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A Study to Find the Incidence of HELLP Syndrome and Partial HELLP Syndrome among Preeclamptic Mothers and their Impact on Fetomaternal Outcome
Get PDFBACKGROUND:
Every woman wishes to have a healthy pregnancy which culminates in a healthy baby and a healthy mother. Unfortunately, some women develop dreaded complications that may result in adverse obstetric outcomes. These include Pregnancy induced hypertension, Pre-eclampsia, Eclampsia and HELLP Syndrome, abruption placenta, placenta previa, RH isoimmunisiation, etc. The HELLP syndrome (haemolysis, elevated liver enzymes, and low platelets) is a variant seen as a complication in severe preeclampsia / eclampsia that is associated with significant maternal and perinatal morbidity and mortality. HELLP is an acroynm coined by Weinstein in 1982. Maternal mortality is due to consequences such as pulmonary oedema, renal failure, disseminated intravascular coagulation and subcapsular liver hematoma. Perinatal mortality appears to be primarily related to the gestational age at the time of delivery. HELLP syndrome is regarded as a higher risk for the mother and neonate compared to pre-eclampsia. As our hospital provides treatment facilities to large number of Preeclampsia, eclampsia and a relatively higher number of patients of HELLP syndrome, we have the opportunity to conduct such studies which can help us to determine the trend of occurrence of HELLP syndrome, its complications and its effect on maternal and fetal outcome. This will help us in understanding better about the pathophysiology of the disease which can be applied to improve the management and thereby improve the maternal and perinatal outcome.
AIM OF THE STUDY:
1. To detect and evaluate the feto-maternal outcome of HELLP syndrome and partial HELLP syndrome among preeclamptic mothers. 2. To determine the trend of occurrence of HELLP syndrome, risk factors, its complications and its effect on maternal and perinatal outcome of HELLP syndrome in pregnant women at Institute of Obstetrics and Gynaecology, Egmore, Chennai.
MATERIALS AND METHODS:
After institutional ethical committee approval and informed written consent, Analysis of 120subjects were selected from the study population which comprised of pre-eclamptic patients attending the outpatient department and those admitted in the antenatal ward as booked cases or referred from outside who appertaining the inclusion criteria during the year 2021 in IOG, Egmore, Madras Medical College Hospital, Chennai, to determine the occurrence and course of HELLP Syndrome in order to make a timely intervention and to render optimal patient treatment, a better maternal and perinatal outcome. History regarding age, parity, gestational age, menstrual history and previous illness were noted. A thorough general and other systemic examination, laboratory testing were done with obstetric examination. Every individual were allocated into one of the following groups: 1. Pregnant mothers with preeclampsia having the features of HELLP syndrome, which included both complete and partial HELLP syndrome. 2. Mothers with preeclampsia having only partial HELLP syndrome. 3. Mothers with preeclampsia without the features of complete HELLP syndrome or partial HELLP syndrome. Outcome will be measured in terms of age of the mother, parity, socioeconomic status, antenatal care status, duration of gestation BP and degree of proteinuria, mode of delivery(Labour Natural/Forceps/vacuum delivery/Assisted breech/LSCS, delivery interval, perintal outcome (a. Alive / Still born / IUD: b. Term / Preterm: c. Birth Wt; d. Apgar)and maternal outcome. Data obtained will be tabulated and analysed systematically.
RESULTS:
A total of 120 patients took part in this study which include population from both IOG and KGH, Triplicane. The mean (SD) age of the study population was 24.28 (5.24) years. The minimum and maximum ages were 17 and 39 years respectively with a range of 22 years. Among the study participants, 64 (53.3%) had severe pre-eclampsia, 19 (15.8%) had HELLP syndrome and the remaining 37 (30.8%) had partial HELLP syndrome. The mean (SD) age of non HELLP individuals was 22.84 (3.76) years and that of HELLP individuals was 25.91 (6.91) years. The mean age in HELLP group is significantly high when compared to the non HELLP group. There was no significant difference between parity and HELLP syndrome although the incidence of HELLP was higher among the multi para women. The mean (SD) age in weeks of non HELLP individuals was 35.92 (2.48) and that of HELLP individuals was 33.89 (2.87). The mean age in HELLP group is significantly lower when compared to the non HELLP group. The incidence of HELLP is higher among unbooked cases 9 (75%) when compared to booked cases of preganancy where the incidence of HELLP is 47 (43.5%). It was found that the clinical parameters like systolic blood pressure, diastolic blood pressure, spot PCR, 24 hour urinary protein and urinary dipstick protein were all significantly higher in the HELLP group when compared to the non HELLP group. The mean haemoglobin and platelet counts were significantly lower in HELLP group when compared to the non HELLP group. Also, LDH levels were found to be significantly elevated in HELLP group. Transfusion history is present significantly higher in those having HELLP. In patients with HELLP syndrome, the peripheral smear contains significantly higher number of abnormal cells. In the non HELLP group, among 64 patients, 36 (64.3%) did not present with any maternal complications and only 28 (43.8%) presented with maternal complications. But, in the HELLP group, among 56 patients only 20 (35.7%) did not have maternal complications and 36 (56.2%) had some form of maternal complications. The number of fetal deaths was found to be more in the HELLP group when compared to the non HELLP group and the difference between two groups is found to be statistically significant. The number of neonatal deaths was found to be more in the HELLP group when compared to the non HELLP group and the difference between two groups is found to be statistically significant. Also, there were significant differences in APGAR scores both at 1 minute and at 5 minutes between the two groups.
CONCLUSION:
Whether HELLP Syndrome TRIAD - liver dysfunction including elevated liver enzymes, haemolysis and thrombocytopenia occur as a distrint entity or a part of a spectrum of pregnancy complications, is still questionable. High maternal and perinatal morbidity and mortality associated with HELLP SYNDROME is alarming. Hence high concern to be given in its management. HELLP Syndrome is an emergency obstetric help. It needs careful and close monitoring to look for maternal and neonatal well being in an equal attention basis. Timely action to be taken regarding delivery regardless of gestational age. So a patient of HELLP SYNDROME to be promptly recognized, timely intervention to be done, and optimal treatment need to be given to decline and to prevent maternal morbidity and mortality
A Study of Effectiveness of Zuspan Regimen of Magnesium Sulphate in Prevention of Eclampsia
Get PDFEclampsia is an extremely severe form of pre eclampsia, characterised by sudden onset of generalised tonic-clonic seizure or coma in pregnancy or postpartum, unrelated to other cerebral conditions, in patients with signs and symptoms of preeclampsia. Ten percent to 15 percent of all pregnancies are complicated by hypertension. Eclampsia and preeclampsia account for about half of these cases
worldwide, (1 in 2000 & 1 in 3448 pregnancies western world respectively) and these conditions have been recognized and described for years despite the general lack of understanding of the disease. In the fifth century, Hippocrates noted that headaches, convulsions, and drowsiness were ominous signs associated with pregnancy. In 1619, Varandaeus coined the term eclampsia in a treatise on gynecology. Eclampsia is designated as antepartum, intrapartum or postpartum depending on the time of
occurrence of convulsions, incidence being 38-53% antepartum, 15-20% intrapartum and 11-44% in the postpartum period. Most antepartum eclampsia occurs in the third trimester (90%). Recent increased incidence of postpartum
eclampsia is attributed to better prenatal care and prophylactic use of magnesium sulphate in antenatal period. Most of the postpartum eclampsia occurs within 48 hours
of delivery. Atypical is the term given to those which occur before 20 weeks or after 48 hours of delivery. Such episodes are proven refractory to magnesium sulphate. It had been demonstrated that in 31.3% of cases eclampsia is not preventable despite adequate prenatal care and admission to hospital. However, 69.7% of the cases are preventable. This study aims to measure the efficacy of Zuspan regimen in prevention of eclampsia. Magnesium sulphate dosage in zuspan regimen - The Zuspan regimen, which is given as a 4‐g IV loading dose followed by continuous IV infusion of 1 g/hour, 24 hours after the delivery or last convulsion, which ever occurred last.
❖ It is a prospective study where all patients admitted to Labour and Delivery at IOG and ISO- KGH as severe pre-eclampsia according to American College of Obstetricians and Gynecologists (ACOG) recommendations are included in study.
❖ Once a patient got diagnosed to be of Severe Preeclampsia, the patient was informed duly about the study, consent obtained and then, patient taken up for the study. Zuspan’s regimen of magnesium sulphate was administered. Thereby, patients got enumerated for the study and thereby quantitative and qualitative efficacy of magnesium sulphate was studied. In this study, the factors responsible for progression of severe preeclampsia to eclampsia got addressed. Prevention of eclampsia was the measure and risk factors assessment was done in every case as per the data sheet. During magnesium sulphate therapy, patients were monitored under intensive care setup and monitoring parameters were recorded. After collecting, the data was
compiled and entered in microsoft excel sheet. Analysis was done using statistical software SPSS version 23. When patient did not progress to eclampsia, it was considered a positive endpoint. The test will be considered significant if P value
0.05, at 95% confidence intervals.
❖ Of the total 224 patients enumerated under the study, 14 patients (6.25%) had Eclampsia. With the successful zuspan’s regimen on flow, they were effectively treated with 2g more of magnesium sulphate and therein, these cases cannot be
coined as magnesium sulphate refractoriness rather than magnesium sulpahte failures.
All magnesium sulphate refractory patients had GDM (100%)and obesity. They were diagnosed with posterior reversible encephalopathy syndrome but 3 of non eclamptic patients had the same too. Two of them had acute kidney injury (14.28%)
and disseminated intravscular coagulation; all eclampsia cases were managed in intensive care unit under multidisciplinary approach. All 14 babies were morbid
enough for a NICU admission (100%) in view of either iatrogenic prematurity / FGR / fetal distress.
❖ The point of appreciation of this study is about the nil maternal mortality. Initially, history speaks about various regimens of magnesium sulphate. Pritchards and Zuspan’s have stood the tests of time. But Pritchards is an intramuscular regimen which makes it so painful. And there had to be shots of lignocaine before the magnesium sulphate injection. Monitoring of serum magnesium levels and stopping the same in case of toxicity was a difficulty for the injected dose would have been absorbed by that time. But on the other hand, Zuspan’s regimen is an intravenous regimen wherein the pain of an intramuscular injection is bypassed and if in case of increased serum magnesium levels, the stopping of infusion is easy and team - friendly. Such a successful regimen should get reflected to rural levels and the same if
followed, the ease and success shall be uniform.
❖ The famous Magpie trial, which gave the universal prophylaxis protocol did reiterate that all severe pre eclampsia patients be given magnesium sulphate prophylaxis, and as a part of selective prophylaxis excluded mild preeclampsia and gestational hypertension, as against belfort [et al.]
❖ 6 cases had antepartum eclampsia and 8 cases had postpartum eclampsia. 8 of them had within 6 hours of the regimen when magnesium sulphate was on flow. The rest were after 6 hours and within 32 hours of magnesium sulpahte infusion. But the occurrence time did not influence the outcome. They got effectively treated with additional two grams of magnesium sulphate. All patients had posterior circulation changes and they got reflected as PRES ie., posterior reversible encephalopathy syndrome as documented in the history about central nervous system changes.
❖ Of these patients, two were teenagers, three were elderly and the rest fell between 20 to 30 years. 8 out of 14 patients were from rural population. 10 out of 14 patients
were primigravida.
❖ Hypothyroidism was found to have a significant increase in incidence as compared to previous trials and supported to be a contributory factoe. Anaemia is
found to be associative factor. There was a 100 % NICU admission and Fetal growth restriction. There were 2 known seizure cases in this group; 2 reported APLA positive
cases and Acute kidney injury cases.
❖ In this prospective, single arm study of effectiveness of zuspan’s regimen of magnesium sulphate in prevention of eclampsia, out of 224 study patients, 14 developed eclampsia during the course of treatment with magnesium sulphate for
severe preeclampsia. Magnesium sulphate dosage in zuspan’s regimen.
The Zuspan’s regimen, which is given as a 4‐g IV loading dose followed by continuous IV infusion of 1 g/hour, 24 hours after the delivery or last convulsion, whichever occurred last. The eclampsia patients were dispersed between antenatal and postnatal,-op periods, various demographies. Significant positive association was found with Anaemia, Obstetric score, Hypothroidism,Neonatal Intensive Care
Admissions and Fetal growth restrictions.
❖ Along the course of conduct of this study, the importance of early diagnosis, early referral were studied as an important decision point in prognosis and fetomaternal outcomes. Dissemination of potential and lifesaving information to all tiers of health care can do wonders in management of hypertensive disorders of pregnancy. Risk stratification of Hypertensive disorders of pregnancy at the field staff level is a pertinent step in screening and early referral.
❖ Zuspan’s regimen of magnesium sulphate is a boon in modern obstetrics because of the ease of administration and outcomes. Dose with respect to BMI can address the refractoriness. Since the success rate is so high, instead of tagging it as failures, it has to be termed as refractoriness. In all the 14 cases of eclampsia in this
study, the one huge risk factor was class 1, 2,3 and morbid obesity in 2, 8,4and 1 patients respectively. 25th edition of William’s obstetrics and various Parkland hospital studies talk about rare magnesium toxicities during prophylactic magnesium sulphate regimen. The reason cited is that the magnesium sulphate had failed to reach the therapeutic levels by our fixed dose regimens. Sliding through this statement to the other end of spectrum, the need for achieving therapeutic level to prevent eclampsia
and therein addressing refractoriness will get addressed. More over, all these mothers settled with additional two grams of magnesium sulphate and magnesium sulphate regimen was continued is fairly a support of the aforememtioned argument.
❖ As a consensus opinion on whether to use magnesium sulphate prophylaxis in non severe gestational hypertension and non severe pre eclampsia, the low incidence of 1 in 100 was cited and exposing 99 to magnesium sulphate was decided against. Since the use of magnesium sulphate offers neuroprotection too, such a decision can be reviewed. on doing that too, refractoriness shall get addressed.
❖ According to Sibai et al trail in lessons learnt from preeclampsia,though the routine use of magnesium sulfate for seizure prophylaxis in women with pre eclamptics is an ingrained obstetric practice, inspite of the 6 to 8% refractoriness at global level, this routine use needs to be curbed.Past decade, saw several observational studies and randomized trials have using various regimens of
magnesium sulfate to prevent and / or to bring down the rate of seizures and complications in women with preeclampsia. There are only 2 cited double-blind,
placebo-controlled trials evaluating magnesium sulfate in mild preeclampsia. Sibai [et al.] quotes as .. There were no case of eclampsia among 181 women assigned to placebo,
and there were no differences in the percentage of women, those of whom progressed to severe preeclampsia (12.5% in magnesium group vs 13.8% in the placebo group, relative risk [RR] 0.90; 95% CI 0.52-1.54). However, the study group enrolled in these trials is too limited to draw any valid conclusions. Sibai et al had further reviewed the 4 randomized controlled trials that did compare the use of nil magnesium sulfate, or that of a placebo vs magnesium sulfate, to prevent eclampsia in patients of severe preeclampsia. The rate of eclampsia was 0.6% out of the 6343 patients assigned to magnesium sulfate vs 2.0 % out of the 6330 patients assigned to a placebo or control (RR 0.39; 95% CI 0.28-0.55). However, the fall in the rates of eclampsia was not associated with a clinically measurable benefit in either maternal or perinatal outcome. In addition, there was a higher rate of clinically significant maternal respiratory depression among those assigned magnesium sulfate. The evidence to date confirms the efficacy of magnesium sulfate in reduction of seizures in women with eclampsia and severe preeclampsia; however, this benefit does not affect overall maternal and perinatal mortality and morbidities. The evidence about the benefit -to risk ratio of magnesium sulfate prophylaxis in mild preeclampsia is yet to be proven, and does not justify its routine use for that purpose is how Sibai et al concludes.
❖ This study at IOG reiterates the clinical efficacy of magnesium sulphate and dose with respect to Body mass index & universal prophyalxis with magnesium sulphate for all preeclampsia patients are my humble submission with respect to refractoriness, that was treated by magnesium sulphate itself, the magic molecule of this study discussion
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