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World Applied Sciences Journal 26 (11): 1459-1463, 2013
ISSN 1818-4952
© IDOSI Publications, 2013
DOI: 10.5829/idosi.wasj.2013.26.11.1280
Corresponding Author: B. Hasannasab, Department of Anesthesiology, Babol University of Medical Science, Babol, Iran.
Tel: +98-111-2274881, Fax: +98-111-2274880.
1459
Maternal and Neonatal Outcomes in HELLP Syndrome,
Partial HELLP Syndrome and Severe Pre-Eclampsia: Eleven
Years Experience of an Obstetric Center in the North of Iran
Zinatossadat Bouzari, Shiva Firoozabadi, Bahman Hasannasab,
1 23
Seyedsina Emamimeybodi and Masoume Golsorkhtabar-Amiri
14
Stem cell research center, Babol University of Medical Science, Babol, Iran
1
Obstetrics & Gynecology Department, Babol University of Medical Science, Babol, Iran
1,2
Anesthesiology Department, Babol University of Medical Science, Babol, Iran
3
Fatemezahra Infertility and Reproductive Health Research center,
4
Babol University of Medical Science, Babol, Iran
Submitted: Sep 2, 2013; Accepted: Oct 8, 2013; Published: Dec 2, 2013
Abstract: Objective: This study aimed to determine the maternal and neonatal outcomes in hemolysis, elevated
liver enzymes and low platelets syndrome (HELLP), partial HELLP syndrome (PHS) and severe pre-eclampsia:
an eleven years experience of an obstetric center in the North of Iran. Methods: This retrospective observational
study was done on pregnant women admitted in the Yahyanejad Hospital in the Babol University of
Medical Science during 1998-2009. A total of 327 pregnant women were categorized into three groups: severe
pre-eclampsia, PHS and HELLP syndrome. Data were analyzed by appropriate tests for continuous or
categorical outcomes with differences considered significant if P < 0.05. Findings: Our finding demonstrated
that the rate of caesarean section, blood transfusion, acute renal failure, admitting in Intensive Care Unit
and liver hematoma were significantly greater in the pregnancy with HELLP syndrome versus severe
pre-eclampsia.(p<0.05). Conclusion: Maternal and neonatal morbidities increased among that HELLP syndrome.
So, immediate diagnosis and proper management could be attempted to improve maternal and prenatal
outcomes.
Key words: HELLP Syndrome Preclamcia Partial HELLP Syndrome
INTRODUCTION The HELLP syndrome is characterized by the
Hypertensive disorders of pregnancy were the most HELLP syndrome (PHS) consists of only one or two
common medical complication that occurs in 5-10% of all elements of the triad [6]. Although, the incidence of
pregnancies [1-2]. Among the types of gestational HELLP syndrome varies from 2 to 12%, 5-20% of the
hypertension, pre-eclampsia is the most dangerous form patients with HELLP syndrome are associated with
is associated with proteinuria [2]. Pre-eclampsia is a hypertension and proteinuria [7]. The incidence of PHS is
multisystem disorder with unknown etiology that can greater and is probably estimated from 21 to 24 % [8].
observe as eclampsia or HELLP syndrome (hemolysis, Maternal outcome in HELLP syndrome include: hepatic
elevated Liver enzymes and low platelets) [3]. The HELLP rupture, acute renal failure (ARF), disseminated
syndrome is a serious health hazard during pregnancy intravascular coagulation (DIC), abruption placenta,
[1-4] and 60% of cases are required delivery by cesarean pulmonary and cerebral edema, intracranial hemorrhage
section [5]. and hypovolemic shock [7, 3]. Prenatal outcomes such as
presence of all three major components, while partial
World Appl. Sci. J., 26 (11): 1459-1463, 2013
1460
respiratory distress syndrome (RDS), intra uterine growth pre-eclampsia was defined as a blood pressure 160/90
restriction (IUGR) and intra uterine Fetal death (IUFD) mm Hg and proteinuria 2 in dipstick or proteinuria of at
were reported about 7.7- 60% in preterm delivery [9]. In a least 2g/24 h, intrauterine fetal growth restriction,
quest were reported patients with a history of HELLP are persistent headache, persistent of epigastric pain, serum
at the increased risk for preeclampsia and HELLP is creatinin levels >1.2 mg/dl and visual disturbances but
associated with long-term morbidities such as depression without alterations in laboratory tests for HELLP
and chronic hypertension [10]. syndrome. HELLP syndrome is characterized based on
Present study aimed to determine maternal and three criteria, including: thrombocytes < 100,000 mm ,
prenatal outcomes of HELLP syndrome and PHS, because aspirate aminotransferase (AST) >70 UI/L, lactate
there is a little information about it in the north of Iran. dehydrogenase (LDH) > 600 UI/L and PHS was defined by
Then we compare maternal and prenatal outcomes the presence of one or two of these parameters. Maternal
between women with HELLP syndrome, PHS and women and neonatal data recorded in the records were reviewed
who have sever pre-eclampsia but normal laboratory tests for maternal outcome such as hepatic rupture, ARF, DIC,
for HELLP syndrome. abruption placenta, pulmonary edema, cerebral edema,
MATERIALS AND METHODS outcomes such as RDS, IUGR and IUFD. Statistical
This retrospective observational study done among Fisher´s Exact test and statistical significance was
admitted the patients in the Yahyanejad Hospital in considered at p< 0.05.
the Babol Medical University during 1998 and 2009.
We reviewed maternal and neonatal medical charts in RESULTS
women who were admitted with a diagnosis of sever
pre-eclampsia, HELLP syndrome and PHS. Exclusion In this retrospective study, out of 375 patients during
criteria included multiple pregnancy, fetal anomalies and 11year with severe pre-eclampsia, HELLP syndrome and
patients with renal and liver disease, pre-eclampsia with PHS after applying the exclusion criteria, 309 patients with
PHS or HELLP syndrome and hematological diseases. severe pre-eclampsia, HELLP syndrome and PHS were
Gestational age was determined from the first day in the enrolled and their maternal and neonatal outcomes were
last menstrual period (LMP), if women were unsure their noted . 89(28.8%) patients with severe pre-eclampsia, 203
LMP, the gestational age was used to the findings of a (65.7%) patents with PHS and 17(55.7%) patients with
dating ultrasound scan that had been done before 20 HELLP syndrome remained for the study. The mean age
weeks of pregnancy. in our patients was 26.59±5.85. The Maternal demographic
We received the ethic permission from the ethic and clinical characteristics for severe pre-eclampsia, PHS
committee of Babol University of Medical Science. and HELLP are shown in Table 1. We found the parity
Patients were categorized into three groups: severe greater than one in 31 cases (34.8%) of the severe
pre-eclampsia, HELLP syndrome and PHS. Severe pre-eclampsia and 73 cases (36%) of the PHS and also,
3
intracranial hemorrhage, hypovolemic shock and prenatal
analyses were performed with the chi-square test and
Table 1: Maternal demographic and clinical characteristics in the three grousp under study
Severe pre-eclampsia Partial HELLP syndrome HELLP syndrome
N=89 N=203 N=17 P-Value
Age(yr) 26.39±5.69 26.67±6.03 26.65±4.76 0.93
Gravidity (%)
1 50(56.2) 113(55.7) 8(47.1) 0.77
2 39(43.8) 90(44.3) 9(52.9)
Parity (%)
0 58(65.2) 130(64) 5(29.4) 0.015
1 31(34.8) 73(36) 12(70.6)
Gestational age at delivery (wk) 35.83±3.61 35.84±2.94 33.76±2.58 0.031
Birth Weight (gr) 2582.06±907.13 2855.02±1267.67 1973.52±747.7 0.004
Sig is P<0.05
PHS; Partial HELLP Syndrome
HELLP; Hemolysis, Elevated Liver enzymes and Low Platelets
World Appl. Sci. J., 26 (11): 1459-1463, 2013
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Table 2: Comprison of maternal and neonatal outcome in pregnancy in the three groups
Maternal neonatal outcomes Severe pre-eclampsia N (%) PHS N (%) HELLP syndrome N (%) P-Value
IUFD 3(3.4) 3(1.5) 0(0.0) 0.46
IUGR 5(5.6) 10(4.9) 3(17.6) 0.098
FD 6(6.7) 11(5.4) 3((17.6) 0.02
Preterm labor 48(3.9) 102(50.2) 3(17.6) 0.022
NICU 20(22.5) 41(20.2) 3(17.6) 0.86
Neonatal mortality 0(0) 0(0) 0(0) 0(0)
Sex
Male 80(89) 176(86.7) 11(64.7) 0.021 1 ver 3, 2 ver 3
Female 9(10.1) 27(13.3) 6(35.3)
Induction of labor 36(40.4) 88(43.3) 11(64.5) 0.179
Cesarean section 3(3.4) 6(3) 4(23.5) <0.001 1 ver 3, 2 ver 3
Blood transfusion 0(0) 7(3.4) 4(23.5) <0.001 1 ver3, 2 ver 3, 1 ver 2 ver 3
Postpartum hemorrhage 0(0) 3(1.5) 1(5.9) 0.134
ARF 0(0) 0(0) 2(11.8) <0.001 1 ver 3, 2 ver 3
Need to ICU 0(0) 1(0.5) 2(11.8) <0.001 1 ver 3, 2 ver 3
Abruption placenta 8(9) 13(6.4) 3(17.6) <0.22
Maternal death 0(0) 0(0) 1(5.9) <0.001 2 ver 3
liver hematoma 1(1.1) 3(1.5) 4(23.5) <0.001 1 ver 3, 2 ver 3
Pulmonary edema 0(0) 0(0) 1(5.9) <0.001
Eclamcia 2(2.2) 2(1) 1(5.9) <0.263
Sig is P<0.05
PHS; partial HELLP Syndrome
HELLP; Hemolysis, Elevated Liver enzymes and Low Platelets
12(70.6%) of the HELLP syndrome. It revealed a DISCUSSION
significant difference between the three groups (p=0.015)
on behalf of the HELLP group. The mean of gestational Pre-eclampsia, PHS and HELLP syndrome are a
age in our patients was 35.72±3.15 wk. The gestational age life –threatening complication in the pregnancy. In the
at delivery and birth weight were lower significantly in the current study, indication for caesarean section, blood
women with HELLP syndrome versus other groups. transfusion, acute renal failure, need to ICU care and liver
(P<0.031 and P<0.004 respectively). hematoma displayed significantly greater in the women
Table 2 described the comparison of maternal and with the HELLP syndrome versus PHS and Pre-eclampsia.
neonatal outcomes in the pregnant women with severe Some queries are inconsistence with our findings.
pre-eclampsia, PHS and HELLP syndrome. Maternal and Gul et al reported perinatal mortality and neonatal
neonatal outcomes in the pregnant women with severe morbidity-mortality is nonsinificant in HELLP syndrome
pre-eclampsia versus PHS are not shown the statistical with severe preeclampsia-eclampsia without HELLP.
significant differences in any variables. Gul interpreted it is according to gestational age before
Also, the comparison of maternal and neonatal and after the 32nd week [11]. Whereas, the mean of
outcomes of the PHS syndrome with HELLP syndrome in gestational age in our patients was 35.72±3.15 wk and also
the pregnant women were shown that the indication for regarding the enhancement of the gestational
caesarean section, blood transfusion, maternal death, consequences which synchronizes by growing pregnancy
ARF, need to Intensive care unit (ICU) and liver in these patients, hence, we contemplate diversity of Gul
hematoma were significantly higher in the pregnancies et al findings with us seems rationale.
with HELLP syndrome versus PHS (p<0.05). (Table 2). The maternal and neonatal morbidities enhanced
Additionally, significant differences were displayed among our patients with the HELLP syndrome.
in the cesarean section, blood transfusion, ARF, maternal Khumsat et al divided the patients in two groups: sever
death, liver hematoma, pulmonary edema and need to ICU preclamcia and HELLP syndrome. Preterm delivery and
care among the three groups. eclamcia showed nonsignificant differences between
It is interesting in our research that 80(89%) of the two groups [9]. However, in Keiser' experience,
infants of preclamcia women and 176(86.7) of PHS were eclampsia does not seem to apply a significant adverse
male which demonstrated a significantly difference versus influence upon the outcome of HELLP syndrome
HELLP women. pregnancies [12].
World Appl. Sci. J., 26 (11): 1459-1463, 2013
1462
We found no significant difference between patients Evaluation of the women complicated with HELLP
age in the pregnant women with sever re-eclampsia, PHS syndrome in the multi prenatal centers of a region is
and HELLP syndrome similar to some studies [7, 8]. suggested for investigate the interference environmental
However, Khumsat and his colleagues resulted women elements.
with HELLP syndrome were significantly older.
Nevertheless, multiparty and lower gestational age were CONCLUSION
significant in the HELLP women in his study and us [9].
Our finding is also according to Vigil et al. and Habi et al. We found maternal and neonatal morbidities
which reported gestational age can be considered a enhanced among the women complicated with HELLP
predictor for long-term consequences at the beginning of syndrome. So, immediate diagnosis and proper
HELLP [13]. management could be attempted to improve maternal and
Also in our research, the preterm labor in pregnant prenatal outcomes.
women with pre-eclampsia, PHS and HELLP syndrome
demonstrated significant difference, although it showed Conflict of Interest: The vice chancellor of Research and
no significant difference within the groups, while Technology of Babol University of Medical Science
Guzel et al. concluded fetal prematurity and low birth assisted us financially.
weight were significantly associated with fetal mortality in
the HELLP syndrome, so he recommended the prevention ACKNOWLEDGEMENT
of prematurity as a prime priority for the fetus in
pregnancies involved with the HELLP syndrome [14]. We hereby thanks to all staffs of labor and delivery
We guess our difference with Guzel is in the small size of rooms of Yahyanejad Hospital for their cordially
sever preclamcia women in his study. contribution.
Analysis of our data demonstrated that the rate of
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