Conservative treatment

Perinatal morbidity and mortality are high (14-20 per cent) and are related to gestational age ( Sibai...efa/ 1993; Visse£..§Dd,.Wall.§D.byig 1995). HELLP often occurs before week 32 of pregnancy (Sibai 1993), and so prolongation of gestation in such patients would be expected to reduce fetal morbidity and mortality. Conservative hemodynamic treatment was evaluated in patients with severe pre-eclampsia with (n = 128) and without (n = 128) the HELLP syndrome (ViSS®E,§D.d,Wa!!.eDbyrg

1995). Using pulmonary artery catheter monitoring, vasodilators were given in combination with plasma expanders to maintain the cardiac index between 3.5 and 4.6 l/min/m2, the pulmonary artery wedge pressure between 10 and 12 mmHg, and the diastolic arterial blood pressure below 100 mmHg. After stabilization for 1 to 3 days, the pulmonary artery catheter was removed and the therapeutic regimen continued until delivery. Termination of pregnancy within 48 h of initiation of therapy occurred in 17 per cent because of fetal distress. In the remaining cases, pregnancy could be prolonged by a mean of 15 days. Maternal mortality did not occur and postpartum morbidity was low. Similar results were observed in pre-eclamptic patients without HELLP. Interestingly, complete antepartum resolution of the HELLP syndrome was observed in 43 per cent; the platelet count rose above 100 000/mm3 before delivery in 61 per cent of cases, and liver rupture and renal failure did not occur. Thus conservative hemodynamically guided treatment may be used in selected patients in whom HELLP appears early in pregnancy and is associated with major maternal or fetal risks. The severity of the syndrome should be moderate (class 2), an initial stay in intensive care is mandatory, and the lack of any clinical or laboratory improvement should prompt expeditious delivery.

Treatment of HELLP associated with pre-eclampsia consists of hypertension control with hydralazine given in increasing dosage in combination with magnesium sulfate to reach a serum level of 2 to 3 mmol/l (Table.,?). Nifedipine or labetalol are alternative treatments for hypertension. Sodium nitroprusside may be given for severe crisis and just before delivery, but should only be given for short periods (30 min) because of the risk of fetal cyanide toxicity. Intravascular volume should be closely monitored to avoid congestive heart failure or renal failure secondary to tubular necrosis ( Sibaieta/ 1993). Platelet transfusions are not indicated because of rapid consumption; these should be limited to the delivery period and for any postpartum complication.

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Table 2 Antepartum strategy for the HELLP syndrome

Table 2 Antepartum strategy for the HELLP syndrome

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