol 2004;31:807–33,
11. ACOG PRACTICE BULLETIN, Clinical Management Guidelines for Obstetrician–Gynecologists, NUMBER 222, VOL. 135, NO. 6, JUNE 2020
12. Shelat PM, Vyas RC, Shah SR, Nathwani ND. Fetomaternal outcome in pregnancy with HELLP syndrome. Int J Reprod Contracept Obstet Gynecol 2020;9:2860-5.
13. Abhijit Rakshit, Sandip Lahiri, Subhash Chandra Biswas, Ramprasad Dey, Biswas Ranu Roy, A study to detect HELLP syndrome and partial HELLP syndrome among preeclamptic mothers and their impact on fetomaternal outcome, Al Ameen J Med Sc i 2014; 7(1) :20-25
14. Chidanandaiah SK, Prathiba M, Tharihalli CT, Gaddi S. Maternal and perinatal outcome in HELLP syndrome at VIMS, Ballari. The New Indian Journal of OBGYN. 2018; 5(1): 18-23.
15. Divya MB, Kondakasseril NR, Andrews MA. Fetomaternal outcome in women with hemolysis, elevated liver enzymes and low platelet count syndrome: a retrospective study. Int J Reprod Contracept Obstet Gynecol 2020;9:3798-801.
16. Novotny S, Lee-Plenty N, Wallace K, Kassahun-Yimer W, Jayaram A, Bofill J, et al. Acute kidney injury associated with preeclampsia or hemolysis, elevated liver enzymes and low platelet syndrome. Pregnancy Hypertens. 2020, 19:94–9.