Síndrome HELLP y rotura hepática en un embarazo gemelar: presentación de un caso / HeLLP Syndrome and Hepatic Rupture in a Twin Pregnancy: A Case Report / Síndrome HeLLP e ruptura hepática em gestação gemelar: relato de caso

Introducción: el síndrome HELLP y rotura hepática es una complicación poco frecuente, especialmente en casos de embarazo gemelar. Se presenta el caso de un hematoma subcapsular hepático roto por síndrome HELLP que complicó un embarazo gemelar que requirió una cesárea de emergencia y para el manejo de la hipovolemia, el empaquetamiento hepático. Presentación del caso: mujer de 41 años, con gestación gemelar de 35 semanas, quien acudió al servicio de emergencia, por contracciones uterinas y ausencia de movimientos fetales. Ante una bradicardia severa de ambos fetos, se optó por una cesárea de urgencia. Al abrir la cavidad abdominal, se encontró hemoperitoneo y se logró extraer ambos fetos vivos. Se realizó una laparotomía media, supra e infraumbilical exploradora (poscesárea) y se halló una rotura hepática del lóbulo derecho. Se procedió a un empaquetamiento hepático con compresas y cierre temporal abdominal; entre tanto, el manejo del shock hipovolémico y la preeclampsia se continuó en la unidad de cuidados intensivos. La paciente se fue de alta en buenas condiciones a los 21 días. Conclusión: el síndrome HELLP produce complicaciones graves, como rotura hepática, que si no es tratada de forma correcta, temprana y multidisciplinaria, puede llevar a producir mortalidad materno-perinatal.

Introduction: HELLP syndrome and hepatic rupture are rare complications, especially in the case of twin pregnancy. Here, we present a case of ruptured hepatic subcapsular hematoma due to HELLP syndrome that caused complication in a twin pregnancy. This case required emergency Cesarean section and management of hypo- volemia hepatic packing. Case presentation: A 41-year-old female pregnant with twins (35 weeks) came to the emergency room for uterine contractions and absence of fetal movements. Due to severe bradycardia in both fetuses, emergency Cesarean section was performed. When the abdominal cavity was opened, hemoperitoneum was found, and both fetuses were extracted alive. A median, supra-, and infraumbilical exploratory laparotomy (post Cesarean section) was performed, and right lobe hepatic rupture was found. Subsequently, hepatic packing with compression and temporary abdominal closure was performed. Hypovolemic shock and preeclampsia was continuously managed in the intensive care unit. At 21 days, the patient was discharged in good condition. Conclusion: HELLP syndrome causes serious complications, such as hepatic rupture, which may lead to maternal and perinatal mortality if not correctly treated early in a multidisciplinary manner.

Introdução: a síndrome HELLP e a ruptura hepática são complicações raras, especialmente em casos de gravidez gemelar. Neste artigo, apresentamos o caso de um hematoma subcapsular hepático rompido devido à síndrome HELLP que complicou uma gravidez gemelar que exigiu uma cesariana de emergência e tamponamento hepático para o manejo da hipovolemia. Apresentação do caso: mulher, 41 anos, gestação gemelar de 35 semanas, recorre ao pronto-socorro por contrações uterinas e ausência de movimentos fetais. Devido à bradicardia grave em ambos os fetos, foi decidida uma cesariana de emergência. Ao abrir a cavidade abdominal o hemoperitônio é localizado, sendo possível extrair ambos os fetos vivos. Foi realizada laparotomia exploradora mediana, supra e infraumbilical (pós-cesariana) sendo constatada ruptura hepática do lobo direito. Foi realizado tamponamento hepático com compressas e fechamento abdominal temporário, e o manejo do choque hipovolêmico e da pré-eclâmpsia foi mantido na Unidade de Terapia Intensiva, onde a paciente recebeu alta em boas condições após 21 dias. Conclusão: a síndrome HELLP produz complicações graves como a ruptura hepática que, se não tratada de forma precoce e multidisciplinar, pode levar à mortalidade materna perinatal.

Preeclampsia y eclampsia complicada con desprendimiento de retina. Comunicación de tres casos

La preeclampsia es un trastorno hipertensivo multisistémico que se presenta después de las 20 semanas de gestación en 5% a 15% de gestantes y es causa de complicaciones que pueden afectar órganos importantes y hasta provocar la muerte durante la gestación o en el posparto. Incluye la preeclampsia severa, eclampsia y síndrome HELLP (hemolysis, elevation of liver enzymes, low platelets, por sus siglas en inglés). Se comunica tres casos de desprendimiento de retina que ocurrieron en dos pacientes con preeclampsia severa y una con eclampsia, todas con hemorragia y alteración visual en el posparto que requirieron tratamiento farmacológico. El desprendimiento de retina es un síntoma asociado a la preeclampsia y eclampsia que puede ser investigado por fundoscopia ocular para determinar si es factible su tratamiento conservador o farmacológico.

Preeclampsia is a multisystemic hypertensive disorder that occurs after 20 weeks of gestation in 5%-15% of pregnant women and is the cause of complications that can affect important organs and even cause death during gestation or in the postpartum period. It includes severe preeclampsia, eclampsia and HELLP (hemolysis, elevation of liver enzymes, low platelets) syndrome. We report three cases of retinal detachment that occurred in two patients with severe preeclampsia and one with eclampsia, all with hemorrhage and visual alteration in the postpartum period that required pharmacological treatment. Retinal detachment is a symptom associated with preeclampsia and eclampsia that can be investigated by ocular fundoscopy to determine whether conservative or pharmacological treatment is feasible.

Les facteurs associés aux morbi-mortalités maternelles de l'éclampsie à la maternité de Befelatanana / Factors associated with maternal eclampsia morbidity and mortality at the maternity hospital of Befelatanana

L'éclampsie est une complication neurologique majeure de la pré-éclampsie sévère, responsable d'une lourde morbidité et mortalité maternelle. L'objectif de cette étude était de déterminer les facteurs associés aux morbimortalités maternelles de l'éclampsie. Patients et Méthodes : Il s'agissait d'une étude rétrospective, transversale, descriptive et analytique ; sur une période de 36 mois, allant de Janvier 2019 à Décembre 2021, réalisée à la maternité de Befelatanana. Les paramètres cliniques et obstétricales, la prise en charge, les complications et l'évolution maternelle ont été les paramètres étudiés. Résultats : Sur 21 514 accouchements, 461 cas (2,14%) d'éclampsie ont été recensé dont 288 cas inclus dans l'étude. L'âge moyen était de 23,29±6 ans ; l'âge gestationnel était > 37 semaine d'aménorrhée dans 60,10% (n= 173) des cas et la grossesse étaient mal suivies dans 49,70% (n=143) des cas. Les complications maternelles dominées par : la détresse respiratoire aigüe sur pneumopathie d'inhalation; le coma prolongé ; une hémorragie intracérébrale et l'association à d'autres complications tel que : un HELLP syndrome, un hématome rétroplacentaire et une insuffisance rénale oligo-anurique aigue. Les facteurs associés aux décès étaient : l'existence de trouble de la conscience postcritique (p=0,026 ; OR=3,2 [1,09-9,37]), l'existence de coma prolongé ≥24h (p=10-8 ; OR=34 [11,47-100,71]), l'existence d'une insuffisance rénale aigue (p=10-4 ; OR=4,42 [2,08-9,4]) et l'association à un HELLP syndrome (p=10-8 ; OR=29,16 [12,08-70,41]). Conclusion : La morbi-mortalité de l'éclampsie reste encore très élevé à Madagascar ; une éducation de la population Malagasy doit être renforcer sur le suivi médical rapproché de la grossesse

Desprendimiento bilateral de retina en una embarazada con síndrome de HELLP. Reporte de caso y revisión de la bibliografía / Bilateral retinal detachment in a pregnant woman with HELLP syndrome. Case report and literature review

Resumen ANTECEDENTES: El síndrome de HELLP es una complicación del embarazo que pone en riesgo la vida de la madre y el feto y es una variante del espectro de la preeclampsia, casi siempre relacionada con cambios visuales; las complicaciones, como el desprendimiento de retina, son excepcionales. CASO CLÍNICO: Paciente de 26 años, primigesta, con 36 semanas de embarazo y trastorno hipertensivo, tipo síndrome de HELLP, que se complicó con desprendimiento bilateral seroso de la retina que se resolvió espontáneamente. CONCLUSIONES: Las manifestaciones oculares relacionadas con la preeclampsia y el síndrome de HELLP suelen ser transitorias y se relacionan más con un síntoma de alarma que con un trastorno orgánico ocular. Es importante que las pacientes con este tipo de afecciones obstétricas reciban atención multidisciplinaria.

Abstract BACKGROUND: HELLP syndrome is a life-threatening complication of pregnancy in both mother and fetus. It manifests as a variant of the preeclampsia spectrum, almost always related to visual changes, complications, such as retinal detachment, are exceptional. CLINICAL CASE: A 26-year-old primigravida patient, 36 weeks pregnant, with hypertensive disorder, HELLP syndrome type, complicated by bilateral serous retinal detachment that resolved spontaneously. CONCLUSIONS: Ocular manifestations related to preeclampsia and HELLP syndrome are usually transient and are related more to an alarm symptom than to an organic ocular disorder. It is important that patients with these types of obstetric conditions receive multidisciplinary care.

Acidosis láctica grave en una mujer embarazada con síndrome HELLP parcial y COVID-19 / Severe lactic acidosis in a pregnant woman with partial HELLP syndrome and COVID-19

Resumen Se presenta el caso de una mujer embarazada secundigesta, cursando la semana 36.5 de gestación, que concurrió a guardia general por tos seca y disnea progresiva de 3 días de evolución, asociadas a cefalea y mialgias. Se realizó hisopado nasofaríngeo para reacción en cadena de la polimerasa (PCR) para SARS-CoV-2, resultando positivo. La saturación de oxígeno era normal, al igual que la radiografía de tórax. En el laboratorio presentó elevación de bilirrubina, transaminasas, fosfatasa alcalina y LDH, además de plaqueto penia leve. Poco después de su ingreso, comenzó con trabajo de parto. Frente a la falta de progresión del mis mo se decidió la finalización del embarazo por cesárea. La gasometría arterial reveló la presencia de acidosis láctica grave. Nunca hubo evidencia clínica de hipoperfusión tisular o sepsis que pudieran explicarla. Cursó su postoperatorio en la unidad de terapia intensiva, realizándose tratamiento de sostén. Todos los parámetros de laboratorio se normalizaron al cabo de 72 horas, evolucionando favorablemente desde el punto de vista clínico. Se interpretó que cursó un síndrome HELLP parcial. La acidosis láctica no es un componente descripto en este síndrome. Tampoco puede adscribirse a la enfermedad leve por SARS-CoV-2. Podría deberse a una sumatoria de causas, incluidas la hiperproducción de ácido láctico en el marco del trabajo de parto, como la disminución de su aclaramiento por la disfunción hepática asociada al síndrome HELLP.

Abstract The present report describes the case of a 23-year old pregnant woman who was in the 36.5th week of gestation of her second pregnancy. She was attended at the emergency room because of dry cough and progressive dyspnea, in association with headache and myalgia. The nasopharyngeal swab for SARS-CoV-2 polymerase chain reaction (PCR) was positive. Oxygen saturation and chest x-ray were normal. Laboratory tests showed elevated values of bilirubin, aminotransferases, alkaline phosphatase and lactic dehydrogenase, and mild thrombocytopenia. Shortly after being admitted she began with labor. Faced with the lack of progression, the termination of the pregnancy by cesarean section was decided. Arterial blood gases showed severe lactic acidosis. She never presented evidence of clinical signs of tissue hypoperfusion or sepsis that could explain it. The patient completed her postoperative period in the intensive care unit, undergoing supportive treatment. All laboratory parameters were normalized after 72 hours, evolving favorably from the clinical point of view. It was interpreted that she had a partial HELLP syndrome. Lactic acidosis is not a component of this syndrome. Nor can it be ascribed to a mild disease by SARS-Cov-2. It probably responded to a summation of causes, including hyperproduction of lactic acid during labor, as well as its reduced clearance because of liver dysfunction related to HELLP syndrome.

Guía de práctica clínica para la prevención y el manejo de la enfermedad hipertensiva del embarazo / Clinical practice guideline for the prevention and management of hypertensive disorders of pregnancy

RESUMEN Objetivos: Proveer recomendaciones clínicas basadas en evidencia para la prevención y el manejo de la enfermedad hipertensiva del embarazo (EHE) en el Seguro Social de Salud (EsSalud) del Perú. Materiales y métodos: se conformó un grupo elaborador de la guía (GEG) que incluyó médicos especialistas y metodólogos. El GEG formuló ocho preguntas clínicas para ser respondidas por la presente Guía de Práctica Clínica (GPC). Se realizaron búsquedas sistemáticas de revisiones sistemáticas y, cuando se consideró pertinente, estudios primarios en PubMed y Central durante 2021. Se seleccionó la evidencia para responder cada una de las preguntas clínicas planteadas . En reuniones de trabajo periódicas, el GEG usó la metodología Grading of Recommendations Assessment, Development, and Evaluation (GRADE) para calificar la evidencia y formular las recomendaciones. Además se resentan los puntos de buenas prácticas clínicas (BPC) y los flujogramas de prevención, manejo y seguimiento. Finalmente, la GPC fue aprobada por Resolución 112-IETSI-ESSALUD-2021. Resultados: En la presente GPC se formularon 11 recomendaciones (6 fuertes y 5 condicionales) que respondieron las preguntas clínicas definidas en el alcance de la GPC, acompañadas de 32 puntos de BPC y 3 flujogramas que abordan temas de prevención, tratamiento y seguimiento de la EHE. Conclusiones: Como recomendaciones centrales de la guía se dan el uso de sulfato de magnesio para el tratamiento de la preeclampsia severa y la eclampsia. La guía deberá ser actualizada en tres años.

ABSTRACT Objectives: To provide clinical recommendations based on evidence for the prevention and management of Hypertensive disorders of pregnancy (HDP) in the Social Health Insurance (EsSalud) of Peru. Materials and methods: A CPG for the the prevention and management of HDP in EsSalud was developed. To this end, a guideline development group (local GDG) was established, including medical specialists and methodologists. The local GDG formulated 8 clinical questions to be answered by this CPG. Systematic searches of systematic reviews and -when it was considered pertinent- primary studies were searched in PubMed y Central during 2021. The evidence to answer each of the posed clinical questions was selected. The quality of the evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. In periodic work meetings, the local GDG used the GRADE methodology to review the evidence and formulate the recommendations, the points of good clinical practice and flowcharts for the prevention, management and follow-up. Finally, the CPG was approved with Resolution 112-IETSI-ESSALUD-2021. Results: This CPG addressed 8 clinical questions, divided into three topics: prevention, management and follow-up of the HDP. Based on these questions, 11 recommendations (6 strong recommendations and 5 weak recommendations), 32 points of good clinical practice, and 3 flowcharts were formulated. Conclusions: The main recommendations in the guideline are the use of magnesium sulfate for the treatment of severe pre-eclampsia and eclampsia. The guideline must be updated in three years' time.

Caracterización y manejo del hematoma hepático subcapsular en mujeres con preeclampsia y síndrome HELLP / Characterization and management of subcapsular hepatic hematoma in women with preeclampsia and HELLP syndrome

RESUMEN Introducción. La mortalidad materna es mayor en los países en desarrollo, por complicaciones del embarazo y/o puerperio, siendo la rotura hepática la complicación más catastrófica. Objetivos. Describir la caracterización y manejo del hematoma hepático subcapsular en pacientes con preeclampsia con criterios de severidad y síndrome HELLP. Métodos. Estudio observacional, retrospectivo y descriptivo, realizado en el Instituto Nacional Materno Perinatal de Perú, entre 2003 y 2020. Participaron pacientes con preeclampsia con criterios de severidad y síndrome HELLP que presentaron hematoma hepático subcapsular. Se recogió información a partir de la historia clínica y se documentó la técnica quirúrgica. En el análisis de datos se utilizó estadística descriptiva. Resultados. En el periodo de estudio se identificaron 53 pacientes con hematoma hepático subcapsular entre 342,000 partos atendidos. El 37,7% fueron gestantes y 62,3% puérperas, siendo los síntomas más frecuentes dolor abdominal superior y cefalea. Se realizó tratamiento quirúrgico mediante laparotomía y empaquetamiento del hígado en el 94,3% de los casos. Las complicaciones más frecuentes fueron falla orgánica múltiple, shock hipovolémico e insuficiencia renal aguda. Se observó una sobrevivencia del 81% de pacientes. Conclusiones. Se evidenció una incidencia de 1,65 casos de hematoma hepático subcapsular x 10,000 partos, con una mortalidad de diez casos (19%). El hematoma hepático subcapsular se debe sospechar en aquellas gestantes con preeclampsia con criterios de severidad que presentan síntomas de dolor epigástrico y cefalea, siendo más frecuente en el posparto. La laparotomía y el empaquetamiento del hígado junto con la reposición de volumen contribuyen al manejo de estas pacientes, lo cual debe realizarse prontamente en pacientes inestables.

ABSTRACT Introduction: Maternal mortality is higher in developing countries, due to pregnancy and/or puerperium complications, with hepatic rupture being the most catastrophic complication. Objective: To describe the characterization and management of subcapsular hepatic hematoma in patients with preeclampsia with severity criteria and HELLP syndrome. Methods: Observational, retrospective and descriptive study performed at the Instituto Nacional Materno Perinatal of Peru between 2003 and 2020. Patients with preeclampsia with severity criteria and HELLP syndrome who presented subcapsular hepatic hematoma participated. Information was collected from the clinical history and the surgical technique was documented. Descriptive statistics were used in the data analysis. Results: During the study period, 53 patients with subcapsular liver hematoma were identified out of 342.000 deliveries attended. The most frequent symptoms were upper abdominal pain and headache; 37.7% were pregnant women and 62.3% were postpartum women. Surgical treatment by laparotomy and liver packing was performed in 94.3% of the cases. The most frequent complications were multiple organ failure, hypovolemic shock and acute renal failure. Survival rate was 81%. Conclusions: An incidence of 1.65 cases of subcapsular hepatic hematoma x 10.000 deliveries was found, with a mortality of ten cases (19%). Subcapsular liver hematoma should be suspected in pregnant women with preeclampsia with severity criteria who present symptoms of epigastric pain and headache, being more frequent in the postpartum period. Laparotomy and liver packing together with volume replacement contribute to the management of these patients, which should be performed promptly in unstable patients.

Comparison of clinical features in antepartum and postpartum HELLP syndrome / 中华妇产科杂志

Objective:To analyze the clinical features and pregnancy outcomes in antepartum and postpartum hemolysis, elevated live enzymes, and low platelet count syndrome(HELLP syndrome).Methods:A retrospective study was conducted to collect maternal and neonatal information of pre-eclampsia complicated with HELLP syndrome in Peking University First Hospital during the ten years from April 2009 to March 2019. A total of 83 pregnant women were included according to the Tennessee Classification System. They were then allocated into two groups based on the onset time of HELLP syndrome: antepartum HELLP syndrome group ( n=70) and postpartum HELLP syndrome group ( n=13). The clinical features, symptoms, laboratory biomarkers, and pregnancy outcomes were compared between the two groups. Results:Among the 83 pregnant women with HELLP syndrome, 70 occurred prenatally (84%, 70/83) and 13 occurred postpartum (16%, 13/83). The twin or triplet pregnancy rate in the postpartum HELLP syndrome group was significantly higher than that in the antepartum HELLP syndrome group [6/13 vs 6% (4/70), P=0.001]. The gestational weeks for HELLP onset and delivery in the postpartum HELLP syndrome group were significantly later than those in the antepartum HELLP syndrome group [(35.8±3.0) vs (31.5±5.2) weeks, P=0.025; (36.7±2.3) vs (32.2±5.0) weeks, P=0.002]. The incidence of early-onset pre-eclampsia in the antepartum HELLP syndrome group was significant higher than that in the postpartum HELLP syndrome group [64% (45/70) vs 2/13, P=0.002]. The quantitative of 24-hour proteinuria was significant higher in the antepartum HELLP syndrome group than that in the postpartum HELLP syndrome group [(4.8±5.1) vs (1.8±1.6) g, P=0.002]. But there were no statistical significances in the comparison of other laboratory test indexes (all P>0.05). There were no significant differences between the two groups in clinical symptoms, severe maternal complications, transfusion or adverse maternal outcomes (all P>0.05). Conclusions:Antepartum and postpartum HELLP syndrome have similar clinical symptoms and laboratory characteristics. Both antepartum and postpartum HELLP syndrome could lead to severe maternal complications, which should be paid special attention in clinical practice, especially to the postpartum HELLP syndrome.

A comparison of clinical characteristics between acute fatty liver of pregnancy and hemolysis, elevated liver enzymes and low platelets syndrome / 中华危重病急救医学

Objective:To compare and analyze the clinical characteristics between acute fatty liver of pregnancy (AFLP) and the hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome.Methods:This is a retrospective cohort study. The clinical data of 13 cases with AFLP and 34 cases with HELLP syndrome were collected from three tertiary referral centers in Yunnan (the First Affiliated Hospital of Kunming Medical University, the Second Affiliated Hospital of Kunming Medical University, and Yan'an Hospital of Kunming City) from January 2016 to December 2021. The patients were diagnosed to AFLP and HELLP syndrome according to the Swansea criteria and the Tennessee classification system. The general characteristics, clinical features, laboratory results within 24 hours after admission, complications, maternal and neonatal outcomes were compared to analysis the differences between the two groups.Results:① Maternal characteristics: compared with HELLP syndrome group, AFLP group had lower body mass index (BMI) and blood pressure at admission (both P < 0.01). ②Clinical features: the most common symptoms in AFLP patients were skin jaundice, abdominal pain, nausea and vomiting, edema. The main manifestations of patients with HELLP syndrome were albuminuria, hypertension, edema, headache. Some patients had multiple symptoms concurrently. ③ Laboratory results: compared with HELLP syndrome group, the levels of platelet count (PLT), total bilirubin (TBil), direct bilirubin (DBil), γ-glutamyl transferase (γ-GGT), alkaline phosphatase (ALP), total bile acid (TBA), serum creatinine (SCr) and international standardized ratio (INR) in AFLP group were significantly increased within 24 hours after admission [PLT (×10 9/L): 107.69±51.13 vs.76.71±43.25, TBil (μmol/L): 121.60 (83.20, 170.00) vs.15.25 (7.22, 29.05), DBil (μmol/L): 86.50 (58.60, 104.00) vs. 4.30 (2.22, 10.10), γ-GGT (U/L): 87.00 (37.00, 127.00) vs. 41.00 (19.00, 64.42), ALP (U/L): 199.10 (109.00, 349.20) vs. 125.50 (90.50, 155.25), TBA (μmol/L): 51.50 (16.20, 117.40) vs. 4.15 (2.02, 6.95), SCr (μmol/L): 155.80 (129.00, 237.00) vs. 79.00 (65.43, 113.70), INR: 1.28 (1.17, 1.63) vs. 0.94 (0.88, 1.08), all P < 0.05], prothrombin time (PT) was significantly prolonged [seconds: 16.10 (14.50, 19.20) vs. 12.40 (11.43, 13.40), P < 0.05]. The level of blood glucose (GLU), fibrinogen (FIB) and the activity of antithrombin Ⅲ (ATⅢ) decreased significantly [GLU (mmol/L): 5.18±1.33 vs. 6.33±1.19, FIB (g/L): 1.96±1.46 vs. 3.81±1.58, ATⅢ (%): 40.61±25.84 vs. 66.39±24.11, all P < 0.05]; ④ Complications: compared with HELLP syndrome group, the incidence of patients with hypoglycemia [30.77% (4/13) vs. 0% (0/34)], acute liver failure [53.85% (7/13) vs. 5.88% (2/34)], acute renal insufficiency [69.23% (9/13) vs. 8.82% (3/34)], coagulopathy [76.92% (10/13) vs. 38.24% (13/34)], disseminated intravascular coagulation (DIC) [53.85% (7/13) vs. 5.88% (2/34)], and multiple organ dysfunction syndrome (MODS) [53.85% (7/13) vs. 5.88% (2/34)] were significantly higher in AFLP group (all P < 0.05). ⑤ Maternal and neonatal outcome: all patients delivered after admission. The total length of hospital and intensive care unit stay were significantly longer in the AFLP group than in the HELLP syndrome group [days: 17.00 (11.00, 25.00) vs. 9.00 (7.00, 12.00), 12.00 (4.00, 22.00) vs. 3.91 (0, 7.00), both P < 0.01]. Two AFLP patients died, including one due to intracranial venous thrombosis and one due to multiple organ failure and cardiopulmonary arrest. There were no deaths in the HELLP syndrome group. Conclusions:There are significant differences in maternal characteristics, laboratory results and complications between AFLP and HELLP syndrome. TBil, γ-GGT, SCr, FIB, INR and ATⅢ activity may help to distinguish the two diseases.

Preeclampsia atípica: a propósito de un caso / Atypical preeclampsia: on the subject of a case

Resumen ANTECEDENTES: El trastorno hipertensivo del embarazo es una de las causas de mortalidad materna y perinatal. Se estima que hay complicaciones incluso hasta en 10% de los embarazos, con un aumento significativo en la incidencia mundial en las últimas dos décadas y alrededor de 50,000 a 60,000 muertes maternas anuales. CASO CLÍNICO: Paciente de 26 años, con 17 semanas de embarazo; acudió a Urgencias debido a un episodio de 20 minutos de evolución de cefalea severa, con posterior episodio convulsivo tónico-clónico generalizado, con tensión arterial al ingreso de 170-102 mmHg, leve palidez mucocutánea, útero grávido con altura uterina de 18 cm y frecuencia cardiaca fetal de 136 lpm. Los estudios paraclínicos confirmaron: síndrome de HELLP, sin duda una situación atípica para las semanas de embarazo en la que sucedió. CONCLUSIONES: Los casos atípicos de preeclampsia suelen ser raros, sobre todo cuando sobrevienen antes de las 20 semanas; cuando así sucede es importante que el proceso diagnóstico sea oportuno al igual que el tratamiento. Es indispensable estar alertas del posible surgimiento de nefritis lúpica, púrpura trombocitopénica trombótica y síndrome urémico hemolítico, embarazo molar y síndrome antifosfolipídico.

Abstract BACKGROUND: Preeclampsia before 20 weeks' gestation is exceptional; it is associated with antiphospholipid syndrome. Hypertensive disorder of pregnancy is the leading cause of maternal and perinatal mortality worldwide, represents a 10% complication of all the pregnancies worldwide, where there has been a significant increase in its incidence has been observed. In the last two decades, with an annual estimate of 50,000 to 60,000 maternal deaths in the world. CLINICAL CASE: 26-year-old woman in the 17th week of pregnancy, who was admitted to the emergency department for a 20-minute evolution of severe headache with subsequent generalized tonic-clonic seizure episode, admission blood pressure was 170/102 mmHg, she was also found with mucocutaneas pallor, gynecological examination found a gravid uterus with a uterine height of 18 cm, and a fetal heart rate of 136 bpm. The paraclinical tests confirmed a HELLP syndrome, being considered an atypical situation due to the gestational age in which she presented. CONCLUSIONS: Atypical cases of preeclampsia are usually rare cases, especially when they appear before week 20; however, in this population it is important to make a diagnosis process in a timely manner, to initiate rapid treatment. Additionally, caution should be exercised with disorders including lupus nephritis, thrombotic thrombocytopenic purpura, and hemolytic uremic syndrome, as well as molar pregnancy and antiphospholipid syndrome.

Investigation of FAS and IL-6 expression in placentas with HELLP syndrome / Investigación de la expresión de FAS e IL-6 en placentas con síndrome de HELLP

SUMMARY: The aim of our study was to investigate the effect of inflammation in the placenta on the pro-apoptotic development after severe preeclampsia. Placenta tissue samples of 15 HELLP syndrome and 15 healthy 35-38th week-pregnant women were involved in the study. Tissue samples were taken only from the maternal side of the placenta and fixed in 10 % formaldehyde, then blocked in paraffin wax and 4-6 mm-thick sections were cut and stained with Harris Hematoxylene-Eosin. Antigen retrieval was performed for sections, incubated with FAS antibody and anti-IL-6 antibody. After the application of streptavidin peroxidase followed by AEC chromogen solution, sections were counterstained with Harris hematoxylin. Significant thickening of the fibrinoid layer, degeneration and apoptotic change in decidua cells, marked increase in the hyalinized area, degenerative changes in the syncytial regions of the chorionic villus and an increase in syncytial nodes and bridges and IL- expression were observed as positive. FAS expression was positive in the pycnotic nuclei of decidual cells in the maternal region and in the syncytial regions. It was observed that the proapoptotic process increased as a result of severe preeclampsia. It was concluded that the control of cytokine activity and reduction of pro-apoptotic signal during the inflammation process will slow down the development of HELLP syndrome.

RESUMEN: El objetivo de nuestro estudio fue investigar el efecto de la inflamación en la placenta sobre el desarrollo proapoptótico después de la preeclampsia severa. Se recogieron muestras de tejido de placenta de 15 mujeres con síndrome de HELLP y 15 mujeres sanas con un embarazo de 35 a 38 semanas. Se tomaron muestras de tejido solo del lado materno de la placenta y se fijaron en formaldehído al 10 %, luego se bloquearon en parafina y se cortaron secciones de 4-6 mm de espesor y se tiñeron con hematoxilena-eosina de Harris. La recuperación del antígeno se realizó para secciones, incubadas con anticuerpo FAS y anticuerpo anti-IL-6. Después de la aplicación de estreptavidina peroxidasa seguida de solución de cromógeno AEC, las secciones se contrastaron con hematoxilina de Harris. Se observó como positivo un engrosamiento significativo de la capa fibrinoide, degeneración y cambio apoptótico en las células de la decidua, aumento marcado en el área hialinizada, cambios degenerativos en las regiones sincitiales de la vellosidad coriónica y un aumento en los nódulos y puentes sincitiales y la expresión de IL-6. La expresión de FAS fue positiva en los núcleos picnóticos de las células deciduales en la región materna y en las regiones sincitiales. Se observó que el proceso proapoptótico se incrementó como consecuencia de la preeclampsia severa. Se concluyó que el control de la actividad de las citocinas y la reducción de la señal proapoptótica durante el proceso de inflamación ralentizarán el desarrollo del síndrome de HELLP.

Mortalidade materna por síndrome hellp: interferência do perfil, condições clínicas e ginecológicas durante a gravidez

Objetivo: Analisar a correlação estabelecida entre perfil, condições clínicas e ginecológicas da gestante e mortalidade materna causada pela síndrome HELLP (Haemolysis, Elevated Liver enzymes and Low Platelets). Material e Método: Estudo correlacional, transversal e retrospectivo, com 143 prontuários, de 2015 a 2019, de gestantes que evoluíram com diagnóstico da Síndrome HELLP procedentes da região do Alto Sertão Produtivo Baiano, interior do Nordeste brasileiro. A coleta de dados ocorreu em fevereiro e junho de 2019. Delineou-se uma amostragem intencional, dispensando-se o cálculo amostral, pois o intuito foi incluir todos os prontuários das gestantes que evoluíram para tal síndrome. Utilizaram-se como instrumentos duas cheklists compostas de questões estruturadas referentes à caracterização das mulheres, dos seus conceitos, do processo gestacional e das condições clínicas maternas. As variáveis foram processadas com o software Statistical Package for the Social Sciences versão 22. Fez-se a análise com a frequência simples das variáveis e as correlações com a mortalidade materna foram submetidas ao teste de Pearson. Considerou-se a significânciap menor ou igual a 5% (0,05). Resultados: As condições clínicas da gestação atual que fizeram correlações significativas com a mortalidade materna, decorrente da síndrome, foram: vias de parto (p= 0,023), eclampsia (p= 0,000), pelo menos dois sintomas de gravidade e complicação (p= 0,005), bem como o tempo entre diagnóstico da síndrome e o parto (p= 0,015). Conclusão: Apenas quatro variáveis sobre as condições clínicas da gestação atual interferiram na mortalidade materna por síndrome HELLP, a exemplo da correlação com o tempo entre diagnóstico e o parto, inédita na literatura científica.

Objective: To analyze the correlation between the profile, clinical and gynecological conditions of the pregnant woman and maternal mortality caused by HELLP (Haemolysis, Elevated Liver Enzymes and Low Platelets) syndrome. Material and Method: Correlational, cross-sectional, and retrospective study based on 143 medical records (from 2015 to 2019) of pregnant women, coming from the Alto Sertão Produtivo Baiano region in Northeast Brazil, who were diagnosed with HELLP syndrome. Data collection took place in February and June 2019. Intentional sampling was used, disregarding sample size calculation, as the aim was to include all pregnant women who had developed this syndrome. Two checklists consisting of structured questions referring to the women characterization, their concepts, the gestational process and maternal clinical conditions were used as instruments. The variables were processed using the Statistical Package for the Social Sciences version 22 software. Simple frequency analysis of the variables and correlations with maternal mortality were performed using Pearson's test. Significance level was considered to be less than or equal to 5% (0.05). Results: The clinical conditions of the current pregnancy that showed significant correlations with maternal mortality resulting from the syndrome were: modes of delivery (p= 0.023), eclampsia (p= 0.000), at least two symptoms of severity and complication (p= 0.005), as well as the time between diagnosis of the syndrome and delivery (p= 0.015). Conclusion: Only four variables on the clinical conditions of the current pregnancy interfered with maternal mortality due to HELLP syndrome, following the correlation with the time between diagnosis and delivery, which has not been recorded in scientific literature.

Objetivo: Analizar la correlación establecida entre el perfil, condiciones clínicas y ginecológicas de la gestante y mortalidad materna por el síndrome HELLP (Haemolysis, Elevated Liver enzymes and Low Platelets). Material y Método: Estudio correlacional, transversal y retrospectivo, con 143 historias clínicas (de 2015 a 2019) de gestantes que desarrollaron diagnóstico de HELLP, provenientes de la región Alto Sertão Produtivo Baiano (interior del noreste brasileño). La recopilación de datos se realizó en los meses de febrero y junio de 2019. La muestra fue intencional, prescindiendo del cálculo muestral, que incluyó a todas las gestantes que evolucionaron a este síndrome. Se utilizaron dos listas de control compuestas que contenían preguntas estructuradas referentes a la caracterización de la mujer, sus conceptos, el proceso gestacional y las condiciones clínicas maternas. Las variables fueron procesadas mediante el software Statistical Package for the Social Sciences versión 22. Se realizaron análisis de frecuencia simple de las variables y correlaciones con la mortalidad materna mediante la prueba de Pearson. Se consideró significación menor o igual al 5% (0,05). Resultados: Las condiciones clínicas del embarazo actual que presentaron correlaciones significativas con la mortalidad materna derivada del síndrome fueron: modos de parto (p= 0,023), eclampsia (p= 0,000), al menos dos síntomas de gravedad y complicación (p= 0,005), así como el tiempo entre el diagnóstico del síndrome y el parto (p= 0,015). Conclusión: Solo cuatro variables sobre las condiciones clínicas del embarazo actual interfirieron en la mortalidad materna por síndrome HELLP, siguiendo la correlación con el tiempo entre el diagnóstico y el parto, inédita en la literatura científica.

Eficacia terapeútica de la dexametasona para la plaquetopenia en pacientes internadas en el servicio de obstetricia con síndrome de HELLP, Hospital Municipal Boliviano Holandes, gestión 2018 / Therapeutic efficacy of dexamethasone for plachetopenia in patients intermitted to the obstetrics service with HELLP syndrome, Municipal Hospital "Boliviano Holandés", management 2018

El síndrome de HELLP se caracteriza por anemia hemolítica microangiopática, disfunción hepática y trombocitopenia. OBJETIVO: determinar la eficacia terapéutica de la dexametasona para la plaquetopenia en pacientes internadas con síndrome de HELLP, en el servicio de Obstetricia del Hospital Municipal Boliviano Holandés, gestión 2018. MATERIAL Y METODOS: se realizó un estudio prospectivo, analítico y de corte dinámico desde el 1 de enero al 31 de diciembre de la gestión 2018, en el servicio de Obstetricia del Hospital Municipal Boliviano Holandés. Se incluyeron en el estudio pacientes internadas con el diagnóstico de HELLP; con edad gestacional mayor a 22 semanas y puérperas que estuvieron cursando los 7 días post parto, a quienes se administró dexametasona. RESULTADOS: se estudió 14 pacientes (100%), las cuales cumplieron los criterios de inclusión, a quienes se administró dexametasona EV (8mg c/12 hrs y 4mg c/12hrs). En relación a la edad, se presentó en mayores de 35 años (43%), teniendo el (71.4%) de las pacientes un nivel de instrucción secundario, de las cuales (50%) realizo menos de 3 controles prenatales durante su gestación. Respecto al recuento plaquetario existe un incremento de 34.500mm3 (p=0.00) tras 48 horas de tratamiento con dexametasona y disminución de enzimas hepáticas GOT (p=0.003) y GPT (p=0.017) respectivamente. CONCLUSION: este estudio demuestra que el uso de dexametasona en pacientes con síndrome de HELLP, es eficaz ya que incrementa el recuento plaquetario y reduce los niveles de transaminasas tras 48 horas de tratamiento

HELLP syndrome is characterized by microangiopathic hemolytic anemia, liver dysfunction, and thrombocytopenia. OBJETIVES: to determine the therapeutic efficacy of dexamethasone for thrombocytopenia in hospitalized patients with HELLP syndrome, in the Obstetrics service of the Municipal Hospital Boliviano Holandés, management 2018. MATERIALS AND METHODS: a prospective, analytical and dynamic study was carried out from January 1 to December 31 of the 2018 administration, in the Obstetrics service of the Holandés Boliviano Municipal Hospital. Hospitalized patients diagnosed with HELLP were included in the study; with gestational age greater than 22 weeks and puerperal women who were attending the 7 days postpartum, who were administered dexamethasone. RESULTS: we studied 14 patients (100%), who met the inclusion criteria, who were administered IV dexamethasone (8mg every 12 hours and 4mg every 12 hours). In relation to age, it was presented in patients older than 35 years (43%), with (71.4%) of the patients having a secondary education level, of which (50%) performed less than 3 prenatal controls during their pregnancy. Regarding the platelet count, there is an increase of 34,500mm3 (p=0.00) after 48 hours of treatment with dexamethasone and a decrease in liver enzymes GOT (p=0.003) and GPT (p=0.017), respectively. CONCLUSIONS: this study shows that the use of dexamethasone in patients with HELLP syndrome is effective since it increases platelet count and reduces transaminase levels after 48 hours of treatment.

Evolución de pacientes con lesión renal aguda secundaria a complicaciones obstétricas tratadas con terapia de reemplazo renal continua / Evolution of patients with acute kidney injury secondary to obstetric complications treated with continuous renal replacement therapy / Evolução de pacientes com lesão renal aguda secundária a complicações obstétricas tratadas com terapia renal substitutiva contínua

Resumen: Introducción: La lesión renal aguda asociada al embarazo o complicaciones obstétricas (PR-AKI) es una enfermedad que ocurre por múltiples etiologías, de la cual poco se ha estudiado, estimándose una mortalidad de 4.3%. Objetivo: Analizar la evolución de las pacientes con lesión renal aguda secundaria a complicaciones obstétricas (PR-AKI) que recibieron terapia de reemplazo renal continua (TRRC) en la Unidad de Cuidados Intensivos del Hospital de la Mujer de Morelia, Michoacán. Material y métodos: Estudio retrospectivo, longitudinal, descriptivo. Se realizó una revisión de expedientes de pacientes que requirieron TRRC secundario a complicaciones obstétricas durante enero de 2013 a diciembre de 2019. Se aplicó la prueba t de Student, considerando los resultados estadísticamente significativos si p < 0.05. Resultados: Se incluyeron 13 pacientes que requirieron TRRC. La edad promedio de las pacientes fue de 26.18 años. Los criterios de TRRC fueron tener AKI grado 2 o 3 y RIFLE etapa lesión o fracaso; potasio ≥ 6.5 mEq/L; urea ≥ 150 mg/dL; índice urinario ≤ 0.5 mL; pH < 7.10 y HCO3 ≤ 20 mEq/L; SCr ≥ 2.4 mg/dL; sobrecarga hídrica > 10%; BUN > 30 mg/dL. Conclusiones: La incidencia de mujeres que requieren TRRC es de 3.2 casos/100 complicaciones obstétricas. Noventa y dos por ciento de las pacientes tuvieron recuperación de la función renal, mientras que la progresión a enfermedad renal crónica dependiente de otras modalidades de terapia de sustitución renal fue de 8%.

Abstract: Introduction: Acute kidney injury associated with pregnancy or obstetric complications (PR-AKI) is a disease that occurs due to multiple etiologies of which little has been studied, with an estimated mortality of 4.3%. Objective: To analyze the evolution of patients with acute kidney injury secondary to obstetric complications (PR-AKI) who received continuous renal replacement therapy (CRRT) in the Intensive Care Unit of the Hospital de la Mujer de Morelia, Michoacán. Material and methods: Retrospective, longitudinal, descriptive study. A review of the records of patients who required CRRT secondary to obstetric complications was carried out during January 2013-December 2019. The Student's t test was applied, considering the statistically significant results if p < 0.05. Results: Thirteen patients who required CRRT were included. The mean age of the patients was 26.18 years. The CRRT criteria were: AKI grade 2 or 3 and RIFLE stage injury or failure and potassium ≥ 6.5 mEq/L; urea ≥ 150 mg/dL; urinary index ≤ 0.5 mL; pH < 7.10 and HCO3 ≤ 20 mEq/L; SCr ≥ 2.4 mg/dL; water overload > 10%; BUN > 30 mg/dL. Conclusions: The incidence of women requiring CRRT is 3.2 cases/100 obstetric complications. Ninety-two percent of the patients had recovery of renal function while the progression to chronic kidney disease dependent on other modalities of renal replacement therapy was 8%.

Resumo: Introdução: A lesão renal aguda associada à gravidez ou complicações obstétricas (PR-LRA) é uma doença que ocorre por múltiplas etiologias das quais pouco tem sido estudada, com mortalidade estimada em 4.3%. Objetivo: Analisar a evolução de pacientes com lesão renal aguda secundária a complicações obstétricas (PR-LRA) que receberam terapia renal substitutiva contínua (TRRC) na Unidade de Terapia Intensiva do Hospital da Mulher de Morelia, Michoacán. Material e métodos: Estudo retrospectivo, longitudinal, descritivo. Uma revisão dos prontuários de pacientes que necessitaram de TRRC secundária a complicações obstétricas foi realizada durante janeiro de 2013-dezembro de 2019. Foi aplicado o teste t de Student, considerando os resultados estatisticamente significativos se p < 0.05. Resultados: Incluíram-se 13 pacientes que necessitaram de TRRC. A média de idade dos pacientes foi de 26.18 anos. Os critérios de TRRC foram ter IRA grau 2 ou 3 e lesão ou falha no estágio RIFLE; potássio ≥ 6.5 mEq/L; ureia ≥ 150 mg/dL; índice urinário ≤ 0.5 mL; pH < 7.10 e HCO3 ≤ 20 mEq/L; SCr ≥ 2.4 mg/dL; sobrecarga hídrica > 10%; BUN > 30 mg/dL. Conclusões: A incidência de mulheres que necessitam de TRRC é de 3.2 casos/100 complicações obstétricas. 92% dos pacientes tiveram recuperação da função renal enquanto a progressão para doença renal crônica dependente de outras modalidades de terapia renal substitutiva foi de 8%.

Hígado agudo graso del embarazo: reporte de caso / Acute fatty liver of pregnancy: case report

El hígado graso del embarazo es una patología poco frecuente en la especialidad obstétrica, cuyo diagnóstico se realiza basado en los criterios de Swansea, muchas veces es un diagnóstico que se realiza por exclusión; usualmente se presenta entre las semanas 30 y 35 del embarazo, y la cura definitiva se realiza con la interrupción expedita del mismo; con una tasa de recuperación casi del 100% si se realiza la interrupción oportuna y una tasa de mortalidad materno fetal actual del 10%. Es importante estar atentos a la ganancia ponderal de la embarazada durante el control prenatal, la epigastralgia, y los signos clínicos asociados a hipoglicemia(AU)

Fatty liver of pregnancy is a rare pathology in obstetrics, whose diagnosis is made based on the Swansea criteria, many times it is a diagnosis that is made by exclusion; It usually occurs between weeks 30 and 35, and the definitive cure is carried out with the expeditious interruption of pregnancy; with a recovery rate of almost 100% if timely interruption is made and a current maternal-fetal mortality rate of 10%. It is important to be attentive to the weight gain of the pregnant woman during prenatal control, epigastric pain, and clinical signs associated with hypoglycemia

Subdiagnóstico de la lesión renal aguda en pacientes obstétricas complicadas en la Unidad de Cuidados Intensivos / Underdiagnosis of acute kidney injury in complicated obstetric patients in the Intensive Care Unit / Subdiagnóstico da lesão renal aguda em pacientes obstétricas complicadas na Unidade de Terapia Intensiva

Resumen: Objetivo: Definir la prevalencia y factores asociados de lesión renal aguda en el embarazo en la Unidad de Cuidados Intensivos del Hospital de la Mujer, Morelia, Michoacán, México. Material y métodos: Estudio retrospectivo, transversal y descriptivo de enero de 2013 a agosto de 2018. Pacientes: 213 expedientes de pacientes obstétricas complicadas. Criterios de inclusión: pacientes obstétricas complicadas que ingresaron a la UCI, pacientes que cumplieron criterios para lesión renal aguda. Criterios de exclusión: pacientes con lesión renal crónica, expediente clínico no disponible. Sólo 154 cumplieron con los criterios de selección. Resultados: Se incluyeron 154 pacientes obstétricas complicadas; un promedio de 25.6p ± 1.6 por año. Treinta y seis por ciento tuvo diagnóstico de eclampsia; 35.3% preeclampsia; 29.3% síndrome de HELLP; 19.3% hemorragia obstétrica, 10% sepsis. Se demostró asociación de PR-AKI con síndrome de HELLP (p = 0.0003) y preeclampsia (p = 0.01). Se encontró un subdiagnóstico de 36.7% al buscar PR-AKI utilizando los criterios RIFLE y AKI (p = 0.000007). De las pacientes con PR-AKI grado 3, sólo 20% requirió terapia de reemplazo renal continua. Conclusiones: La lesión renal asociada al embarazo complicado tiene una prevalencia de 6.7%. Las complicaciones asociadas a PR-AKI son síndrome de HELLP y preeclampsia. La PR-AKI está subdiagnosticada hasta en 36.7%.

Abstract: Objective: To define the prevalence and associated factors of acute renal injury in pregnancy (PR-AKI) in the Intensive Care Unit (ICU) of the Women's Hospital, Morelia, Michoacán, Mexico. Material and methods: Retrospective, cross-sectional and descriptive study from January 2013-August 2018. Ambit: Intensive Care Unit of the Women's Hospital. Patients: We reviewed 213 files of complicated obstetric patients. Inclusion criteria: complicated obstetric patients that merit admission to the ICU, patients who met criteria for LRA. Exclusion criteria: patients with chronic. Main variables of interest: Complicated obstetric patients (preeclampsia, eclampsia, HELLP syndrome, hemorrhagic shock and sepsis). It was investigated if they developed PR-AKI. Results: 154 complicated obstetric patients were included; an average of 25.6p ± 1.6 per year. 36% had a diagnosis of eclampsia; 35.3% pre-eclampsia; 29.3% HELLP syndrome; 19.3% obstetric hemorrhage, 10% sepsis. Association of PR-AKI with HELLP syndrome (p = 0.0003) and pre-eclampsia (p = 0.01) was demonstrated. A subdiagnosis of 36.7% was found when searching for PR-AKI using the RIFLE and AKI criteria (p = 0.000007). Of the patients with PR-AKI grade 3, 20% required continuous renal replacement therapy. Conclusions: Renal injury associated with complicated pregnancy has a prevalence of 6.7%. The complications that most develop PR-AKI are HELLP syndrome and preeclampsia. PR-AKI is underdiagnosed.

Resumo: Objetivo: Definir a prevalência e os fatores associados à Lesão Renal Aguda na gravidez na Unidade de Terapia Intensiva do Hospital de la Mujer, Morelia, Michoacán, México. Material e métodos: Estudo retrospectivo, transversal e descritivo de janeiro de 2013 a agosto de 2018. Pacientes: 213 prontuários obstétricos complicados. Critérios de inclusão: pacientes obstétricas complicadas admitidas na UTI, pacientes que preencheram os critérios para Lesão Renal Aguda. Critérios de exclusão: pacientes com Lesão Renal Crônica, ficha clínica não disponível. Apenas 154 atenderam aos critérios de seleção. Resultados: 154 pacientes obstétricas complicadas foram incluídas; uma média de 25.6p ± 1.6 por ano. 36% tiveram diagnóstico de eclâmpsia; 35.3% pré-eclâmpsia; 29.3% síndrome HELLP; 19.3% hemorragia obstétrica, 10% sepse. Foi demonstrada uma associação de PR-AKI com síndrome HELLP (p = 0.0003) e pré-eclâmpsia (p = 0.01). Foi encontrado subdiagnóstico de 36.7% na busca de PR-AKI pelos critérios RIFLE e AKI (p = 0.000007). Dos pacientes com PR-AKI grau 3, 20% necessitaram de terapia de reposição renal contínua. Conclusões: Lesões renais associadas à gravidez complicada apresentam prevalência de 6.7%. As complicações associadas à PR-AKI são a síndrome HELLP e a pré-eclâmpsia. PR-AKI é subdiagnosticado em até 36.7%.

Manejo de la ruptura hepática espontánea en el síndrome de HELLP / Management of spontaneous hepatic rupture in HELLP syndrome

Introducción. El síndrome de HELLP es una variante grave de la preeclampsia, con una baja incidencia, entre el 0,5-0,9 % de todos los embarazos. La ruptura hepática espontánea en el embarazo es infrecuente, presenta una alta mortalidad, y se ha relacionado con hemangiomas hepáticos, coriocarcinoma y síndrome de HELLP. Caso clínico. Mujer de 29 años con embarazo de 34,3 semanas, con actividad uterina progresiva, sufrimiento fetal agudo y hallazgos compatibles con síndrome de HELLP. Se practicó cesárea de urgencia encontrando hemoperitoneo y ruptura hepática del lóbulo derecho, por lo que se realizó empaquetamiento abdominal y posterior reintervención quirúrgica. Discusión. La ruptura hepática espontánea en el embarazo es una entidad infrecuente y potencialmente mortal. Es esencial un alto nivel de sospecha para realizar el diagnóstico y la rápida intervención. Requiere un manejo multidisciplinario para un resultado exitoso. Se han descrito múltiples tratamientos que dependen de las manifestaciones clínicas y extensión de la lesión, pero es claro que la laparotomía primaria y el taponamiento constituyen la mejor elección ante el hallazgo intraoperatorio.

Introduction. HELLP syndrome is a severe variant of preeclampsia with a low incidence, between 0.5-0.9% of all pregnancies. Spontaneous hepatic rupture in pregnancy is rare, has a high mortality, and has been associated with hepatic hemangiomas, choriocarcinoma, and HELLP syndrome. Clinical case. 29-year-old woman with a 34.3-week pregnancy, with progressive uterine activity and acute fetal distress and findings compatible with HELLP syndrome. An emergency cesarean section was performed, finding hemoperitoneum and hepatic rupture of the right lobe, performing abdominal packing and subsequent surgical reoperation. Discussion. Spontaneous liver rupture in pregnancy is a rare and potentially fatal entity. A high level of suspicion is essential to make the diagnosis and prompt intervention. It requires multidisciplinary management for a successful outcome. Multiple treatments have been described that depend on the clinical manifestations and extent of the lesion, but it is clear that primary laparotomy and packing constitute the best choice before the intraoperative finding.

Risk factors and optical coherence tomography characteristics of exudative retinal detachment in patients with HELLP syndrome / 中华眼底病杂志

Objective:To observe and analyze the risk factors and optical coherence tomography (OCT) characteristics of exudative retinal detachment in patients with HELLP syndrome.Methods:A retrospective clinical study. From January 2015 to March 2021, 168 eyes of 84 patients with HELLP syndrome who were hospitalized in The Third Central Hospital of Tianjin were included in the study. The average age of the patients was 30.96±4.09 years old. The patient’s general clinical data which included age, gestational week of delivery, type of HELLP syndrome, onset time of HELLP syndrome, parity, number of pregnancy, systolic and diastolic blood pressure, total amount and duration of glucocorticoid, whether been admitted to intensive care unit; laboratory indicators, which included platelet count,serum albumin, serum uric acid, 24-hour urine protein quantification,aspartate aminotransferase, lactate dehydrogenase, total bilirubin (TBIL) were collected. Whose the general condition was not allowed, however patients had a complaint of vision loss or suspected retinal detachment under direct ophthalmoscope examination, B-mode ultrasound was used to assist in the diagnosis. According to the presence or absence of exudative retinal detachment, patients were divided into retinal detachment group (net detachment group) and non-retinal detachment group (non-retinal detachment group), respectively 31 (36.90%, 31/84), 53 (63.10%, 53/84) cases. Among the 31 cases in the network disconnection group, 34 eyes in 17 cases underwent OCT. Two independent sample t tests were used to compare the measurement data of normal distribution between groups, Wilcoxon rank sum test was used to compare skewed distributions; the χ2 test was used to compare count data. The variables with statistical differences in univariate analysis were selected as independent variables, and binary logistic regression analysis was performed. Results:Among 84 patients, HELLP syndrome was classified into partial type and complete type, 41 (48.81%, 41/84) and 43 (51.19%, 43/84) cases, respectively. Compared with the non-net-off group, the patients in the off-line group had shorter gestational weeks ( t=2.51), higher diastolic blood pressure ( t=-2.61), greater total glucocorticoid use ( Z=-2.14), and longer use time of glucocorticoid ( Z=-2.75), the difference were statistically significant ( P<0.05); TBIL ( Z=-2.49), serum albumin ( t=2.06) levels decreased, and 24-hour urine protein quantitative ( Z=-4.35) levels increased, the difference were statistically significant ( P<0.05). Logistic regression analysis showed that the increase of 24-hour urine protein level increased the risk of exudative retinal detachment ( P<0.05) (odds ratio=1.20, 95% confidence interval 1.06-1.37). Among the 34 eyes that underwent OCT examination, 18 eyes showed that the retinal pigment epithelium (RPE) layer was not smooth, thickened, and seemed to have adhesion to the detached retina. After the reattachment of retinal detachment, the abovementioned changes of RPE still existed, but reduced; the ellipsoid zone still has discontinuity, partial rupture, and even extensive loss in 16 eyes. Conclusion:The quantitative increase of 24-hour urine protein is a risk factor for the occurrence of exudative retinal detachment in HELLP syndrome; some patients with exudative retinal detachment are still missing the ellipsoid zone after reattachment.

Update on thrombocytopenia in pregnancy / Atualização sobre trombocitopenia na gravidez

Abstract Thrombocytopenia, defined as platelet count < 150,000mm3, is frequently diagnosed by obstetricians since this parameter is included in routine surveillance during pregnancy, with an incidence of between 7 and 12%. Therefore, decisions regarding subsequent examination and management are primordial. While most of the cases are due to physiological changes, as gestational thrombocytopenia, other causes can be related to severe conditions that can lead to fetal or maternal death. Differentiating these conditions might be challenging: they can be pregnancy-specific (pre-eclampsia/ HELLP syndrome [hemolysis, elevated liver enzymes, low platelets]), or not (immune thrombocytopenia purpura, thrombotic thrombocytopenic purpura or hemolytic uremic syndrome). Understanding the mechanisms and recognition of symptoms and signs is essential to decide an adequate line of investigation. The severity of thrombocytopenia, its etiology and gestational age dictates different treatment regimens.

Resumo Trombocitopenia, definida como uma contagem de plaquetária < 150.000mm3, é frequentemente diagnosticada pelos obstetras, uma vez que este parâmetro está incluído na vigilância de rotina durante a gravidez, com uma incidência de entre 7 e 12%. Assim, decisões relativas à avaliação e orientação subsequentes são primordiais. Embora a maioria dos casos ocorra devido a alterações fisiológicas, como a trombocitopenia gestacional, outras causas podem estar relacionadas com condições graves que podem levar à morte fetal ou materna. Distinguir entre estas entidades pode ser desafiante: elas podem ser específicas da gravidez (pré-eclâmpsia/síndrome HELLP [hemolysis, elevated liver enzymes, low platelets]) ou não (púrpura trombocitopênica imune, púrpura trombocitopênica trombótica ou síndrome hemolítico urêmico). Compreender os mecanismos e reconhecer os sinais e sintomas é essencial para decidir uma adequada linha de investigação. A severidade da trombocitopenia, a sua etiologia e a idade gestacional ditam regimes de tratamento diferentes.

Coronavirus 2019, thrombocytopenia and HELLP syndrome: association or coincidence? / Coronavírus 2019, trombocitopenia e síndrome HELLP: Associação ou coincidência?

Abstract The present report describes the case of a 31-year-old primigravida, with dichorionic twins at 31 weeks. She presented with history of myalgia, jaundice, and abdominal discomfort. No flu-like symptoms as fever or cough. She was not aware of exposure to COVID-19. Normal blood pressure and O2 saturation. Laboratory tests showed platelet count of 218,000 mm3, alanine aminotransferase (ALT) 558 IU and serum creatinine 2.3 mg/dl. Doppler ultrasound in one twin was compatible with brain sparing. Partial hemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome was the hypothesis, and a cesarean section was performed. On day 2, the white-cell count reached 33,730, with decreased consciousness and mild respiratory distress. Tomography revealed both lungs with ground-glass opacities. Swab for COVID-19 polymerase chain reaction (PCR) was positive. Thrombocytopenia in patients with COVID-19 appears to be multifactorial, similar to what occurs in preeclampsia and HELLP syndrome. We assume that the synergism of these pathophysiological mechanisms could accelerate the compromise of maternal conditions and could be a warning to the obstetric practice.

Resumo O presente relato descreve o caso de uma gestante de 31 anos, gemelar dicoriônica com 31 semanas, com queixa de mialgia, icterícia e desconforto abdominal. A paciente não apresentava sintomas gripais como febre ou tosse e não tinha conhecimento de exposição ao COVID-19. Pressão arterial e saturação de oxigênio normais. Os exames laboratoriais apresentaram contagem de plaquetas de 218,000 mm3, ALT 558 IU e creatinina 2.3 mg/dl. Doppler compatível com centralização de um dos fetos. Síndrome de hemolysis, elevated liver enzymes, low platelet count (HELLP) parcial foi a hipótese diagnóstica inicial e a cesariana foi realizada. No segundo dia, a paciente apresentou leucócitos de 33.730 com queda do nível de consciência e desconforto respiratório leve. A tomografia revelou opacidade pulmonar em vidro fosco bilateralmente. A pesquisa de COVID-19 por polymerase chain reaction (PCR)/swab teve resultado positivo. Trombocitopenia em pacientes com COVID-19 é multifatorial, semelhante ao que ocorre na pré-eclâmpsia e na síndrome HELLP. Acreditamos que o sinergismo da fisiopatologia das doenças em questão pode acelerar o comprometimento materno e deve servir de alerta para a prática obstétrica.