Severe preeclampsia, including the HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome, has been shown to increase maternal and neonatal morbidity and mortality rates. In the second trimester, expectant management with aggressive monitoring of the status of both mother and fetus improves perinatal outcomes.
Severe preeclampsia, including the HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome, has been shown to increase maternal and neonatal morbidity and mortality rates. In the second trimester, expectant management with aggressive monitoring of the status of both mother and fetus improves perinatal outcomes.
Severe preeclampsia, including the HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome, has been shown to increase maternal and neonatal morbidity and mortality rates. In the second trimester, expectant management with aggressive monitoring of the status of both mother and fetus improves perinatal outcomes.
Severe preeclampsia, including the HELLP (hemolysis,
elevated liver enzymes, and low platelet count) syn- drome, has been shown to increase maternal and neona- tal morbidity and mortality rates, 1 particularly if occur- ring in the second trimester. 2, 3 The usual management of severe preeclampsia remote from term has been the de- livery of the fetus, regardless of gestational age. 1 Recently, expectant management of women with severe pre- eclampsia but without the HELLP syndrome between 28 and 32 weeks gestation has been shown to reduce neona- tal complications and neonatal stay in the intensive care unit. 4 In the second trimester, expectant management with aggressive monitoring of the status of both mother and fetus improves perinatal outcomes. 5 The success of this management, however, is limited by adverse maternal outcomes occurring in women with severe preeclampsia at the mid trimester. 2 An increased risk of maternal morbidity and death is reported in women with the HELLP syndrome, particu- larly in those with a platelet count <100,000 cells/L. 6 From the Division of Maternal-Fetal Medicine, University of Tennessee, a the Perinatal Diagnostic Center, Central Baptist Hospital, b and the De- partment of Obstetrics and Gynecology, University of Cincinnati College of Medicine. c Received for publication December 1, 1999; revised January 27, 2000; accepted March 4, 2000. Reprint requests: Baha M. Sibai, MD, Department of Obstetrics and Gy- necology, University of Cincinnati College of Medicine, 231 Bethesda Ave, PO Box 670526, Cincinnati, OH 45267. Copyright 2000 by Mosby, Inc. 0002-9378/2000 $12.00 + 0 6/1/106975 doi:10.1067/mob.2000.106975 HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome versus severe preeclampsia: Onset at 28.0 weeks gestation Bassam Haddad, MD, a John R. Barton, MD, b Jeffrey C. Livingston, MD, a Rabih Chahine, MD, a and Baha M. Sibai, MD c Memphis, Tennessee, Lexington, Kentucky, and Cincinnati, Ohio OBJECTIVE: Our purpose was to determine whether the onset of the HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome in women at 28.0 weeks gestation is associated with an in- creased risk of adverse maternal and perinatal outcomes in comparison with the risk for women with severe preeclampsia but without the HELLP syndrome at a similar gestational age. STUDY DESIGN: Sixty-four patients with either the HELLP syndrome (n = 32) or severe preeclampsia but absent HELLP syndrome laboratory test results (n = 32), admitted at 28.0 weeks gestation between July 1, 1992, and April 30, 1999, were studied. Maternal and perinatal outcomes were compared between the 2 groups. Statistical analysis was performed by the Student t test and the Fisher exact test. RESULTS: There were no significant differences between the 2 groups regarding African-American race (59% vs 75%), nulliparity (50% vs 56%), or the use of corticosteroids (59% vs 78%). There were no maternal deaths. One woman with the HELLP syndrome had a liver hematoma. The rate at which transfusion of blood products was required was significantly greater in women with the HELLP syndrome than in those with se- vere preeclampsia only (25% vs 3%; P < .05). There were no significant differences between the 2 groups with respect to eclampsia (16% vs 13%), abruptio placentae (6% vs 9%), disseminated intravascular coagu- lopathy (13% vs 0%), pulmonary edema (13% vs 6%), acute renal failure (3% vs 0%), pleural effusion (3% vs 3%), or ascites (6% vs 16%). No significant differences were found between the 2 groups with respect to neonatal death (11% vs 17%), respiratory distress syndrome (78% vs 86%), or composite neonatal morbidity. CONCLUSIONS: Except for the need for transfusion of blood products in women with the HELLP syndrome, onset at 28.0 weeks gestation is not associated with an increased risk of adverse maternal or neonatal out- comes in comparison with the risk for women with severe preeclampsia but without the HELLP syndrome at a similar gestational age. (Am J Obstet Gynecol 2000;183:1475-9.) Key words: HELLP syndrome, severe preeclampsia, second trimester, maternal outcome, neonatal outcome Obstetrics In addition, women with the HELLP syndrome were re- ported to have an increased risk of adverse maternal out- come in comparison with those who had severe pre- eclampsia but not the HELLP syndrome. 7, 8 However, the differences in the outcomes observed in these studies may be related to earlier gestation in women with the HELLP syndrome than in women with severe preeclamp- sia alone and may also reflect a greater severity of the dis- ease process. To clarify this hypothesis, we conducted this study to determine whether onset of the HELLP syn- drome at 28.0 weeks gestation is associated with an in- creased risk of maternal and perinatal morbidity in com- parison with the risk associated with severe preeclampsia without the HELLP syndrome at a similar gestational age. Material and methods We reviewed the medical records of women with the HELLP syndrome and of those with severe preeclampsia but without the HELLP syndrome who were admitted to the E.H. Crump Womens Hospital, Memphis, Tennessee (between July 1, 1992, and April 30, 1999) and to the Central Baptist Hospital, Lexington, Kentucky (between March 1, 1994, and April 30, 1999). Women with a history of hematologic or liver diseases were excluded from analysis. The HELLP syndrome was defined by using the strict criteria of Sibai 9 to avoid any misinterpretation of the re- sults regarding different diagnostic criteria for the HELLP syndrome or incomplete HELLP syndrome. The diagnosis was made by the presence of all 3 of the follow- ing criteria: hemolysis (characteristic peripheral blood smear and serum lactate dehydrogenase >600 U/L or serum total bilirubin 1.2 mg/dL), elevated liver en- zymes (serum aspartate aminotransferase 70 U/L), and low platelet counts (<100,000 cells/L). 9 Women with class 3 HELLP syndrome (eg, platelet count of 100-150 l0 3 /L), as defined by Martin et al, 7 and those with in- complete HELLP syndrome, as described by Audibert et al, 8 were therefore excluded from this study. Women were considered to have severe preeclampsia if they met one or more of the following criteria of The American College of Obstetricians and Gynecologists 1 : systolic blood pressure >160 mm Hg or diastolic blood pressure >110 mm Hg, headache, visual disturbances, epigastric or right-upper-quadrant pain, eclampsia, pulmonary edema, and proteinuria (urinary protein level >5 g/24 h). Women with severe preeclampsia selected for analysis also met all the following laboratory criteria: platelet count 150,000 cells/L, serum lactate dehydrogenase <600 U/L, serum total bilirubin <1.2 mg/dL, and serum aspartate amino- transferase <70 U/L. All women routinely received intra- venous magnesium sulfate to prevent and control convul- sions. Blood products were used to correct severe anemia or coagulation abnormalities, as needed. Gestational age was determined by using the best ob- stetric criteria, including either last menstrual period or ultrasonography (where available) at <20 weeks gesta- tion, or both. Only those women admitted at 28.0 weeks gestation were included in the analysis. Maternal vari- ables studied included age, race (African-American or white), parity, previous preeclampsia, chronic hyperten- sion, gestational stage at diagnosis, mean arterial blood pressure, headache, visual change, nausea and vomiting, epigastric or right-upper-quadrant pain, and adverse ma- ternal outcome. Maternal outcomes included eclampsia, abruptio placentae, disseminated intravascular coagu- lopathy (DIC), acute renal failure, pulmonary edema, pleural effusion, ascites, the need for transfusion, and liver hematoma. DIC was defined as the presence of 3 of the following criteria: low platelet count (<100,000 cells/L), low fibrinogen level (<300 mg/dL), positive D-dimers (40 mg/dL), or prolonged prothrombin time (14 seconds) and partial thromboplastin times (40 sec- onds). Acute renal failure was diagnosed in the presence of oligouria or anuria in association with creatinine clear- ance 20 mL/min and an elevated serum creatinine level 2 mg/dL. Pulmonary edema and pleural effusion were assessed on the basis of clinical findings and radiography of the chest. The diagnosis of severe ascites was made by estimation during ultrasonographic examination, com- puted tomography, or cesarean delivery or laparotomy (1000 mL of fluid measured by suction apparatus). The neonatal medical records were reviewed for the following outcomes as diagnosed by the attending pedia- trician: respiratory distress syndrome, bronchopul- monary dysplasia, intraventricular hemorrhage (grade III/IV), necrotizing enterocolitis (grade 2/3), duration of stay in an intensive care unit, and neonatal death. Data are presented as mean SD, median and range, or frequency, as appropriate. Categoric data were com- pared by the Fisher exact test. Continuous variables were analyzed by the Student t test. A P value < .05 was consid- ered significant. Results During the study period, 32 women met the criteria of the HELLP syndrome and were compared with 32 women who had severe preeclampsia but not the hema- tologic and hepatic abnormalities. The findings in these women are shown in Table I. Rates of nausea and vomit- ing and of epigastric pain were significantly higher in the women with the HELLP syndrome. Laboratory results are shown in Table II. Complications are presented in Table III. The overall rate of adverse maternal outcomes for women with the HELLP syndrome was statistically similar to that for women with severe preeclampsia only (44% vs 38%, re- spectively). However, significantly more women with the HELLP syndrome needed transfusion of blood products than did those without the HELLP syndrome (25% vs 1476 Haddad et al December 2000 Am J Obstet Gynecol 3%; odds ratio, 10.3; 95% confidence interval, 1.2-88.4; P < .05). No statistical differences were found between the 2 groups for all other adverse maternal outcomes studied. The perinatal mortality rate for both groups was 250 of 1000 women. The stillbirth rates for women with the HELLP syndrome and for those without the HELLP cri- teria were statistically similar (16% vs 9%; odds ratio, 1.8; confidence interval, 0.4-8.3; P = .70). Neonatal mortality and morbidity rates are presented in Table IV. No statisti- cal differences were found in the neonatal outcomes be- tween the 2 groups. Volume 183, Number 6 Haddad et al 1477 Am J Obstet Gynecol Table I. Clinical findings in 2 study groups HELLP syndrome (n = 32) Preeclampsia without HELLP syndrome (n = 32) Age (y, mean SD)* 24.4 4.7 21.9 4.7 Gestational age at diagnosis (wk, mean SD) 25.8 2.5 26.2 1.5 Arterial blood pressure (mm Hg, mean SD) 130 18 132 11 Maternal stay (d, mean SD) 7.8 2.7 9.5 8.1 African-American (No.) 19 (59%) 24 (75%) Nulliparity (No.) 16 (50%) 18 (56%) Previous preeclampsia (No.) 14 (44%) 18 (56%) Chronic hypertension (No.) 4 (13%) 10 (31%) Headache (No.) 9 (28%) 14 (44%) Visual change (No.) 6 (19%) 6 (19%) Nausea and vomiting (No.) 13 (41%) 2 (6%) Epigastric or right-upper-quadrant pain (No.) 19 (59%) 3 (9%) Corticosteroid prophylaxis (No.) 18 (67%) 24 (83%)ll *P < .05. P < .01. P < .0001. Five stillbirths excluded from analysis. llThree stillbirths excluded from analysis. Table II. Laboratory findings in 2 study groups HELLP syndrome (n = 32) Preeclampsia without HELLP syndrome (n = 32) Platelet count nadir (10 3 /L)* 57 (17-95) 195 (153-292) Lactate dehydrogenase (U/L)* 1347 (407-5720) 228 (152-431) Aspartate aminotransferase (U/L)* 182 (71-2924) 29 (12-56) Serum creatinine (mg/dL) 0.9 (0.5-10.4) 0.9 (0.6-5.3) Serum uric acid (mg/dL) 7.3 (2.8-20) 7 (4.5-12.3) Values are expressed as median and range. *P < .001. Table III. Maternal complications in 2 study groups HELLP syndrome Preeclampsia without (n = 32) HELLP (n = 32) No. % No. % Odds ratio and 95% confidence interval Eclampsia 5 16 4 13 1.3 (0.3-5.3) Abruptio placentae 2 6 3 9 0.6 (0.1-4.1) DIC 4 13 0 NA Transfusion of blood products* 8 25 1 3 10.3 (1.2-88.4) Acute renal failure 1 3 0 NA Ascites 2 6 5 16 0.4 (0.1-2) Pulmonary edema 4 13 2 6 2.1 (0.4-12.6) Pleural effusion 1 3 1 3 1 Cesarean delivery 25 93 29 100 NA Cesarean delivery for fetal distress 4 16 8 28 0.5 (0.1-1.9) NA, Not applicable. *P < .05. Five stillbirths excluded from analysis. Three stillbirths excluded from analysis. Comment The ultimate goal of any protocol for management of severe preeclampsia is to reduce maternal mortality and morbidity rates, followed by delivery of a healthy and ma- ture baby. Seven percent of the cases of severe pre- eclampsia occur in the second trimester, and the gesta- tional age has a critical influence on perinatal outcome. 2 The optimal management in the second trimester usually depends on balancing the risks to the mother and fetus resulting from expectant management against the risks of extreme prematurity in the event of immediate delivery. 3 Severe preeclampsia occurring in the second trimester has been reported to be associated with an increased in- cidence of adverse maternal outcomes, with a high rate of abruptio placentae (22%), HELLP syndrome (17%), eclampsia (17%), and DIC (8%). 2 Under these adverse maternal conditions, expeditious delivery has been rec- ommended because the risks resulting from a delayed de- livery outweigh the possible benefits of pregnancy pro- longation. 10 The overall rate of adverse maternal outcomes ob- served in women with the HELLP syndrome (44%) was similar to that observed in those with severe preeclampsia but not the HELLP syndrome (38%) during the second trimester. Except for hematologic changes, the inci- dences of all other adverse maternal outcomes studied among women with the HELLP syndrome and those with severe preeclampsia but not the HELLP syndrome were not statistically different. Our finding of similar rates of eclampsia in women with the HELLP syndrome and in those with severe preeclampsia only is not in agreement with that of Martin et al, 11 who reported that eclampsia was more frequent in women with the HELLP syndrome than in those without the HELLP syndrome at 24 to 32 weeks gestation. This may be related to a bias in their re- cruitment, because 13 (93%) of the 14 women with eclampsia before 28 weeks had the HELLP syndrome. 11 Although the rate of DIC in our study appeared to be higher in women with the HELLP syndrome (13%) than in those with severe preeclampsia (0%), this difference was not statistically significant. We cannot, however, ex- clude a type II statistical error because the estimated power analysis is 0.54. Moreover, these findings are in agreement with those of Martin et al, 7 who reported DIC rates of 12% in women with the HELLP syndrome, classes 1 and 2 (eg, platelet count <100 10 3 cells/L) and 1% in those with severe preeclampsia but without the HELLP syndrome. In the management of patients with severe preeclamp- sia developing before 28 weeks gestation, the presence of the HELLP syndrome was considered to be an indication for delivery within 48 hours of the start of corticosteroid treatment for enhancing fetal lung maturity. 10 In our study perinatal and neonatal mortality and morbidity rates were statistically similar between the women with the HELLP syndrome and those with severe preeclamp- sia. These findings are similar to those of other investiga- tors, 12-14 who found that neonatal morbidity and death were related to gestational age at delivery rather than to the severity of the HELLP syndrome or preeclampsia. The HELLP syndrome is associated with an increased risk of adverse maternal outcomes, in comparison with the risks associated with other forms of severe pre- eclampsia. However, the HELLP syndrome usually has an earlier onset than other forms of severe preeclampsia. 8, 11 This aspect is of interest because it suggests that the ges- tational age at which the disease is diagnosed might cor- relate with severity. Indeed, studies comparing expectant management in women with severe preeclampsia with and without the HELLP syndrome but matched for ges- tational age failed to demonstrate any differences in ad- verse maternal outcomes, except for transfusion of blood products. 14, 15 Because expectant management in women with severe preeclampsia but without the HELLP syn- drome at <32 weeks gestation improves neonatal out- come, 4, 5 the results of this study raise the issue regarding expectant management in women with the HELLP syn- drome developing before 28.0 weeks gestation. We 1478 Haddad et al December 2000 Am J Obstet Gynecol Table IV. Neonatal findings in 2 study groups HELLP syndrome Preeclampsia without HELLP Odds ratio and (n = 27) (n = 29) 95% confidence interval Gestational age at delivery (wk, mean SD) 26.7 1.3 27.3 1.4 Delivery weight (g, mean SD) 740 224 825 167 Small for gestational age (No.)* 10 (37%) 5 (17%) 3.4 (1-11.3) Neonatal death (No.) 3 (11%) 5 (17%) 0.6 (0.1-2.8) Respiratory distress syndrome (No.) 21 (78%) 25 (86%) 0.6 (0.1-2.3) Bronchopulmonary dysplasia (No.) 15 (56%) 9 (31%) 2.8 (0.9-8.3) Intraventricular hemorrhage, grade III/IV (No.) 1 (4%) 2 (7%) 0.5 (0-6.1) Necrotizing enterocolitis grade 2/3 (No.) 2 (7%) 2 (7%) 1.1 (0.1-8.3) Mechanical ventilation (No.) 25 (93%) 27 (93%) 0.9 (0.1-7.1) Time in neonatal intensive care unit (d, mean SD) 74 41 55 29 Stillbirths excluded from analysis. *Defined as delivery weight at <10th percentile. P = .05. should, however, caution that women with DIC should not be managed expectantly. Magann et al, 16 in a randomized study, analyzed the usefulness of dexamethasone (20 mg/d) administered until delivery to 25 women with the HELLP syndrome. They found a significantly increased entry-to-delivery interval in treated women in comparison with nontreated women (41 15 vs 15 4.5 hours, P < .01). This, in turn, should have a beneficial effect on neonatal outcome. Re- cently, Tompkins and Thiagarajah, 17 in a retrospective study, reported a beneficial effect of corticosteroid treat- ment given to enhance fetal lung maturity on laboratory parameters of women with the HELLP syndrome. 17 The number of patients admitted before 28 weeks gestation, their clinical course, and the neonatal outcome, however, were not provided in either study. 16, 17 On the basis of our results and the data reported in the literature, 14-17 expectant management may be beneficial in some women with the HELLP syndrome at or before 28 weeks gestation, as reported for women with severe preeclampsia in the second trimester in the absence of the HELLP syndrome. 5 The ideal approach to answer this important clinical question would be a randomized trial comparing outcomes for women managed expectantly by means of high-dose corticosteroid therapy with outcomes for those managed by immediate delivery. REFERENCES 1. The American College of Obstetricians and Gynecologists. Hy- pertension in pregnancy. Washington: The College; 1996. Tech- nical Bulletin No.: 219. 2. Sibai BM, Taslimi M, Abdella TN, Brooks TF, Spinnato JA, An- derson GD. Maternal and perinatal outcome of conservative management of severe preeclampsia in midtrimester. Am J Ob- stet Gynecol 1985;152:32-7. 3. Pattinson RC, Odendaal HJ, Du Toit R. Conservative manage- ment of severe proteinuric hypertension before 28 weeks gesta- tion. S Afr Med J 1988;73:516-8. 4. Sibai BM, Mercer BM, Schiff E, Friedman SA. Aggressive versus expectant management of severe preeclampsia at 28 to 32 weeks gestation: a randomized controlled trial. Am J Obstet Gy- necol 1994;171:818-22. 5. Sibai BM, Akl S, Fairlie F, Moretti M. A protocol for managing se- vere preeclampsia in the second trimester. Am J Obstet Gynecol 1990;163:733-8. 6. Sibai BM, Ramadan MK, Usta I, Salama M, Mercer BM, Fried- man SA. Maternal morbidity and mortality in 442 pregnancies with hemolysis, elevated liver enzymes, and low platelets (HELLP syndrome). Am J Obstet Gynecol 1993;169:1000-6. 7. Martin JN Jr, Rinehart BK, May WL, Magann EF, Terrone DA, Blake PG. The spectrum of severe preeclampsia: comparative analysis by HELLP (hemolysis, elevated liver enzyme levels, and low platelet count) syndrome classification. Am J Obstet Gy- necol 1999;180:1373-84. 8. Audibert F, Friedman SA, Frangieh AY, Sibai BM. Clinical utility of strict diagnostic criteria for the HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome. Am J Obstet Gy- necol 1996;175:460-4. 9. Sibai BM. The HELLP syndrome (hemolysis, elevated liver en- zyme levels, and low platelets): much ado about nothing? Am J Obstet Gynecol 1990;162:311-6. 10. Friedman SA, Schiff E, Lubarsky SL, Sibai BM. Expectant man- agement of severe preeclampsia remote from term. Clin Obstet Gynecol 1999;42:470-8. 11. Martin JN Jr, Perry KG, Miles JF, Blake PG, Magann EF, Roberts WE, Martin RW. The interrelationship of eclampsia, HELLP syn- drome, and prematurity: cofactors for significant maternal and perinatal risk. Br J Obstet Gynaecol 1993;100:1095-100. 12. Magann EF, Perry KG, Chauhan SP, Graves GR, Blake PG, Mar- tin JN Jr. Neonatal salvage by weeks gestation in pregnancies complicated by HELLP syndrome. J Soc Gynecol Investig 1994; 1:206-9. 13. Abramovici D, Friedman SA, Mercer BM, Audibert F, Kao L, Sibai BM. Neonatal outcome in severe preeclampsia at 24 to 36 weeks gestation: does the HELLP (hemolysis, elevated liver en- zymes, and low platelet count) syndrome matter? Am J Obstet Gynecol 1999;180:221-5. 14. Visser W, Wallenburg HCS. Temporising management of severe pre-eclampsia with and without the HELLP syndrome. Br J Ob- stet Gynaecol 1995;102:111-7. 15. van Pampus MG, Wolf H, Westenberg SM, van der Post JAM, Bonsel GJ, Treffers PE. Maternal and perinatal outcome after ex- pectant management of the HELLP syndrome compared with preeclampsia with HELLP syndrome. Eur J Obstet Gynecol Re- prod Biol 1998;76:31-6. 16. Magann EF, Bass D, Chauhan SP, Sullivan DL, Martin RW, Mar- tin JN Jr. Antepartum corticosteroids: disease stabilization in pa- tients with the syndrome of hemolysis, elevated liver enzymes, and low platelets (HELLP). Am J Obstet Gynecol 1994;171: 1148-53. 17. Tompkins MJ, Thiagarajah S. HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome: the benefit of cor- ticosteroids. Am J Obstet Gynecol 1999;181:304-9. Volume 183, Number 6 Haddad et al 1479 Am J Obstet Gynecol
The Hebrew and The Arabic Version of The LittlEARS® Auditory Questionnaire For The Assessment of Auditory Development - Results in Normal Hearing Children and Children With Cochlear Implants