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.

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.

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.

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%.

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.

Maternal mortality in pregnant women with positive SARS-CoV-2 antibodies and severe preeclampsia. Report of 3 cases / Mortalidad materna en gestantes con anticuerpos a SARS-CoV-2 positivos y preeclampsia severa. Reporte de 3 casos

Abstract Maternal mortality from COVID-19 is rare in developed countries, but its association with other obstetric complications increases the risk. It is also associated with fetal death. Postpartum women are at risk of thrombosis that increases with COVID-19 coagulopathy. Comorbidities such as obesity, diabetes, and hypertension increase the risk of death from COVID-19, and pregnant women have more complications during the third trimester than in the first trimester, with higher risk than non pregnant women of entering the ICU and requiring mechanical ventilation. In this report, stroke, diabetes and intracerebral hemorrhage were the three causes of death described, all within the context of stillbirth, severe preeclampsia, eclampsia and/or HELLP syndrome.

Resumen La mortalidad materna por COVID-19 es poco frecuente en países desarrollados, pero su asociación a otras complicaciones obstétricas aumenta el riesgo. Además, está asociada a muerte fetal. Las puérperas, tienen riesgo de trombosis que se incrementa con la coagulopatía por COVID-19. Las comorbilidades como obesidad, diabetes, hipertensión incrementan el riesgo de muerte asociada a COVID-19 y las gestantes en el tercer trimestre se complican más que en el primero, teniendo más riesgo que las mujeres no gestantes de ingresar a UCI y requerir ventilación mecánica. En este reporte, el accidente cerebrovascular isquémico y hemorrágico y la diabetes fueron las tres causas de muerte, todas en un contexto de óbito fetal, preeclampsia severa, eclampsia y/o síndrome HELLP.

Analysis of epidemiological profile and ventilator parameters of postpartum women submitted to mechanical ventilation guided by electrical impedance tomography / Análise de perfil epidemiológico e parâmetros ventilatórios de puérperas submetidas à ventilação mecânica por meio da tomografia por impedância elétrica

INTRODUCTION: Pregnancy-related diseases have aggravated the situation of postpartum women, who end up using Mechanical Ventilation (MV) when admitted to Intensive Care Units (ICU). Although MV has benefits, it is associated with deleterious effects that can be minimized with the use of Electrical Impedance Tomography (EIT). OBJECTIVE: The aim was to analyze the epidemiological profile and ventilatory parameters of mothers, which developed HELLP Syndrome, sepsis and/or Acute Respiratory Distress Syndrome (ARDS), under MV and monitored with EIT. METHODS: The study was observational, cross-sectional, retrospective and prospective conducted between March and September 2018, using data collection forms filled from the database and sociodemographic, obstetric and ventilatory records of postpartum women admitted to adult ICU. RESULTS: The sample consisted of 13 postpartum women, 8 with sepsis (61.5%), 7 with HELLP syndrome (53.8%) and 4 with ARDS (30.8%). Five patients (38.5%) evolved with more than one of these conditions. Regarding the ventilatory parameters evaluated, VT 378.9 (±103.9) mL were observed and mean values found for PEEP 9.8 (±1.9) cmH2O and driving pressure 11.1 (±1.4) cmH2O are below recommendations in the literature, predicting lower mortality and morbidity index. CONCLUSION: The relevance of the driving pressure assessment in the MV setting was demonstrated, a parameter assessed by the EIT and directly related to static lung compliance (Cstat), PEEP, VT and optimization of regional pulmonary ventilation. It is highlighted the need for future research with greater clinical significance regarding the profile of postpartum women about the increasingly frequent diseases in this population.

INTRODUÇÃO: As doenças relacionadas à gravidez tem agravado o quadro de puérperas, que acabam fazendo uso de Ventilação Mecânica (VM) quando internadas em Unidades de Terapia Intensiva (UTI). A VM, apesar de trazer benefícios, está associada a efeitos deletérios que podem ser minimizados com o uso da Tomografia por Impedância Elétrica (TIE). OBJETIVO: Analisar o perfil epidemiológico e parâmetros ventilatórios de puérperas que evoluíram com Síndrome HELLP, Sepse e/ou Síndrome do Desconforto Respiratório Agudo (SDRA), sob VM e monitoradas com a TIE. MÉTODOS: Estudo observacional, transversal retrospectivo e prospectivo, realizado entre março e setembro de 2018, por meio de fichas de coletas preenchidas a partir de banco de dados/prontuários sociodemográficos, obstétricos e ventilatórios de puérperas internadas em UTI. RESULTADOS: Amostra composta por 13 puérperas, oito com Sepse (61,5%), sete com Síndrome HELLP (53,8%) e quatro com SDRA (30,8%), demonstrando que cinco (38,5%) pacientes evoluíram com mais de uma dessas patologias. Acerca dos parâmetros ventilatórios avaliados, observou-se VT 378.9 (± 103.9) e que valores médios encontrados para PEEP 9.8 (±1.9) e driving pressure 11.1 (±1.4) estão abaixo dos preconizados pela literatura, predizendo menores índices de mortalidade e morbidade. CONCLUSÃO: Demonstrou-se relevância da avaliação de driving pressure no cenário da VM, parâmetro avaliado por meio da TIE e diretamente relacionado à Cst, PEEP, VT e otimização da ventilação pulmonar regional. Destaca-se a necessidade de pesquisas futuras que apresentem maiores significâncias clínicas voltadas ao perfil de puérperas em relação às doenças cada vez mais frequentes nesta população.

Atuação do enfermeiro a pacientes portadoras de síndrome hipertensiva específica da gestação / Nursing's action against patients with specific hypertensive management syndrome

Objetivo: Identificar a importância da assistência de enfermagem às gestantes com Síndrome Hipertensiva Gestacional. Método: Estudo bibliográfico, descritivo e exploratório, realizado busca no banco de dados da Biblioteca Virtual em Saúde (BVS), Sistema Latino-Americano e do Caribe de Informações em Ciências da Saúde (LILACS), Scientific Eletrônic Library Online (SCIELO) e Bancos de dados em enfermagem (BDENF). Resultados: A Síndrome Hipertensiva da Gravidez (SHEG) apresenta como uma das mais importantes complicações durante o ciclo gravídicopuerperal e a sua etiologia ainda permanece desconhecida. A pré-eclâmpsia evolui naturalmente e quando não tratada/interrompida a gestação, ocorre o desenvolvimento para as formas mais graves, especialmente, a eclampsia e a síndrome HELLP. É de grande importância que o profissional de enfermagem atue de forma mais efetiva e presente, para que as reais necessidades das pacientes sejam supridas, havendo melhora do quadro clínico e eventuais complicações sejam evitadas. Conclusões: A assistência efetiva durante o pré-natal, pelos profissionais, diminui os índices de SHEG em gestantes e as tiram do grupo de risco, principalmente as que possuem fatores predisponentes e etiológicos. Assim, é possível descrever a atuação do enfermeiro frente à patologia, observando a necessidade de um trabalho conjunto à uma equipe multidisciplinar para que ocorra um atendimento eficaz à gestante (AU)

This study aimed to identify and characterize the importance of nursing care for pregnant women with Gestational Hypertensive Syndrome. Method: Bibliographic,descriptive and exploratory study, searches the database of the Virtual Health Library (VHL), Latin American and Caribbean Health Sciences Information System (LILACS), Scientific Electronic Library Online (SCIELO) and Banks. of Nursing Data (BDENF). Results: Hypertensive Pregnancy Syndrome (SHEG) is one of the most important complications during the pregnancy-puerperal cycle and its etiology is still unknown. Preeclampsia evolves naturally and when untreated / interrupted pregnancy develops into the most severe forms, especially eclampsia and HELLP syndrome. It is of great importance that the nursing professional acts more effectively and present, so that the real needs of patients are met, with improvement of the clinical picture and eventual complications are avoided. Conclusions: The effective prenatal care by professionals reduces the rates of SHEG in pregnant women and remove them from the risk group, especially those with predisposing and etiological factors. Thus, it is possible to describe the role of nurses in the pathology, noting the need for a joint work with a multidisciplinary team for effective care to pregnant women (AU)

Hígado graso agudo del embarazo en una gestante peruana: a propósito de un caso / Acute fatty liver of pregnancy in a Peruvian pregnant woman: a case report

RESUMEN El hígado graso agudo del embarazo es una rara enfermedad de la gestación que se presenta con mayor preponderancia durante el tercer trimestre. Su etiología es desconocida, pero se evidencia un depósito micro vesicular de grasa a nivel del hepatocito. Tiene una mortalidad materno-fetal hasta un 20% debido a que el único tratamiento es terminar la gestación. Se reporta el caso de una gestante de 28 años de edad, con 36 semanas de embarazo, que acude con cuadro clínico de dolor abdominal asociado a malestar general, náuseas y vómitos. Los exámenes de laboratorio mostraron alteración del perfil hepático, falla renal y coagulopatía. La ecografía abdominal mostró infiltración hepática grasa. Se brindó manejo de soporte y regulación de trastornos hemodinámicos. El manejo final fue intervención de cesárea por emergencia debido a complicación de óbito fetal. La paciente fue dada de alta con mejoría de cuadro clínico y de las alteraciones de laboratorio.

ABSTRACT Acute fatty liver of pregnancy is a rare disease of pregnancy that occurs with greater preponderance during the third trimester. Its etiology is unknown, but there is evidence of a micro vesicular fat deposit in the hepatocyte. It has a maternal-fetal mortality up to 20% because the only treatment is to end gestation. We present a case of a 28-year-old pregnant woman, with 36 weeks of pregnancy, who had abdominal pain associated with general malaise, nausea and vomiting. Laboratory tests showed liver profile alteration, renal failure and coagulopathy. Abdominal ultrasound showed fatty liver infiltration. Support management and correction of hemodynamic disorders were provided. The final management was emergency caesarean section to avoid fetal death as a dreaded complication. The patient was discharged with improvement of clinical symptoms and laboratory alterations.

Diagnóstico y manejo del síndrome HELLP en un hospital peruano / Diagnosis and management of HELLP syndrome at a Peruvian hospital

RESUMEN Introducción . El síndrome HELLP está caracterizado por hemólisis, enzimas hepáticas elevadas y plaquetopenia. Es una de las complicaciones maternas más graves del embarazo, con cifras significativas de morbimortalidad materna y riesgo elevado de insuficiencia renal, hematoma hepático, coagulopatía intravascular diseminada, politransfusión. Objetivos . Describir la presentación clínica, diagnóstico, complicaciones y manejo de los casos con síndrome HELLP en un hospital peruano. Métodos . Estudio descriptivo, retrospectivo de los casos diagnosticados con síndrome de HELLP en un hospital peruano. Resultados . En 30 618 partos atendidos, se encontró 71 casos de síndrome HELLP, con incidencia de 0,23%. Fueron multíparas el 68%, con edad promedio de 33 años. El diagnóstico se confirmó durante el embarazo en 46% y en el puerperio en 54%. De las gestantes, 58% desarrolló síndrome HELLP antes de las 37 semanas. La morbilidad materna incluyó insuficiencia renal en 25%, hematoma hepático con o sin rotura en 11%, insuficiencia respiratoria en 7%, eclampsia en 6%. El 85% de las pacientes requirió transfusiones con hemoderivados y/o plaquetas. La mortalidad materna fue 3%. Conclusiones . En la población estudiada, el síndrome HELLP se presentó con morbilidad materna elevada. Las muertes se asociaron a hematoma hepático y eclampsia.

ABSTRACT Introduction : HELLP syndrome is characterized by hemolysis, elevated liver enzymes, and thrombocytopenia; it is one of the most serious maternal complications of pregnancy, with significant morbidity and mortality, and high risk of renal failure, hepatic hematoma, disseminated intravascular coagulopathy and receiving multiple blood transfusions. Objective : To describe the clinical presentation, diagnosis, complications and management of patients with HELLP syndrome in a Peruvian hospital. Method : Descriptive, retrospective study of cases with HELLP syndrome at a Peruvian hospital. Results : Out of 30 618 deliveries, 71 cases of HELLP syndrome were found, with an incidence of 0.23%; 68% of cases were multiparous, with an average age of 33. Diagnosis was confirmed during pregnancy in 46% (58% of them developed HELLP syndrome before 37 weeks of gestation) and in the puerperium in 54%. Maternal morbidity included renal failure in 25%, hepatic hematoma with or without rupture in 11%, respiratory failure in 7%, eclampsia in 6%; patients required platelets or blood products transfusions in 85% of cases. Maternal mortality was 3%. Conclusions : In the population studied, HELLP syndrome was associated with high maternal morbidity. Maternal death was mainly due to liver hematoma or eclampsia.

Diagnóstico y manejo oportunos del síndrome HELLP

El síndrome HELLP (SH) es una complicación severa del embarazo caracterizada por hemólisis, enzimas hepáticas elevadas y plaquetopenia. Es una de las situaciones más graves del embarazo, provocando tasas elevadas de morbimortalidad maternoperinatal. La complicación más frecuente del SH es la hemorragia, necesitándose transfusión de sangre y/o hemoderivados para corregir la hipovolemia, anemia o coagulopatía, siendo la complicación más catastrófica el hematoma hepático espontáneo. El parto es el único tratamiento efectivo para el SH. La mortalidad perinatal está relacionada directamente con la edad gestacional. No se ha logrado consenso sobre el manejo del SH que ocurre antes de las 34 semanas de gestación, cuando las condiciones maternas y fetales son estables. El objetivo de la presente revisión es resumir la información existente sobre el manejo oportuno del SH. Se concluye que la vía del parto dependerá de las condiciones cervicales y la estabilidad materno-fetal. Se necesitan estudios adecuados para determinar si hay beneficio con el manejo expectante en gestaciones pretérmino, y la administración de corticoides para mejorar el recuento de plaquetas en el SH.

HELLP syndrome (HS) is a severe complication of pregnancy characterized by hemolysis, elevated liver enzymes and low platelets. It is one of the most serious maternal complications and is associated with high maternal and perinatal morbidity and mortality. Childbirth is the only effective treatment against HS. The most frequent complication of HS is hemorrhage, requiring blood transfusions and/or blood products to correct hypovolemia, anemia or coagulopathy; spontaneous liver hematoma is the most catastrophic problem. Perinatal mortality is directly related to gestational age. There is no consensus on HS management occurring before 34 weeks of gestation when maternal and fetal conditions are stable. The purpose of this review is to summarize the existing information about the timely management of HS. It is concluded that the birth route will depend on cervical conditions and maternal and fetal stability. Appropriate studies are needed to determine if there is benefit in expectant management in preterm pregnancies and in corticosteroids administration to improve platelet count in HS.

Metas del tratamiento de pacientes con preeclampsia, previo al parto, en una unidad de cuidados intensivos / Goals of prepartum treatment of preeclamptic patients in the intensive care unit

Resumen OBJETIVO: Determinar el porcentaje de alcance de las metas del tratamiento previo al parto de pacientes con preeclampsia internadas en la unidad de cuidados intensivos. MATERIALES Y MÉTODOS: Estudio de serie de casos, retrospectivo, antes y después, efectuado en pacientes con preeclampsia internadas en la unidad de cuidados intensivos de un hospital de alta especialidad de la Ciudad de México. Se incluyeron pacientes de cualquier edad y paridad, con más de 20 semanas de embarazo y preeclampsia severa. Se compararon los valores antes y después del tratamiento intensivo (medición basal y previa a la finalización del embarazo) considerando nueve metas: 1) presión arterial media ≤ 95 mmHg; 2) presión venosa central 6 a 10 cm agua; 3) diuresis 1.5 a 2 mL/kg/hora; 4) glucemia menor de 160 mg/dL; 5) presión coloidosmótica plasmática de 24 ± 2 mmHg; 6) pH arterial 7.37 a 7.44; 7) hemoglobina 10 a 14 g/dL; 8) ≥ 100,000 plaquetas/µL y 9) sin convulsiones. Se consideró meta cumplida la medición anteparto en el límite deseado y meta no cumplida cuando resultó diferente. Se utilizó estadística descriptiva y prueba t de Student. RESULTADOS: Se estudiaron 100 pacientes con preeclampsia severa. Las metas y porcentaje de cumplimiento fueron: ausencia de convulsiones 100%, glucemia 93%, cuenta plaquetaria 86%, hemoglobina 74%, presión arterial media 39%, diuresis 36%, pH arterial 30%, presión venosa central 24% y presión coloidosmótica plasmática 11%. El promedio general fue 54.77%. CONCLUSIONES: Solo cuatro metas alcanzaron el porcentaje de cumplimiento ≥ 70% y cinco con cumplimiento menor de 70%. La evaluación por metas permite identificar las fortalezas y puntos débiles del tratamiento de la preeclampsia en la unidad de cuidados intensivos.

Abstract OBJECTIVE: To know the percentage of goals achieved from the prepartum treatment of preeclamptic pregnant patients in the Intensive Care Unit (ICU). MATERIALS AND METHODS: A cross-sectional study included 100 preeclamptic pregnant patients admitted to the ICU of a high-specialty hospital in Mexico City. Values before and after intensive treatment (baseline and antepartum measurement) were compared considering nine goals: 1) mean arterial pressure ≤95 mmHg 2) central venous pressure 6 to 10 cm water, 3) diuresis 1.5 to 2 mL/K weight/hour, 4) blood glucose <160 mg / dL, 5) plasma colloid osmotic pressure 24 ± 2 mmHg, 6) pH arterial blood 7.37 to 7.44, 7) hemoglobin 10 to 14 g / dL, 8) platelet count ≥100,000 platelets / µL and 9) absent seizures. It was considered as a goal met when the antepartum measurement was in the desired range and goal not met when it was different. Statistical analysis: descriptive statistics and Student´s t-test. RESULTS: Goals met absent seizures 100%, blood glucose 93%, platelet count 86%, hemoglobin 74%, mean blood pressure 39%, diuresis 36%, pH arterial blood 30%, central venous pressure 24% and plasma colloid osmotic pressure 11%. The overall average was 54.77%. CONCLUSIONS: the goals with percentage of compliance ≥70% were seizures, blood glucose, platelet count and hemoglobin. The goals with compliance <70% were mean blood pressure, diuresis, pH arterial blood, central venous pressure and plasma colloid osmotic pressure. The evaluation by goals allows to identify the strengths and weaknesses of the treatment of preeclampsia in the ICU.

Rotura hepática en síndrome de HELLP: electrofulguración y uso de malla. Reporte de caso

Hepatic subcapsular hematoma is a rare and lethal complication of HELLP syndrome presenting during pregnancy or the postpartum in women with severe preeclampsia or eclampsia. Maternal and perinatal mortality is high, hence the importance of prevention, early recognition, and timely and multidisciplinary treatment. We present a case of spontaneous rupture of subcapsular hepatic hematoma in which treatment consisted in electrofulguration and placement of hemostatic mesh, and a review of the literature.

El hematoma subcapsular hepático es una complicación rara y letal del síndrome HELLP, que se presenta en gestantes o puérperas con preeclampsia severa o eclampsia. La mortalidad materna y perinatal en estos casos es elevada. De ahí la importancia de su prevención, reconocimiento precoz y tratamiento oportuno y multidisciplinario. Se presenta un caso de rotura espontánea de hematoma subcapsular hepático, en el cual se realizó manejo con electrofulguración asociada a la colocación de malla hemostática. Se realiza revisión bibliográfica.