Cite this asZelmat S, Belhachemie N, Kerbouia DBK, Boucherit E, Mazour F (2020) Hellp Syndrom, A Real General Desease that Threatens the Maternal Morbidity and Mortality at the EHU in Oran. J Cardiovasc Med Cardiol 7(2): 094-097. DOI: 10.17352/2455-2976.000120
Hellp Syndrome (hemolysis, elevatedliver enzymes, lowplatelet count) is an obstetric emergency. It is a form of severity of preeclampsia, itsdiagnosisisdifficultbecause the biologicalpictureisoftenincomplete and rough [1-6]. Several classifications have emerged, the best knownisthat of MISSISSIPI. [7-10], defined by:
Class 1: la plus grave, avec :
Platelet count l à ≤ 50,000/ml . ASAT orALAT ≥70 IU/L. .LDH≥ 600 IU/L.
Class 2: Platelet count 500,000/ml - 100,000/ml . ASAT or ALAT ≥70 IU/L . LDH≥ 600 IU/L.
Class 3: Platelet count 100,000/ml _150000/ml . ASAT or ALAT ≥70 I. LDH≥ 600 IU/L.
It is a syndrome thatisoftenvery progressive, sometimeshyperacute in the form of a multi-visceralfailure syndrome. This pathologyisendowedwith a heavymaternofetalmorbidity and mortality. Maternalmorbidityis all the more severe as the diagnosisis made late . HS isassociatedwith 40% of severematernal complications , compared to 10% in isolatedseverepre-eclampsia. Incomplete or partial forms have a more favorable maternalprognosisthancompleteformscorrelatedwith the severity of preeclampsia.
Regardless of biologicalcriteria . HS complications are related to systemicfailurecaused by disseminated microangiopathy. Multi-visceralgravidarfailureis an evolution of the diseasebeyond HS and not an intrinsic complication of HS .
The main objective of ouris to determine the incidence of complications related to the HELLP syndrome at the gynecologicalobstetricsdepartment of the UniversityHospital Oran.
Weconducted a cross-sectionalstudy over 4 yearsfromJanuary 1st, 2015 to December 31st, 2019, in the Gynecology and ObstetricsDepartment of the Oran EHU, in patients with HS.
The studyconcerns all patients withpre- or post-partum HS whowereadmitted to the Gynecology and ObstetricsDepartment of Oran EHU.
Criteria for non-inclusion are:
- Class III HS according to the MISSISSIPI classification.
- Thrombocytopenia due to another cause (congenital, thrombocytopenic purpura, uremichemolytic syndrome, hepaticsteatosis).
- An elevation of ASAT and LDH due to another cause.
We first describe the clinicalcharacteristics of the population, including all the patients included in the “2013 to 2016” study, wethenstudy
Maternal and fetal complications related to HS: complications consideredwerematernaldeaths, neurological complications (eclampsia, retro placentalhematoma, sub-capsularhematoma of the peroperative and fetal liver (in utero death, spontaneous or iatrogenicprematurity and intrauterinegrowth retardation).
Takingintoaccount the prevalence of PE reported in the literature, wecalculatedthatat least 165 cases of pregnantwomenshouldbeincluded.
The patient with HS isexaminedrapidly, and her file isseen by the resuscitator, whoassesses the degree of urgency and determines, in collaboration with the obstetrician, the orientation, either in intensive care unit or in GHR unit, or in the operating room or at the delivery block.
The major role of the resuscitatorwho must initiate emergency therapyis:
- The stabilization of the lesionwithantihypertensivetherapywith the electric syringe and orallywith a monitoring of the vital parameters.
- Corticotherapy for pulmonarymaturity and targetedplatelet.
- Transfusion of platelet pellet in HS type 1 (thrombocytopenia ≤ 50000).
- Monitoring of the clinical and biologicalevolution of HS thatisunpredictable
- The search for complications: eclampsia,oedemaaugue of the lung,
placental retro hematoma, renalfailure ,hematomaundercapsularliver.
This involves the collaboration of the departments of biology, biochemistry of hemobiology, radiology, hematology and transfusion center.
The passage to the operating room: The treatment of HS isrepresentedprimarily by the termination of pregnancy but thisdecisionmaybeshifted in certain cases, after a multidisciplinarydecision of the resuscitator, the obstetrician and the pediatrician. The important role of the resuscitatoranesthesiologist in the operating room, whichoftenrepresents more than 50% of the decision-to-birth time, must betakenintoaccount by the choice of the type of anesthesiaaccording to the context, and the management of the per and post complications. procedure.
Criteria for transfer to intensive care: It isrecommended to anticipate and organize the continuous surveillance of patients presenting or likely to have one or more organfailures, related to a severeobstetricpathology, or with a maternalpathologycomplicated by pregnancy, and to orient the patient to a resuscitation unit in the event of persistingorganfailurerequiring replacement, multi-visceralfailure or life-threatening conditions according to the agreement establishedbetweeneach unit of obstetrics and an adult intensive care unit, especially if the establishment where the maternitywardislocated has it.
Statistical analysis: The descriptive analysis of the variables isdone by calculatingfrequencies, characteristics of central tendency or dispersion: the mean (m), the median (me), the variance (σ2), the standard deviation (σ) as well as the determination of the confidence intervals (95% CI) around the mean, and the median (me) for the risk α = 0.05 for the quantitative variables.
The determination of frequencies and confidence intervals for qualitative variables.
The confidence intervalaround the meanisshown by the Standard Deviationaround the mean (mean ± SD).
During the studyperiod, wecollected 165 cases of HS out of a total of 20,283 deliveries. The estimated incidence of this syndrome is 0.8%, or 1 case for 116 pregnancies. Wefound 167 pre-eclamptic patients admittedduring the sameperiod, the incidence of HS in preeclamptic patients collectedduring the sameperiodis 14.13%.
Of these 165 patients, 121 (73.3%) weretransferredfromanotherperipheralhealthfacility. And 44 patients (26.7%) werereferred to the specialized consultation service of the Oran EHU,
Our patients are mainlymultiparas; the frequency of the multiparityis 45%, the nulliparousis 28.5% and the primiparityis 26.5%. The averageparity in our patients is 2 ± 1 childrenwithextremesrangingfrom 0 to 9 with a median of 1.The averageage of our patients is 32 ± 6.33. Pregnancywas not regularlyfollowedin 97 patients, or 59%. HS wasdiagnosedat an averageterm of 33 weeks of amenorrhea.
In ourstudy, 105 patients had complications, 63.6% of whichincludedmaternaldeaths (n= 10),
The descriptive analysis of the variables (23, 03%), 20 cases of HRP (12.12%), 17 patients complicated of CIVD (10.3%), and 10 patients complicatedwith PAO: HSCF wasfoundin 11 patients (6.06%), and retinaldetachmentwasfoundin 2 patients (1.21%) and encephalopathyin 3 patients (1.81%). The diagnosis of acute pulmonaryedemaisbased on clinical and radiological data. Abdominal ultrasoundwasperformedsystematically, in view of the persistence of abdominal pain in search of HSCF.
CIVD wasdefined by the combination of thrombocytopenialessthan 100,000 platelets / mm-3, fibrinogen<3g / Let, the presence of fibrindegradationproducts or D-dimer> 3 μg / mL.
It isnotedthat acute renalfailurediagnosedwith RIFLE criteriawas the mostfrequent complication foundin 62 patients (37.75%), whichwasestablishedafter an averagedelay of 4.5 after admission of HS. , Diuresiswasretainedin 9 patients while 53 parturientswasoliguricthree patients required extrarenal treatmentwith an average of 6 ± 2.2 sessions per patient, 1 has evolved to chronicrenalfailure.
The rates of prematurity (ofteniatrogenic), IUGR and MFIU, were 52, 7%, 87.4% and 26% respectively and noted 23 newbornswhodiedatbirth.
Our results are consistent in part withthose of the Leboterfseries , in 2003, Kirkpatrick , in 2008 and Roopa , in 2010, with an incidence of HS in relation to the number of pregnanciesrangingfrom 0.2 to 1% of pregnancies.
In 2012, in a retrospectiveMoroccanstudyin 2008, Mamouni , out of 61 cases found an incidence of 0.27%, of which 67% weretransfersfromperipheralmaternityhospitals.
In ourstudy, 105 patients had complications, 63.6% whichissimilar to the Mamouni study117 with 74% of the complications, and the study of Hani bilal45 with 52% .But ourresults are superior to the study of Sibaï , in 1993 and Beucher , in 2008 whofoundthat HS isassociatedwith 40% of maternal complications.
The authors [13,20], findthat the complications are all the more important that the diagnosisis made late. This shows that the discovery of HS islate in ourcontext. So weattribute the complications in ourstudy to a late consultation, a non-monitoring pregnancy or adeceptiveclinicalpicturethatiscertainlyat the origin of a lateevacuation.
In ourseries, acute renalfailurewas the mostcommon complication with 39.4%. This is consistent with a Tunisianstudydonein 2000 by Ben letaifa , whofoundthat acute renalfailurewas. morefrequentlyfoundin 1/3 cases. This isexplained by the authors, by the constant association, with the vascular-renaldisease, of a dehydrationfavored by the digestive disorders.
The incidence of HS in our institution is high by around 0.8%, due to a high frequency of peripheraltransfers, whichis a clear invitation to action to improve screening, surveillance and treatmentat the periphery.
HS is a seriousdisease for the mothersinceitcanpresentitself in the form of a multi-visceralfailure, and fatal for the fetus, the precocity of the treatmentis the onlyguarantee of a betterprognosis.
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