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HELLP syndrome after the improvement of coagulation and fibrinolysis parameters in severe preeclampsia
cYNlKoLoGY &OBSTETRICS International
Journal of Gynecology & Obstetrics 52 (1996) 279-280
Letter to the editor
HELLP syndrome after the improvement of coagulation and fibrinolysis parameters in severe preeclampsia M. Furuhashi*,
H. Oda, N. Imai
Department of Obstetrics and Gynecology, Handa City Hospital, Handa, Japan Received 13 July 1995; revision received I October 1995; accepted 5 October 1995
Keywords:
HELLP syndrome;Preeclampsia;Coagulation;Fibrinolysis
HELLP syndrome (hemolysis, elevated liver enzymes and low platelets) is a variant of preeclampsia [ 11.The etiology of HELLP syndrome is still poorly understood and no single precipitating cause has been reported [2]. We present a case of HELLP syndrome which occurred after improvement of coagulation and fibrinolysis, both of which are parameters of preeclampsia. A 39-year-old woman, gravida II para I, was admitted to our department suffering from severe preeclampsia at 33 weeks and 2 days’ gestation. Prenatal follow-up had been normal until 32 weeks’ gestation, when during a routine visit she was found to have proteinuria, pitting edema on tibia, and hypertension (147/105 mmHg). On admission, the patient’s blood pressure was in the range 162/96-2201140. A non-stress test was reactive. Although the level of hypertension, proteinuria and edemawas unchanged, the coagulation and fibrinolysis parameters improved * Corresponding author, Tel.: +8l 569 229881; Fax: +8l 569 243253. 0020-7292/96/$15.00 0 1996 International SSDI 0020-7292(95)02596-5
(Table 1). Eleven days after admission, the patient suddenly complained of epigastric pain. A cesarean section was carried out following the diagnosis of HELLP syndrome and a 1960-g femaleinfant with Apgar scoresof 8 was delivered. The liver was found to be discolored and hard. After the cesarean section, all the evidence of hemolysis, elevated liver enzymes (aspartate Table I Coagulation and fibrinolysis HELLP syndrome
parameters before the onset of
Fibrinogen (mg/dl) Antithrombin III (%) Thrombin-antithrombin complex htW Fibrin/fibrinogen degradation products (&ml) Cross-linked fibrin degradation product (&ml)
Day -8
Day -I
399 84 14.1
436 129 12.7
11.3
5.5
8.2
2.4
Day 0 is the day of onset of HELLP syndrome.
Federation of Gynecology and Obstetrics
280
M. Furuhashi et al. / Internotional Journal of Gynecology & Obstetrics 52 (19%) 279-280
aminotransferase 1529 U/l, alanine aminotransferase801 U/l) and low platelet count (3.9 x 10’) were obtained. The patient was associated with disseminated intravascular coagulopathy (DIC) and multiorgan failure. Despite intensive care, she died 2 days after onset. Preeclampsiais known to be a chronic DIC state and coagulation and fibrinolysis have been used as parameters for the disease [3]. HELLP syndrome is characterized primarily by microangiopathic hemolytic anemia. Thus, in a patient with preeclampsia, improvement of the DIC state has been considered to be an important point for prevention of HELLP syndrome. However this fatal case not only demonstrates that the onset of HELLP syndrome is independent of improvement
of coagulation and tibrinolysis but it also emphasizes that careful management of the patient with preeclampsia is required. References [l] Weinstein L. Syndrome of hemolysis, elevated liver enzymes,and low platelet count: a severeconsequenceof hypertension in pregnancy. Am J Obstet Gynecol 1982; 142: 159-167. [2] Sibai BM. The HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets): much ado about nothing? Am J Obstet Gynecol 1990, 162: 311-316. [3] Terao T, Maki M, Ikenoue T, Gotoh K, Murata M, Iwasaki H et al. The relationship between clinical signs and hypercoagulable state in toxemia of pregnancy. Gynecol Obstet Invest 1991; 31: 74-85.
Journal of Gynecology & Obstetrics 52 (1996) 279-280
Letter to the editor
HELLP syndrome after the improvement of coagulation and fibrinolysis parameters in severe preeclampsia M. Furuhashi*,
H. Oda, N. Imai
Department of Obstetrics and Gynecology, Handa City Hospital, Handa, Japan Received 13 July 1995; revision received I October 1995; accepted 5 October 1995
Keywords:
HELLP syndrome;Preeclampsia;Coagulation;Fibrinolysis
HELLP syndrome (hemolysis, elevated liver enzymes and low platelets) is a variant of preeclampsia [ 11.The etiology of HELLP syndrome is still poorly understood and no single precipitating cause has been reported [2]. We present a case of HELLP syndrome which occurred after improvement of coagulation and fibrinolysis, both of which are parameters of preeclampsia. A 39-year-old woman, gravida II para I, was admitted to our department suffering from severe preeclampsia at 33 weeks and 2 days’ gestation. Prenatal follow-up had been normal until 32 weeks’ gestation, when during a routine visit she was found to have proteinuria, pitting edema on tibia, and hypertension (147/105 mmHg). On admission, the patient’s blood pressure was in the range 162/96-2201140. A non-stress test was reactive. Although the level of hypertension, proteinuria and edemawas unchanged, the coagulation and fibrinolysis parameters improved * Corresponding author, Tel.: +8l 569 229881; Fax: +8l 569 243253. 0020-7292/96/$15.00 0 1996 International SSDI 0020-7292(95)02596-5
(Table 1). Eleven days after admission, the patient suddenly complained of epigastric pain. A cesarean section was carried out following the diagnosis of HELLP syndrome and a 1960-g femaleinfant with Apgar scoresof 8 was delivered. The liver was found to be discolored and hard. After the cesarean section, all the evidence of hemolysis, elevated liver enzymes (aspartate Table I Coagulation and fibrinolysis HELLP syndrome
parameters before the onset of
Fibrinogen (mg/dl) Antithrombin III (%) Thrombin-antithrombin complex htW Fibrin/fibrinogen degradation products (&ml) Cross-linked fibrin degradation product (&ml)
Day -8
Day -I
399 84 14.1
436 129 12.7
11.3
5.5
8.2
2.4
Day 0 is the day of onset of HELLP syndrome.
Federation of Gynecology and Obstetrics
280
M. Furuhashi et al. / Internotional Journal of Gynecology & Obstetrics 52 (19%) 279-280
aminotransferase 1529 U/l, alanine aminotransferase801 U/l) and low platelet count (3.9 x 10’) were obtained. The patient was associated with disseminated intravascular coagulopathy (DIC) and multiorgan failure. Despite intensive care, she died 2 days after onset. Preeclampsiais known to be a chronic DIC state and coagulation and fibrinolysis have been used as parameters for the disease [3]. HELLP syndrome is characterized primarily by microangiopathic hemolytic anemia. Thus, in a patient with preeclampsia, improvement of the DIC state has been considered to be an important point for prevention of HELLP syndrome. However this fatal case not only demonstrates that the onset of HELLP syndrome is independent of improvement
of coagulation and tibrinolysis but it also emphasizes that careful management of the patient with preeclampsia is required. References [l] Weinstein L. Syndrome of hemolysis, elevated liver enzymes,and low platelet count: a severeconsequenceof hypertension in pregnancy. Am J Obstet Gynecol 1982; 142: 159-167. [2] Sibai BM. The HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets): much ado about nothing? Am J Obstet Gynecol 1990, 162: 311-316. [3] Terao T, Maki M, Ikenoue T, Gotoh K, Murata M, Iwasaki H et al. The relationship between clinical signs and hypercoagulable state in toxemia of pregnancy. Gynecol Obstet Invest 1991; 31: 74-85.