- Email: [email protected]
Postpartum HELLP syndrome
243
Europeun Journul of Obstetrics & Gynecology and Reproductirv Biology, 43 (1992)243-344 lb 1992 Elsevier Science Publishers B.V. All rights reserved 0028.2243/92/$05.(K)
EUROBS 01208
Case Reports
Postpartum HELLP syndrome Ahmet Yilmaztiirk ’ and Wolfgang Schliiter ’ ’ GynGkologi.sch-Geburtshilfliche Abteilung des Kreiskrankenhuuses Dannenberg / Elbe. Dunnenberg and ’ Frauenklinik des Krei.skrankenhuuses Heide. Heide. F. R.G.
Accepted for publication II April 19Y1
Summary Presented is a case of postpartum low platelet count.
pre-eclampsia-eclampsia
HELLP syndrome; Pre-eclampsia-eclampsia;
with hemolysis,
elevated
liver enzymes
and
Puerperium: Post partum
Introduction The HELLP syndrome is characterized by the presence of hcmolysis. glevated liver enzymes and low platelet count in combination with pre-eclampsiaeclampsia. It’s etiology is unknown. This syndrome is considered to be a variant of pre-eclampsia-eclampsia; however, recently, a largely independent cause has been discussed [ 1,3]. The underlying pathophysiological mechanism in HELLP syndrome is an acute disorder of microcirculation. Changes in perfusion and coagulation may result in subcapsular liver hematoma with rupture and profuse intra-abdominal bleeding, acute renal failure, intracerebral hemorrhage as well as abruptio placentae and severe postpartum hemorrhage. Accordingly, the maternal mortality rate ranges from 3 to 5%, and the perinatal mortality rate is as high as 33% [4-61. Undelayed delivery with a liberal indication for cesarean section is recommended [4-61. We report a case of HELLP syndrome, that developed after operative delivery by cesarean section. Case report A 27-year-old woman, II-gravida, ted to the hospital with diagnosed
associated
I-para, was admittwin pregnancy in
Correspondence: Univ-Doz. A. Yilmaztiirk, Chefarzt d. GymGeburtsh. Abt. des Kreiskrankenhauses Dannenberg/Elbe. 3138 Dannenberg, F.R.G.
the 39th week of gestation. As the leading twin showed breech presentation, delivery was performed by cesarean section. The patient’s medical history was completely uneventful, regular prenatal visits had shown no pathology. On admission the patient was healthy without any abnormal findings. Fetal heart rate monitoring was reactive. Ultrasound imaging confirmed the breech presentation without any additional pathologic findings. Preoperative laboratory results (blood smear, platelet count, coagulation parameters, liver enzymes. renal parameters, electrolytes) were normal. Cesarean section was performed without any complications. During the early postoperative period, arterial hypertension developed with a maximum in systolic pressures of 190 mmHg and diastolic pressures of 110 mmHg. Antihypertensive therapy with dihydralazine was initiated. Postoperative laboratory results showed no change as compared to preoperative values. During the first postoperative day hemoglobin had fallen to 9.2 g/dl, the hematocrit was 28%. The platelet count was 27000/~1. Total bilirubin was increased to 2.2 mg/dl. serum glutamic-oxaloacetic transaminase at 185 U/l, serum glutamic-pyruvic transaminasc at 99 U/l. lactate dehydrogenase at 1000 U/l and creatinine at 1.4 mg/dl. A blood smear revealed schistocytes. poikiloand anisocytosis (Fig. I). The blood pressure normalized under continued antihypertensive therapy. Laboratory results returned to their normal range during the following days. On discharge the patient was completely recovered. The newborns perinatal period was uneventful.
The absence of pain in the upper right abdominal quadrant is also remarkable. This leading symptom, caused by tension of the liver capsule after obstruction of sinusoidal perfusion, was not present in our case, perhaps because the patient had received narcotic analgesics postoperatively. This could cause a delayed diagnosis or even overlooking this dangerous disorder. Our reported case points out the importance of diligent diagnostic procedures if pre-eclampsia should develop in the postpartum period under special consideration of the blood cell smear, liver enzymes and platelet count which are conclusive for HELLP-syndrome. References
Fig. 1. HELLP syndrome, peripheral blood smear: schistocytes, poikilo-anisocytosis.
The reported case suggests the postpartum development of a HELLP syndrome in combination with a monosymptomatic pre-eclampsia-eclampsia. In the literature no case of postpartum developed HELLP syndrome has been described until now. The occurrence of pre-eclampsia-eclampsia with hemolysis, elevated liver enzymes and low platelet count after delivery is well established; however, in all reported cases HELLP-syndrome persisted since late pregnancy
[2,7,81.
1 Drack G, Neftel K, Lauper U, Gmiir D. ‘HELPP-Syndram’ ohne Fragmentozyten: Spielen medikamenteninduzierte Antikijrper eine Rolle? Geburtsh Frauenheilk 1989;49:1006-1009. 2 Egley CC, Gutliph JA, Bowes WA. Severe hypoglycemia associated with HELLP syndrome. Am J Obstet Gynecol 1985;152:566-567. Mathis G, Parschalk 0, Sutterliitti G, Helfenbein E. Schwere Thrombozytopenie, Hamolyse und Leberfunctionsstijrung in der Spatschwangerschaft. Dtsch Med Wochenschr 1988;113:1598-1600. Niesert St, Dribusch E, Bettmann 0, Kaulhausen H. Leberfunktionsstlirung, Thrombopenie und Hamolyse bei einer besonderen Verlaufsform der Schwangerschaftshypertonie (sag. HELLP-Syndrom). Geburtsh. Frauenheilk 1988;48:637-640. Rath W, Loos W, Kuhn W, Graeff H. Die Bedeutung der Friihzeitigen Labordiagnostik fur das geburtshilfliche Vorgehen bei schweren Gestosen und HELLP-Syndrom. Geburtsh Frauenheilk 1988;48:127-133. Rath W, Loos W, Kuhn W, Graeff H. Von interdisziplinirer Bedeutung: das HELLP-Syndrom: eine schwere Komplikation der Gestose. Dtsch. Arzteblatt 1989;86(A): 464-466. Schwartz ML, Brenner W. Severe preeclampsia with persistent postpartum hemolysis and thrombocytopenia treated by plasmapheresis. Obstet Gynecol 1985;65:53s55s. Weinstein L. Preeclampsia/eclampsia with hemolysis, elevated liver enzymes, and thrombocytopenia. Obstet Gynecol 1985;66:657-660.
Europeun Journul of Obstetrics & Gynecology and Reproductirv Biology, 43 (1992)243-344 lb 1992 Elsevier Science Publishers B.V. All rights reserved 0028.2243/92/$05.(K)
EUROBS 01208
Case Reports
Postpartum HELLP syndrome Ahmet Yilmaztiirk ’ and Wolfgang Schliiter ’ ’ GynGkologi.sch-Geburtshilfliche Abteilung des Kreiskrankenhuuses Dannenberg / Elbe. Dunnenberg and ’ Frauenklinik des Krei.skrankenhuuses Heide. Heide. F. R.G.
Accepted for publication II April 19Y1
Summary Presented is a case of postpartum low platelet count.
pre-eclampsia-eclampsia
HELLP syndrome; Pre-eclampsia-eclampsia;
with hemolysis,
elevated
liver enzymes
and
Puerperium: Post partum
Introduction The HELLP syndrome is characterized by the presence of hcmolysis. glevated liver enzymes and low platelet count in combination with pre-eclampsiaeclampsia. It’s etiology is unknown. This syndrome is considered to be a variant of pre-eclampsia-eclampsia; however, recently, a largely independent cause has been discussed [ 1,3]. The underlying pathophysiological mechanism in HELLP syndrome is an acute disorder of microcirculation. Changes in perfusion and coagulation may result in subcapsular liver hematoma with rupture and profuse intra-abdominal bleeding, acute renal failure, intracerebral hemorrhage as well as abruptio placentae and severe postpartum hemorrhage. Accordingly, the maternal mortality rate ranges from 3 to 5%, and the perinatal mortality rate is as high as 33% [4-61. Undelayed delivery with a liberal indication for cesarean section is recommended [4-61. We report a case of HELLP syndrome, that developed after operative delivery by cesarean section. Case report A 27-year-old woman, II-gravida, ted to the hospital with diagnosed
associated
I-para, was admittwin pregnancy in
Correspondence: Univ-Doz. A. Yilmaztiirk, Chefarzt d. GymGeburtsh. Abt. des Kreiskrankenhauses Dannenberg/Elbe. 3138 Dannenberg, F.R.G.
the 39th week of gestation. As the leading twin showed breech presentation, delivery was performed by cesarean section. The patient’s medical history was completely uneventful, regular prenatal visits had shown no pathology. On admission the patient was healthy without any abnormal findings. Fetal heart rate monitoring was reactive. Ultrasound imaging confirmed the breech presentation without any additional pathologic findings. Preoperative laboratory results (blood smear, platelet count, coagulation parameters, liver enzymes. renal parameters, electrolytes) were normal. Cesarean section was performed without any complications. During the early postoperative period, arterial hypertension developed with a maximum in systolic pressures of 190 mmHg and diastolic pressures of 110 mmHg. Antihypertensive therapy with dihydralazine was initiated. Postoperative laboratory results showed no change as compared to preoperative values. During the first postoperative day hemoglobin had fallen to 9.2 g/dl, the hematocrit was 28%. The platelet count was 27000/~1. Total bilirubin was increased to 2.2 mg/dl. serum glutamic-oxaloacetic transaminase at 185 U/l, serum glutamic-pyruvic transaminasc at 99 U/l. lactate dehydrogenase at 1000 U/l and creatinine at 1.4 mg/dl. A blood smear revealed schistocytes. poikiloand anisocytosis (Fig. I). The blood pressure normalized under continued antihypertensive therapy. Laboratory results returned to their normal range during the following days. On discharge the patient was completely recovered. The newborns perinatal period was uneventful.
The absence of pain in the upper right abdominal quadrant is also remarkable. This leading symptom, caused by tension of the liver capsule after obstruction of sinusoidal perfusion, was not present in our case, perhaps because the patient had received narcotic analgesics postoperatively. This could cause a delayed diagnosis or even overlooking this dangerous disorder. Our reported case points out the importance of diligent diagnostic procedures if pre-eclampsia should develop in the postpartum period under special consideration of the blood cell smear, liver enzymes and platelet count which are conclusive for HELLP-syndrome. References
Fig. 1. HELLP syndrome, peripheral blood smear: schistocytes, poikilo-anisocytosis.
The reported case suggests the postpartum development of a HELLP syndrome in combination with a monosymptomatic pre-eclampsia-eclampsia. In the literature no case of postpartum developed HELLP syndrome has been described until now. The occurrence of pre-eclampsia-eclampsia with hemolysis, elevated liver enzymes and low platelet count after delivery is well established; however, in all reported cases HELLP-syndrome persisted since late pregnancy
[2,7,81.
1 Drack G, Neftel K, Lauper U, Gmiir D. ‘HELPP-Syndram’ ohne Fragmentozyten: Spielen medikamenteninduzierte Antikijrper eine Rolle? Geburtsh Frauenheilk 1989;49:1006-1009. 2 Egley CC, Gutliph JA, Bowes WA. Severe hypoglycemia associated with HELLP syndrome. Am J Obstet Gynecol 1985;152:566-567. Mathis G, Parschalk 0, Sutterliitti G, Helfenbein E. Schwere Thrombozytopenie, Hamolyse und Leberfunctionsstijrung in der Spatschwangerschaft. Dtsch Med Wochenschr 1988;113:1598-1600. Niesert St, Dribusch E, Bettmann 0, Kaulhausen H. Leberfunktionsstlirung, Thrombopenie und Hamolyse bei einer besonderen Verlaufsform der Schwangerschaftshypertonie (sag. HELLP-Syndrom). Geburtsh. Frauenheilk 1988;48:637-640. Rath W, Loos W, Kuhn W, Graeff H. Die Bedeutung der Friihzeitigen Labordiagnostik fur das geburtshilfliche Vorgehen bei schweren Gestosen und HELLP-Syndrom. Geburtsh Frauenheilk 1988;48:127-133. Rath W, Loos W, Kuhn W, Graeff H. Von interdisziplinirer Bedeutung: das HELLP-Syndrom: eine schwere Komplikation der Gestose. Dtsch. Arzteblatt 1989;86(A): 464-466. Schwartz ML, Brenner W. Severe preeclampsia with persistent postpartum hemolysis and thrombocytopenia treated by plasmapheresis. Obstet Gynecol 1985;65:53s55s. Weinstein L. Preeclampsia/eclampsia with hemolysis, elevated liver enzymes, and thrombocytopenia. Obstet Gynecol 1985;66:657-660.