Postpartum heparin therapy for patients with the syndrome of hemolysis, elevated liver enzymes, and low platelets (HELLP) is associated with significant hemorrhagic complications.

OBJECTIVE: To compare the outcome of two groups of 16 patients with hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome treated with heparin therapy or treated conservatively in the postpartum period. STUDY DESIGN: This is a retrospective cohort study comparing 16 consecutive patients with HELLP syndrome admitted to the ICU at the University of Florence (Italy) after delivery and treated with heparin, to 16 patients with the same disease admitted to the University of Virginia (UVA, USA) and treated with supportive therapy. RESULTS: Nine patients in the Florence group developed disseminated intravascular coagulation (DIC). Six of them developed postpartum hemorrhage that was medically and surgically controlled. Five hysterectomies were performed and seven other laparotomies were necessary in four patients to control further bleeding complications. In the UVA group, one patient developed DIC and another one a retroperitoneal hematoma that resolved with no need for surgical intervention. CONCLUSIONS: Heparin therapy for postpartum patients with HELLP syndrome was associated with bleeding complications. We speculate that the heparin therapy was the cause for the bleeding complications occurred in the Florence group of patients.

Prediction of 'awakening' and outcome in prolonged acute coma from severe traumatic brain injury: evidence for validity of short latency SEPs.

OBJECTIVE: To evaluate the prognostic value of somatosensory evoked potentials (SEPs) in severe traumatic brain injury (TBI) considering both 'awakening' and disability. METHODS: SEPs were recorded in 60 severe TBI with duration of acute coma>7 days. N20-P25 amplitudes, their side-to-side asymmetry and CCT were measured. SEPs on each hemisphere were classified as normal (N), pathological (P) or absent (A). 'Awakening' and disability were assessed after at least 12 months using Glasgow Outcome Scale (GOS). SEP predictive value was compared with GCS and EEG reactivity RESULTS: Seventy-five percent regained consciousness. 29/60 had a good outcome (GOS 4-5) and 31/60 had a bad outcome (GOS 1-3). According to the ROC curve, SEP findings were classified in 3 grades. Grade I (NN, NP) had PPV of 93.1% for 'awakening' and 86.2% for good outcome. Grade III (AA) had PPV of 100% for bad outcome and 72.7% for 'awakening'. Grade II (PP, NA, PA) was associated with the wider range of outcome. A multivariate analysis including SEP grading, GCS and EEG reactivity did not increase the percentage of cases prognosticated by SEP alone. CONCLUSIONS: We confirm the high predictive value of SEPs in TBI, which is greater than GCS and EEG reactivity. Indeed, SEP grades I and III were able to predict the correct prognosis in more than 80% of severe TBI. Therefore, SEPs should be used more widely in the prognosis of severe TBI. SIGNIFICANCE: Differently from post-anoxic, in post-traumatic coma the presence of normal SEPs has a favourable predictive value both for 'awakening' and disability. We think that in literature enough attention has still not been paid to this finding.