Prolongation of pregnancy in patients suffering from HELLP syndrome

Purpose: In contrast to routine recommendations initial studies have now demonstrated that pregnancy prolongation in patients with HELLP syndrome may offer certain advantages. Since fetal prognosis depends on the gestational time of delivery, the question of a conservative management in patients with HELLP syndrome is of great importance. The aim of the study was to investigate the effect of pregnancy prolongation on the maternal and fetal course of HELLP syndrome. Study design: Thirty-eight consecutive patients with HELLP syndrome were prospectively studied during prolongation of pregnancy and were compared with a control group comprising twenty patients with HELLP syndrome in whom pregnancy was terminated by delivery within 12 hours after admission. Inclusion criteria for the diagnosis HELLP syndrome were the simultaneous occurrence of a platelet count less than 100.00/mu l, serum aspartate aminotransferase (AST) above 40 U/I, and a significant haemolysis as reflected by haptoglobin levels below 50 mg/dl. Exclusion criteria of prolongation were acute fetal distress symptoms, disseminated intravascular coagulation or imminent eclampsia. The aim of the study was to prolong pregnancies less than 32(nd) week of gestation and to stabilize HELLP syndrome associated symptoms in women beyound the 32(nd) week of gestation before their pregnancies were terminated. All patients belonging to the study group received a daily dosage of 40 mg i.v. methylprednisolone. The controls did not receive any steroids. The patients of both groups were treated, if necessary, with dihydralazine and/or magnesium sulfate. Results: Pregnancies of patients of the study group were prolonged over a median period of 6.5 days. Patients of pregnancies below the 32(nd) week of gestation were prolonged over a median period of 12.0 days. In case of imminent fetal asphyxia and/or imminent eclampsia pregnancies were terminated at admission in five patients. Likewise, in prolonged pregnancies these were terminated due to severe maternal preeclamptic symptoms in three cases. Both, prolongation of pregnancy versus immediate delivery in the controls led to a comparable improvement of biochemical parameters of HELLP syndrome. In the study group the maternal platelet count increased from 69 800 +/- 23 000/mu l (vs. controls: 61 900 rt 32 900/mu l) to 231 900/mu l. AST decreased from 129 +/- 143 U/l (vs. 130 +/- 114 U/I) to 14+/- 4.6 U/I. LDH decreased from 548 +/- 353 U/I (vs. 665.8 +/- 201.5 U/L) to 263 +/- 94 U/I. Haptoglobin increased from 17.0 +/- 12.1 mg/dl (vs. 12.5 +/- 8.6) to 91.5 +/- 12.5 mg/dl (n.s. vs. controls). Conclusion: The results demonstrat that conservative management of HELLP syndrome can normalise clinical and biochemical pathology and can also contribute to a reduction of maternal and fetal risk. Particularly fetuses of low gestational age may benefit, due to additional maturation, from the prolongation of pregnancies. The mechanisms of the clinical improvement during prolongation are still not clear. Additional extensive studies should evaluate corresponding risks of this management and should define inclusion criteria for prolongation. Furthermore the effect of different existing therapeutic regimes (steroid vs, non-steroid therapy) on the course of pregnancies complicated by HELLP syndrome should be investigated.