This document provides information about HELLP syndrome, including:
1. HELLP syndrome is characterized by hemolysis, elevated liver enzymes, and low platelet count. It occurs in 0.2-0.6% of pregnancies and is caused by abnormal vascular tone and coagulation defects.
2. Clinical presentation is often unclear but includes right upper quadrant pain, nausea, and headache. Diagnosis is based on low platelets (<100,000/μl), elevated liver enzymes, and signs of hemolysis on blood smear.
3. Complications include eclampsia, abruption, renal failure, and liver hematoma rupture. Management involves delivery after 34 weeks if possible, with
A comprehensive overview of hypertensive disorders in pregnancy with its complications and management. Mainly focused on gestational hypertension, preeclampsia and eclampsia.
The increased cardiac output related to pregnancy can lead to heart failure, and the increased heart rate in the third trimester can lead to ischemic events. The potential obstetrical complications include preeclampsia or other hypertensive related disorders, premature birth, and small-for-gestational-age births.
Fetal growth restriction (FGR), formerly called intrauterine growth restriction (IUGR), refers to a condition in which an unborn baby is smaller than it should be because it is not growing at a normal rate inside the womb.
Mild FGR usually doesn't cause long-term problems. In fact, most babies who have it catch up in height and weight by age 2. But severe FGR can seriously harm a baby before and after birth. The extent of the problems depends on the cause and how severe the growth restriction is. It also depends on what point in the pregnancy it starts.
A comprehensive overview of hypertensive disorders in pregnancy with its complications and management. Mainly focused on gestational hypertension, preeclampsia and eclampsia.
The increased cardiac output related to pregnancy can lead to heart failure, and the increased heart rate in the third trimester can lead to ischemic events. The potential obstetrical complications include preeclampsia or other hypertensive related disorders, premature birth, and small-for-gestational-age births.
Fetal growth restriction (FGR), formerly called intrauterine growth restriction (IUGR), refers to a condition in which an unborn baby is smaller than it should be because it is not growing at a normal rate inside the womb.
Mild FGR usually doesn't cause long-term problems. In fact, most babies who have it catch up in height and weight by age 2. But severe FGR can seriously harm a baby before and after birth. The extent of the problems depends on the cause and how severe the growth restriction is. It also depends on what point in the pregnancy it starts.
Pregnancy induced hypertension introduction
Classification of pregnancy induced hypertension
Preeclampsia -
Definition
Criteria for diagnosis of preeclampsia,
Epidemiology of preeclampsia,
Risk factors of preeclampsia,
Pathogenesis of preeclampsia,
Pathophysiology of preeclampsia,
Course of preeclampsia,
Complications of preeclampsia,
What is HELLP ?
Management of preeclampsia at home, at hospital, during labour, during puerperium,
Management of acute fulminant preeclampsia
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Medical Technology Tackles New Health Care Demand - Research Report - March 2...pchutichetpong
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CHAPTER 1 SEMESTER V - ROLE OF PEADIATRIC NURSE.pdfSachin Sharma
Pediatric nurses play a vital role in the health and well-being of children. Their responsibilities are wide-ranging, and their objectives can be categorized into several key areas:
1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
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Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
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Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
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Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
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Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
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Communicating effectively with healthcare teams.
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Educating families about their child's condition and treatment options.
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Objective: Contribute to improving the quality of care for children by participating in research initiatives.
This includes tasks like:
Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
By fulfilling these objectives, pediatric nurses play a crucial role in ensuring the optimal health and well-being of children throughout all stages of their development.
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Dr Natasha Azzopardi Muscat, Director, Country Health Policies and Systems Division, World Health Organisation EURO
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2. HELLP Syndrome is characterized by
Hepatic endothelial disruption followed by platelet
activation, aggregation and consumption,
ultimately resulting in ischemia and hepatocyte
death
3. In 1982 -- Weinstein coined the acronym HELLP
to describe a syndrome consisting of
Hemolysis
Elevated Liver Enzymes and
Low Platelet Count.
4. INCIDENCE
• HELLP Syndrome occurs in 0.2 to 0.6% of all pregnancies
• Incidence of HELLP in women with pre eclampsia is
20 %
70% cases are diagnosed in antenatal period
30% after delivery.
5. PATHOGENESIS
It is attributed to-
› Abnormal vascular tone
› Vasospasm
› Coagulation defects
This vasculopathy is either limited to a hepatic segment or
diffuse throughout liver
6. Classical Histological Lesion In Liver
Periportal or focal parenchymal necrosis occurs in which hyaline
deposits of fibrin like material are present
↓
Obstruction of hepatic blood flow
↓
Periportal necrosis
Intra hepatic hemorrhage
Subcapsular hematoma
Eventual rupture of Glisson’s capsule
9. • Destruction of RBCs by haemolysis results in↑serum lactate
dehydrogenase (LDH) levels and ↓ haemoglobin concentrations
• In about 10% of women - Haemoglobinaemia or
haemoglobinuria is macroscopically recognizable
• Liberated haemoglobin is converted to unconjugated bilirubin
in the spleen or may be bound in the plasma by haptoglobin
• The haemoglobin-haptoglobin complex is cleared quickly by the
liver, leading to low or undetectable haptoglobin levels in the
blood
10. But
The demonstration of low or undetectable haptoglobin
concentration is a more specific indicator.
The diagnosis of haemolysis is supported by -
- high LDH concentration and
- presence of unconjugated bilirubin
11. THROMBOCYTOPENIA
Platelets < 150/L in pregnancy may be caused by-
› Gestational thrombocytopenia (GT)
› Immune thrombocytopenic purpura (ITP)
› Preeclampsia
› HELLP syndrome
12. THROMBOCYTOPENIA
• ↓Platelet count in HELLP syndrome is due to their
↑consumption
• Platelets are activated, and adhere to damaged vascular
endothelial cells, resulting in ↑ platelet turnover with shorter
lifespan
Patient with well developed HELLP syndrome may develop
DIC
13. IMMUNE SYSTEM DISORDER THEORY
• In patient with HELLP Syndrome -- Abnormal T & B
lymphocyte function has been observed
• There is an increased neutrophil- endothelial adhesiveness
in pre- eclamptic patients → explains diffuse vascular
implications of disease process
17. CLASSIFICATION
TENNESSEE CLASSIFICATION
Based on laboratory criteria
1. Platelet count < 100,000/µL
2. AST ≥ 70 IU/L & LDH ≥ 600 IU/L
3. Hemolysis on peripheral smear
Partial HELLP Full HELLP
Any 2 of 3 criteria All of 3 criteria
18. CLASSIFICATION
MISSISIPI CLASSIFICATION
CLASS I
› Platelet ≤ 50,000/µL(severe
thrombocytopenia)
› AST ≥ 70 IU/L› LDH ≥ 600 IU/L
› Hemolysis on smear
CLASS II
› Platelet 50,000/µL to
100,000/µL (moderate
thrombocytopenia)
› AST ≥ 70 IU/L› LDH ≥ 600 IU/L
› Hemolysis on smear
CLASS III
› Platelet 100,000/µL to150,000/µL
(mild thrombocytopenia)
› AST ≥ 40 IU/L › LDH ≥ 600 IU/L
› Hemolysis on smear
19. DIAGNOSIS
CLINICAL FEATURES
•Higher degree of suspicion is needed as clinical
presentation in most cases is unclear & may be missed
•About 10% of cases present before 27 weeks
46% cases before 37 weeks and
14% present at term
•With postpartum presentation, the onset is typically
within first 48 hrs of delivery.
20. DIAGNOSIS
Symptoms
•Right sided upper abdominal
pain or pain around stomach
•Nausea
•Headache
•Malaise
Signs
•Right upper quadrant
tenderness
•Increased blood pressure
•Proteinuria
•Edema
Any PW presenting in OPD with malaise or viral like illness in
2nd or 3rd trimester should be evaluated with CBC and Liver
function tests
26. • Patient should be admitted in tertiary care center with a
multidisciplinary team for careful maternal and fetal supervision
• At 34 weeks - Immediate delivery should be conducted.
• At 30-34 weeks – Stabilization of clinical condition,steroid
administration, delivery after 48 hrs can be planned.
• Pregnancy below 30 weeks ---- should be prolonged under strict
observation, if clinical situation permits .
MANAGEMENT
27. Mode of Delivery
• Vaginal route is preferred.
• LSCS is done for obstetric reasons.
• Management during Caesarean Section :
• General anaesthesia for platelet count < 75,000 /mm3
• Transfuse 6 units platelet if count is below 40,000 /mm3
• Insert subfascial drain
• Secondary skin closure may be done after 48 hours to prevent
any haematoma formation or subcutaneous drain is given.
• Observe for bleeding from upper abdomen before closure.
29. Antenatal steroid has been used to
MANAGEMENT
• Speed up foetal lung maturity
• Reduce the risk of IVH , NEC, Retolental fibroplasia.
•Betamethasone --12mg , two doses ,24 hrs apart.
•Dexamethasone ---6mg , four doses , 6hrs apart
30. Steroid Treatment
Benefit of steroid treatment for HELLP syndrome was first reported in
1984
Mech. of Action- Unknown
Proposed mech. - Diminishes oedema, inhibits endothelial
activation and reduces endothelial dysfunction
↓
Prevention of thrombotic microangiopathic anaemia, Inhibition
of cytokine production
↓
Induces anti-inflammatory effects in HELLP syndrome
MANAGEMENT
31. MANAGEMENT
Available evidence does not support high and repeated dose of
corticosteroid treatment
Can improve the outcome of pregnancy affected by HELLP
syndrome
For selected high risk cases with profound thrombocytopenia
with CNS dysfunction
- 20mg IV dexamethasone every 6hrs up to 4 doses is
given.
32. MANAGEMENT
Steroid is not curative but may create a WINDOW
OF OPPORTUNITY for intervention before
maternal condition may again deteriorate
33. MANAGEMENT
• If platelet count <40,000/µL, 6 – 10 U of platelet
transfusion is required.
• Platelet transfusion is required if there is bleeding from
wound or intra peritoneal bleeding.
• PRBC and FFP is required if coagulopathy is present.
35. Management of post partum HELLP Syndrome
• About 30% of HELLP syndromes develop after birth
• The time of onset ranges from few hrs to 7 days but the
majority within the first 48 hours after delivery
• In post-partum HELLP syndrome, risk of renal failure and
pulmonary oedema is ↑ hence intensive monitoring of the
mother is required.
In most women, the maternal platelet count starts decreasing
immediately post-partum with an increasing trend on the third
day
36. Management of post partum HELLP Syndrome
• Women with HELLP syndrome who show progressive ↑
of bilirubin or creatinine for > 72 hours after delivery
may benefit from plasma exchange with fresh frozen
plasma
• In case of continuing haemolysis, persistent
thrombocytopenia and hypoproteinaemia -- PRBC,
Platelets as well as Albumin supplementation is
required
37. Management of post partum HELLP Syndrome
Recurrence rate - 20% in subsequent pregnancies.
Women with a history of HELLP syndrome at or before 28
weeks gestation during the index pregnancy are at ↑ risk for
several obstetric complications like:
- Preterm birth
- Pregnancy- induced hypertension
- Increased neonatal mortality in a subsequent pregnancy.
38. Suspected Liver Hematoma Rupture
• Rare but potentially life threatening
condition
• May occur antepartum, intrapartum, or
in the postpartum period
• Severe epigastric or retrosternal (pain on
inspiration), with or without
shoulder/neck pain.
39. • Rupture Occurs 1 in 40,000 to 1 in 250,000 deliveries and about
1% to < 2% of the cases with HELLP syndrome
• Should be suspected when profound hypovolemic shock occurs in
a previously hypertensive patient
• Diagnosis can be made by ultrasound or CT of the liver which can
diagnose intraperitoneal bleeding.
• In most cases, rupture involves the right lobe of the liver and is
preceded by a parenchymal liver hematoma.
Suspected Liver Hematoma Rupture
40. • Maternal and fetal mortality increases substantially when a
subcapsular liver hematoma is present.
• Mortality may exceed 50% when frank rupture of the capsule
involves liver tissue.
• Management depends on maternal hemodynamic status,
integrity of the capsule (ruptured or intact), and the fetal
condition.
Liver Hematoma Rupture
41. Conservative management should be done in hemodynamically stable
women with an unruptured hematoma.
Liver Hematoma Rupture
– Close monitoring of the patient’s hemodynamic and
coagulation status
-- Serial assessment of the hematoma with ultrasound or
CT scan
• Exogenous trauma to the liver should be avoided, such as frequent
abdominal palpation, emesis, or convulsions.
• Any sudden increase in intra-abdominal pressure can lead to rupture
of hematoma
42. When rupture occurs
Liver Hematoma Rupture
-- It is a surgical emergency
-- Maternal resuscitation with fluids and PRBC to
maintain blood pressure and tissue perfusion should
be done.
-- Correction of coagulopathy with fresh frozen
plasma and platelets is required.
43. – Packing and drainage (preferred)
– Ligation of the hepatic lacerations
– Embolization of the hepatic artery to the affected liver
segment, and loosely suturing omentum or surgical
mesh to the liver surface
– Recombinant factor VII A
Liver Hematoma Rupture
Options at laparotomy include : –
44. PROGNOSIS OF HELLP SYNDROME
• Maternal mortality -- 0 to 15%.
• Maternal morbidity - Acute renal failure, Hepatic infarct,
Hepatic hematoma, Hepatic rupture,
• Disseminated intravascular coagulation, Post-partum
hemorrhage
• Pulmonary edema may occur
• There are usually no long term maternal complications.
45. CONCLUSION
• Precise diagnosis
• Early and aggressive treatment may help in
achieving favorable maternal and perinatal
outcomes.