Fatma İrem YEŞİLER, Behiye Deniz KOSOVALI, Tülay TUNÇER PEKER, Menekşe ÖZÇELİK, Necmettin ÜNAL, Mustafa BAYAR

YOĞUN BAKIM ÜNİTEMİZDE HELLP SENDROMU DENEYİMLERİMİZ

Amaç: HELLP sendromu, hemoliz, yükselmiş karaciğer enzimleri ve trombosit sayısında azalma ile karakterize, ağır pre¬eklampsi ve eklampsiyle ilişkili hayatı tehdit eden bir durumdur. Çalışmamızın amacı, yoğun bakım ünitesine (YBÜ) kabul edilen HELLP sendromlu hastaları retrospektif olarak değerlendirmektir. Gereç ve Yöntemler: Ocak 2011 ile Aralık 2015 arasında yoğun bakım ünitesine kabul edilen 19 HELLP sendromlu hastanın medikal kayıtlarını retrospektif inceledik. Bulgular: Yoğun bakım ünitesine kabul edilen 19 HELLP sendromlu hastanın ortalama yaşı 30.0 ± 5.1 yıl ve ortalama gebelik yaşı 32.2 ± 4.8 hafta idi. YBÜ kabuldeki ortalama Akut Fizyoloji ve Kronik Sağlık Değerlendirme Sistemi (APACHE II) skoru, Sıralı Organ Yetmezliği Değerlendirmesi (SOFA) skoru, Glasgow Koma Skalası (GCS) sırasıyla 25.9 ± 4.0, 14.2 ± 2.8 ve 5.2 ± 2.7 idi. On iki hastanın (%63,6) mekanik ventilasyon gereksinimi oldu. Sekiz hastanın (%42.1) akut böbrek hasarı varken sadece 1 hastaya renal replasman tedavisi gerekti. On bir hastaya (%57.9) terapötik plazma değişimi yapıldı. Üç hastada (%15.8) yaygın damar içi pıhtılaşma (DIC), 5 hastada (%26.3) akut solunum sıkıntısı sendromu (ARDS), 3 hastada (%15.8) septik şok ve 1 hastada (%5.3) kardiyojenik şok vardı. Ortalama YBÜ kalış süresi 8.1 ± 4.7 gündü. Hem anne hem de fetal mortalite oranı %10,5 idi. Sonuç: HELLP sendromunda, maternal/fetal morbidite ve mortalite riski yüksektir. Erken tanı, yoğun bakım ünitesinde yakın takip, multidisipliner ekip tarafından yönetim HELLP sendromunun komplikasyonlarını önleyebilir ve prognozu iyileştirebilir.

Anahtar Kelimeler:

HELLP sendromu, preeklampsi, eklampsi, gebelik, yoğun bakım ünitesi, HELLP syndrome, preeclampsia, eclampsia, pregnancy, intensive care unit

OUR EXPERIENCE ABOUT HELLP SYNDROME IN INTENSIVE CARE UNIT

Aim: HELLP syndrome is a life-threatening condition frequently associated with severe preeclampsia-eclampsia and is characterized by hemolysis, elevated liver enzymes and low plateletes. The aim of our study was to evaluate retrospectively the patients with HELLP syndrome admitted to the intensive care unit (ICU). Material and Methods: We retrospectively reviewed the medical records of 19 patients with HELLP syndrome admitted to ICU between January 2011 and December 2015. Results: The mean maternal age was 30.0 ± 5.1 years and the mean gestational age was 32.2 ± 4.8 weeks of 19 patients with HELLP syndrome admitted to the ICU. The mean Acute Physiology and Chronic Health Evaluation System (APACHE II) score, Sequential Organ Failure Assessment (SOFA) score, Glasgow Coma Scale (GCS) were 25.9 ± 4.0, 14.2 ± 2.8 and 5.2 ± 2.7 at ICU admission, respectively. Mechanical ventilation was required for 12 patients (63.6%). Eight patients (42.1%) had acute kidney injury and only 1 patient was required renal replacement therapy. Therapeutic plasma exchange was performed to 11 patients (57.9%). Three patients (15.8%) had dissemine intravascular coagulation (DIC), 5 patients (26.3%) acute respiratory distress syndrome (ARDS), 3 patients (15.8%) septic shock, and 1 patient (5.3%) cardiogenic shock. The mean length of ICU stay was 8.1 ± 4.7 days. Both of maternal and fetal mortality rate was 10.5%. Conclusion: Maternal/fetal morbidity and mortality are high in HELLP syndrome. Early diagnosis, close follow-up in intensive care unit, appropriate treatment and management by multidisciplinary team may prevent complications and improve prognosis of HELLP syndrome.

Keywords:

HELLP syndrome, preeclampsia, eclampsia, pregnancy, intensive care unit,

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REFERENCES: 1- Lam MT, Dierking E. Intensive Care Unit issues in eclampsia and HELLP syndrome. Int J Crit Illn Inj Sci 2017; 7:136-41.
2- Khalid F, Mahendraker N, Tonismae T. HELLP Syndrome. 2022 Jun 16. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–. PMID: 32809450.
3- Weinstein L. Syndrome of hemolysis, elevated liver enzymes, and low platelet count: a severe consequence of hypertension in pregnancy. Am J Obstet Gynecol. 2005; 193:859.
4- Abildgaard U, Heimdal K. Pathogenesis of the syndrome of hemolysis, elevated liver enzymes, and low platelet count (HELLP): a review. Eur J Obstet Gynecol Reprod Biol. 2013 Feb; 166(2): 117-23.
5- Ağaçayak E, Bugday R and Peker N, et al. Factors Affecting ICU Stay and Length of Stay in the ICU in Patients with HELLP Syndrome in a Tertiary Referral Hospital. International Journal of Hypertension. Vol. 2022.
6- Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury; 2012. Available from:https://www.kdigo.org/wp-content/uploads/2016/10/kdigo-2012-aki guidelineenglish.pdf
7- ARDS Definition Task Force, Ranieri VM, Rubenfeld GD, Thompson BT, Fergoson ND, Caldwell E, et al. Acute respiratory distress syndrome: The Berlin definition. JAMA 2012;307(23):2526-33. https://doi.org/10.1001/jama.2012.5669
8- Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med. 2021 Nov;47(11):1181-1247.
9- Taylor FB, Toh CH, Hoots WK, Wada H, Levi M. Towards definition, clinical and laboratory criteria, and a scoring system for disseminated intravascular coagulation. Thrombosis and Haemostasis. 2001; 86: 1327–1330.
10- Yosunkaya A, Keçecioğlu A, Erdem TB, Borazan H. Selçuk Tıp Üniv. Dergisi 2011; 27(1): 18-23.
11- Yucesoy G, Cakiroglu Y, Bodur H, Ozkan S, Tan T. An analysis of HELLP syndrome cases: does platelet count predict adverse maternal and fetal outcomes in women with HELLP syndrome? Arch Gynecol Obstet 2011; 283: 941-5.
12- Gedik E, Yücel N, Sahin T, Koca E, Colak YZ, Togal T. Hemolysis, elevated liver enzymes, and low platelet syndrome: Outcomes for patients admitted to intensive care at a tertiary referral hospital. Hypertens Pregnancy. 2017 Feb; 36(1): 21-29.
13- Fitzpatrick KE, Hinshaw K, Kurinczuk JJ, Knight M. Risk factors, management, and outcomes of hemolysis, elevated liver enzymes, and low platelets syndrome and elevated liver enzymes, low platelets syndrome. Obstet Gynecol. 2014 Mar;123(3):618-627.
14- Javier E, Fonseca M, Clandia C. Dexamethasone treatment does not improve the outcome of woman with HELLP syndrome: a double blind, placebo controlled randomized clinical trail. Am J Obstet Gynecol. 2005; 193: 1591-8.
15- Bang NO, Satia MN, Poonia S. Obstetric and neonatal outcome in pregnancies complicated by hemolysis elevated liver enzymes low platelet count syndrome at a tertiary care centre in India. Int J Reprod Contracept Obstet Gynecol 2016; 5: 2407-12.
16- Isler CM, Rinehart BK, Terrone DA, Martin RW, Magann EF, Martin JN Jr. Maternal mortality associated with HELLP syndrome. Am J Obstet Gynecol 1999; 181: 924-8.
17- Kirkpatrick CA. The HELLP syndrome. Acta Clin Belg. 2010 Mar-Apr;65(2):91-7.
18- Haram K, Svendsen E and Abildgaard U. The HELLP syndrome: Clinical issues and management. A Review. BMC Pregnancy and Childbirth 2009, 9: 8.
19- Togal T, Yucel N, Gedik E, Gulhas N, Toprak HI, Ersoy MO. Obstetric admissions to the intensive care unit in a tertiary referral hospital. J Crit Care 2010; 25: 628-633.
20- Özçelik M, Turhan S, Bermede O, Yılmaz AA, Ünal N, Bayar MK. Outcomes of Antepartum and Postpartum Obstetric Admissions to the Intensive Care Unit of A Tertiary University Hospital: An 8-Year Review. Turk J Anaesthesiol Reanim 2017; 45: 303-9.
21- Yi HY, Jeong SY, Kim SH, et al. Indications and characteristics of obstetric patients admitted to the intensive care unit: a 22-year review in a tertiary care center. Obstet Gynecol Sci. 2018 Mar;61(2):209-219.
22- Drakeley AJ, Le Roux PA, Anthony J, Penny J. Acute renal failure complicating severe pre eclampsia requiring admission to an obstetric intensive care unit. Am J Obstet Gynecol 2002; 186: 253-6.
23- Selcuk NY, Odabas AR, Centikaya R, Tonbul HZ, San A. Outcome of pregnancies with HELLP syndrome complicated by acute renal failure (1989-1999). Ren Fail 2000; 22: 319-27.
24- Sadaf N, Haq G, Shukar-ud-Din S. Maternal and foetal outcome in HELLP syndrome at tertiary care hospital. J Pak Med Assoc Vol. 63, No. 12, December 2013, 1500-03.
25- Martin JN Jr, Owens MY, Keiser SD, et al. Standardized Mississippi Protocol treatment of 190 patients with HELLP syndrome: slowing di sease progression and preventing new major maternal morbidity. Hipertens Pregnancy 2012;31(1):79–90.
26- Sibai BM. Diagnosis, controversies, and management of the syn¬drome of hemolysis, elevated liver enzymes, and low platelet count. Obstet Gynecol 2004; 103: 981-91.
27- Sibai BM, Ramadan MK, Usta I, et al. Maternal morbidity and mortality in 442 pregnancies with hemolysis, elevated liver enzymes, and low platelets (HELLP syndrome). Am J Obstet Gynecol 1993; 169: 1000.
28- Selo-Ojeme DO, Omosaiye M, Battacharjee P, Kadir RA. Risk factors for obstetric admissions to the intensive care unit in a tertiary hospital: a case-control study. Arch Gynecol Obstet 2005; 272: 207–210.
29- Erkurt MA, Sarici A, Kuku I, et al. The effect of therapeutic plasma exchange on management of HELLP Syndrome: The report of 47 patients. Transfus Apher Sci. 2021 Oct;60(5):103248.
30- Simetka O, Klat J, Gumulec J, Dolezalkova E, Salounova D, Kacerovsky M. Early identification of women with HELLP syndrome who need plasma exchange after delivery. Transfus Apher Sci. 2015 Feb;52(1):54-9.