Abstract
The syndrome of haemolysis, elevated liver enzymes and low platelets (HELLP Syndrome) is a consequence of severe preeclampsia/eclampsia. The clinical course is characterized by an unusual presentation with abdominal pain, and manifestations of inadequate haemostasis and excessive bleeding are common. Maternal and perinatal morbidity and mortality are high. We report our experience with 33 patients over a five-year period. The mean gestational age (GA) of the pregnancies was 34 ± 2.8 wk including 11 patients who delivered 12 neonates of less than 34 wk GA. The most common presenting complaints were right upper quadrant or epigastric pain in 25 patients (76%) and nausea or vomiting in 14 patients (42%). Diagnosis was missed or delayed in 12 patients (36%). Thirty-one patients (94%) were delivered by Caesarean section and a deteriorating maternal condition was the most common indication for operative delivery. Twenty-three patients received general anaesthesia, eight received epidural anaesthesia and there were no complications related to the anaesthetic. There was clinical evidence of abnormal haemostasis: seven patients had excessive blood loss at Caesarean section, two had postpartum haemorrhage, three developed DIC and four developed wound haematoma. The average decrease in haemoglobin concentration was 32 g · L−1 and twelve patients (36%) received blood transfusions. There was one stillbirth. There were no neonatal deaths but morbidity was prominent and related primarily to prematurity. Delayed or missed diagnosis is common in HELLP syndrome and a premature delivery by Caesarean section is usual. HELLP syndrome represents a relative contraindication to regional anaesthesia and epidural anaesthesia should be restricted to patients without clinical evidence of bleeding, a platelet count > 100 × 109 · L−1, and a normal bleeding time. A paediatrician should attend the delivery to provide care for the premature, often growth-retarded neonate. Following delivery the mother should be closely monitored for the development of haemorrhagic complications or eclampsia.
Résumé
La prééclampsie sévère et l’ éclampsie peuvent entraîner un syndrome incluant hémolyse, élévation des enzymes hépatiques et thrombocytopénie; c’est le «HELLP syndrome». Il se présente souvent par des douleurs abdominales accompagnées de signes de coagulopathie; la morbidité et la mortalité maternelles et néonatales sont considérables. Durant les cinq dernières années, nous avons participé an traitement de 33 victimes de ce syndrome. Elles en étaient en moyenne à 34 ± 2, 8 semaines de grossesse et 25 d’ entre elles (76%) se présentèrent avec de la douleur à l’épigastre ou à l’hypochondre droit tandis que 14 (42%) avaient des nausées et/ou des vomissements. Trente et une (94%) patientes accoucherènt par césarienne, précipitée habituellement par une détérioration de leur état. Lors de la césarienne, on fit 23 à patientes une anesthésie générale et à huit, une péridurale. Il n’ y eu aucune complication d’ ordre anesthésique mais sept patientes perdirent beaucoup de sang lors de la césarienne, deux saignerènt en postpartum, trois développèrent une CIVD et quatre, un hématome. La concentration de l’ hémoglobine dans le sang baissa en moyenne de 31 g · L−1 et douze patientes (36%) reçurent une transfusion sanguine. A part une mortinaissance, il n’ y eu pas de décès en période néonatale toutefois, la morbidité découlant surtout de la prématurité était significative. Avec. le HELLP, il est fréquent que le diagnostic soit posé tardivement et qu’ une césarienne s’ impose rapidement. Le HELLP constitue une contrindication relative à l’ anesthésie régionale et on ne devrait réserver l’ anesthésie péridurale qu’ aux cas où rien ne suggère une coagulopathie, où le décompte plaquettaire est > 100 × 109 · L−1 et où le temps de saignement est normal. Lors de l’ accouchement, un pédiatre de vrait être présent pour s’ occuper du prématuré et/ou du nouveau-né avec retard de croissance. En postopératoire, on devrait être à l’ affût de complications d’ ordre hémorragique et de l’ éclampsie.
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Crosby, E.T. Obstetrical anaesthesia for patients with the syndrome of haemolysis, elevated liver enzymes and low platelets. Can J Anaesth 38, 227–233 (1991). https://doi.org/10.1007/BF03008152
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DOI: https://doi.org/10.1007/BF03008152