Renal capsular vein thrombosis.

A 30-year-old pregnant woman developed postpartum HELLP syndrome. Abdominal computed tomography revealed a high-density vessel structure in contact with the right kidney and connected to the right ovarian vein, suggesting thrombosis in the right inferior renal capsular vein (RCV). RCV thrombosis is a rare thrombotic disorder in postpartum women, and hypercoagulability related to the pregnancy complications may be the predisposing factor. The potential risk for pulmonary embolism in the rare pregnancy-related thrombosis should be recognized.

Síndrome de encefalopatía posterior reversible en preeclampsia grave / Posterior reversible encephalopathy syndrome in severe preeclampsia

El síndrome de encefalopatía reversible posterior (PRES), es una entidad clínico radiológica caracterizada por déficit neurológico, convulsiones, pudiendo llegar a un estado de coma. Requiere diagnóstico por imagen para evidencia de edema vasogénico proceso fisiopatológico reversible, apoyados por tomografía computarizada o resonancia magnética, esta última con mayor sensibilidad para diferenciarla del edema citotóxico que es irreversible. Fisiopatológicamente está asociada a mala autorregulación cerebral secundaria varios factores, en este caso, preeclampsia grave, donde destaca el compromiso clínico e imagenológico del tronco encefálico. La instauración de un tratamiento adecuado y oportuno permite visualizar la regresión de las lesiones, que de no ser así terminaran infartándose.

The posterior reversible encephalopathy syndrome (PRES) is a clinical radiological entity characterized by neurological deficit, seizures, and may reach a coma. It requires diagnostic imaging for evidence of vasogenic edema reversible pathophysiological process, supported by computerized tomography or magnetic resonance, the latter with greater sensitivity to differentiate it from cytotoxic edema that is irreversible. Pathophysiologically, several factors are associated with poor cerebral self-regulation, in this case, severe preeclampsia, which highlights the clinical and imaging involvement of the brainstem. The establishment of an appropriate and timely treatment allows visualizing the regression of the lesions, which otherwise would end up infracting.

Liver Injury in Hemolysis, Elevated Liver Enzymes, and Low Platelets Syndrome Measured by Diffusion-Weighted Magnetic Resonance Imaging.

OBJECTIVE: The objective of this study was to evaluate acute liver injury (ALI) detected by diffusion-weighted magnetic resonance imaging (MRI) and the associated laboratory findings in women with hemolysis, elevated liver enzymes, and low platelet (HELLP) syndrome. STUDY DESIGN: This was a retrospective, observational study of women with HELLP syndrome defined by serum aspartate aminotransferase (AST) levels ≥100 U/L and thrombocytopenia with platelets ≤100,000/µL. All women underwent MRI postpartum including diffusion-weighted imaging to estimate the volume of ALI with reconstructed apparent diffusion coefficient (ADC) maps. The ADC map and the volume of ALI were compared with laboratory abnormalities by Spearman's correlation analysis. RESULTS: From March 2013 through August 2015, 16 women with HELLP syndrome underwent MRI, and of these, 14 (88%) women had areas of increased signal intensity suggestive of ALI. Their median (range) maximum AST level was 262 (140-1,958) IU/L, and at the time of MRI, AST was 103 (36-1,426) IU/L. Both of these AST levels significantly correlated with ADC map as well as the volume of ALI (both p-values <0.001). CONCLUSION: Women with HELLP syndrome frequently exhibited areas of abnormal diffusion in the liver on diffusion-weighted MRI, suggestive of ALI. The extent of liver injury was significantly correlated with serum AST.

Evaluation of maternal liver elasticity by acoustic radiation force impulse elastosonography in hypertensive disorders of pregnancy: a preliminary descriptive study.

PURPOSE: To compare maternal liver elasticity scores by Acoustic Radiation Force Impulse (ARFI) elastosonography in healthy and preeclamptic pregnancies and its association with the severity of the disease. MATERIALS AND METHODS: Forty-two healthy, 33 mild, 33 severe preeclamptic and 28 pregnant women with Hemolysis, Elevated Liver enzymes and Low Platelets (HELLP) syndrome were included into the study. Maternal liver elasticity was measured by ARFI elastosonography at the first day of puerperium. The maternal and neonatal outcomes of the patients were retrieved from the medical records. RESULTS: The ARFI-Mean liver elastosonography scores of controls and mild preeclamptic women were lower than severe preeclamptic and HELLP syndrome women (p: 0.001). The mean ARFI elastosonography score >1.22 m/s indicated the effect of severe preeclampsia on maternal liver elasticity with 72.7% sensitivity and 74.7% specificity (Area under curve [AUC], 0.835, 95% confidence interval [CI], 0.757-0.913). The mean ARFI elastosonography score >1.31 m/s indicated the effect of HELLP syndrome on maternal liver elasticity with 78.6% sensitivity and 75.9% specificity (AUC, 0.794, 95% CI, 0.695-0.892). CONCLUSIONS: The maternal liver becomes stiffer in severe preeclampsia and HELLP syndrome measured by ARFI elastosonography. The increased maternal liver ARFI scores may alert the obstetrician about the possible maternal puerperal morbidity.

A HELLP syndrome complicates a gestational trophoblastic neoplasia in a perimenopausal woman: a case report.

BACKGROUND: HELLP syndrome is a combination of symptoms described as hemolysis, elevated liver enzymes and low platelets, that complicates 0.01-0.6 % of pregnancies. HELLP syndrome has been scarcely reported associated with partial moles, another rare complication of pregnancy. This manuscript describes the only reported case of HELLP syndrome associated with a complete invasive hydatiform mole. CASE PRESENTATION: We report a perimenopausal patient in prolonged remission from an uncommon high-risk invasive complete mole. The diagnosis was set in a context of early onset preeclampsia and HELLP syndrome. The development of life-threatening complications required primary hysterectomy. Postoperative hCG quickly returned to normal with EMA/CO multi-agent chemotherapy. CONCLUSION: Our patient is in prolonged remission from a complete mole complicated with EOP and HELLP syndrome. This exceptional case of complicated gestational trophoblastic neoplasia reflects a very rare condition in which several risk factors for placental ischemia are associated. Emergency hysterectomy should be considered as salvage initial treatment in such life-threatening situations.

Doppler hepático na pré-eclâmpsia e na síndrome HELLP / Doppler ultrasonography of the liver in pre-eclampsia and HELLP syndrome

O fígado está entre os múltiplos órgãos que podem ser afetados na pré-eclâmpsia, e a função hepática pode ser gravemente prejudicada na síndrome HELLP. A ultrassonografia com Doppler constitui um método não invasivo que pode ser usado para o estudo da circulação hepática durante a gravidez. Com o objetivo de apresentar as evidências científicas disponíveis sobre as alterações do fluxo hepático na gravidez, foi realizada pesquisa da literatura mundial por meio das bases de dados MEDLINE/PubMed e LILACS. Em estudos de Dopplerfluxometria e Dopplervelocimetria, isoladamente ou associados ao eletrocardiograma e cardiografia por impedância, foram observadas alterações na circulação hepática durante a gravidez complicada por pré?eclâmpsia e síndrome HELLP. Entre os desafios para a pesquisa nesse campo destacamos a necessidade de aperfeiçoamento da técnica de exame, o estabelecimento de curvas de normalidade para as gestantes brasileiras, de indicadores de agravamento da pré?eclâmpsia e a aplicação potencial do método para o estudo da hipertensão crônica na gravidez.(AU)

The liver is among multiple organs that may be affected in pre-eclampsia, and liver function can be impaired in HELLP syndrome. Doppler ultrasonography of the liver provides a noninvasive method to study liver circulation during pregnancy. This paper reviews scientific evidence available in MEDLINE/ Pubmed and LILACS databases. Doppler studies on hepatic blood flow, flow velocities and vascular resistance indices, isolated or combined with Doppler?electrocardiography and impedance cardiography, observed changes in pregnancies complicated by pre?eclampsia and HELLP syndrome. Challenges to this research topic include improvements in Doppler examination techniques, establishment of normal values for Brazilian pregnant women, predictors for severe pre?eclampsia and potential use of hepatic Doppler use in chronic hypertension as well.(AU)

Maternal and fetal parameters including umbilical artery PI and fibrinogen/CRP ratio as predictive factors of perinatal outcome in women with HELLP syndrome.

INTRODUCTION: HELLP syndrome appears in approximately 0.2-1% of all pregnancies and is associated with in- creased maternal and fetal mortality and morbidity. It is diagnosed in cases when all three of the following criteria are present: (1) microangiopathic hemolytic anemia with abnormal blood smear low serum haptoglobin and elevated LDH levels; (2) elevated ASPATand ALAT (levels of both enzymes more than twice the upper limit of normal values), or bilirubin more than 1.2 mg/dl; 3) platelet count below 150x1009 L(-1). The etiopathogenesis of HELLP syndrome is associated with abnormal placentation in the first trimester production of cellular active substances, and pathological response of the maternal organism. Objectives: The aim of the study was to establish maternal and fetal characteristics and perinatal outcome in HELLP syndrome. The examination protocol included comparison of maternal blood parameters, umbilical artery pulsatility index (UmbA PI) in relation to short-term neonatal outcomes. MATERIAL AND METHODS: Retrospective data analysis of patients hospitalized at the Perinatology and Gynecology Department, Polish Mother's Memorial Hospital Research Institute between 2009-2013, due to HELLP syndrome was conducted. RESULTS: None of the investigated maternal or fetal parameters correlated with the neonatal outcome. CONCLUSIONS: Our study demonstrated that maternal parameters do not influence the perinatal outcome in women with HELLP syndrome. Moreover UmbA PI and fibrinogen/CRP ratio do not correspond to neonatal parameters, either Thus, none of the examined features can be used as a prognostic factor of the neonatal outcome. Further studies with large sample size are necessary but the rarity of this complication limits the possibility of research.

Predictive value of umbilical artery Doppler for adverse perinatal outcome in patients with HELLP syndrome.

OBJECTIVE: In this study, we aimed to evaluate in a prospective design the importance of pathologic umbilical artery (UA) Doppler findings as a predictive marker for neonatal outcome in patients with HELLP syndrome. PATIENTS AND METHODS: A total of 45 pregnant women at 24-42 weeks of gestation with a diagnosis of HELLP syndrome were included. The study group consisted of 20 patients with abnormal UA Doppler results, and the remaining 25 HELLP syndrome patients with normal UA Doppler results were assigned to the control group. All patients were followed up until delivery, and the neonatal characteristics were compared. RESULTS: Baseline characteristics of the groups were similar. In the study group, gestational week at delivery and infant birth weight were significantly lower (p < 0.05). The rates of significant neonatal morbidity, neonatal mortality, and neonatal intensive care unit (NICU) admission were significantly higher in study group patients (p < 0.05). CONCLUSIONS: UA Doppler abnormalities can be considered predictive of poor neonatal prognosis in patients with HELLP syndrome, as they were significantly related with higher rates of neonatal mortality and significant morbidity.

[Role of whole-body ultrasound in severe pre-eclampsia and post-partum hemorrhage]. / Pré-éclampsie sévère et hémorragie post-partum: apport de l'échographie « corps entier ¼

PURPOSE: Management of severe pre-eclamptic patients is a challenge for the staff on obstetrical wards. We demonstrate that ultrasound applied to several organs performed at a patient's bedside gave the information required for the patient's management, without the need to transfer her to the radiology department or to call external consultants. CLINICAL FEATURES: A 29-yr-old severely pre-eclamptic patient with HELLP syndrome (hemolysis, cytolysis, thrombopenia) presented, in the post-partum period, with an occult uterine hemorrhage diagnosed with bedside abdominal/pelvic ultrasound. Ultrasound was also used to insert a central venous catheter. After undergoing a hysterectomy to control hemorrhage and receiving activated factor VII, the patient recovered uneventfully. Hemodynamic management was optimized non-invasively using pulmonary and cardiac ultrasound, when the patient developed hemorrhagic shock followed by pulmonary edema. Volume replacement was guided by cardiac ultrasound findings, and we were able to detect incipient interstitial pulmonary edema and follow its course using pulmonary ultrasound. CONCLUSION: Practitioners must be aware of the role of whole-body ultrasound in the diagnosis and treatment of complex, multi-organ conditions such as pre-eclampsia. Moreover, ultrasound helps in the management of global hemodynamics. The training of anesthesiologists in a variety of ultrasound techniques should be encouraged.

Decreased hepatic perfusion in patients with HELLP syndrome.

A total of 20 women with HELLP syndrome (haemolysis, elevated liver enzymes and low platelets), and 20 gestational age-matched healthy controls participated in this study which was conducted at Assiut University Maternity Hospital, Egypt. Dual hepatic perfusion was assessed by evaluation of hepatic artery blood flow and portal vein blood flow. The total liver blood flow was taken as the sum of flow volumes in the common hepatic artery and portal vein as assessed by Doppler ultrasound. The total liver blood flow decreased significantly in women with HELLP syndrome, compared with controls.

Partial mole with fetal triploidy as a cause for imminent HELLP-syndrome at 16 weeks of gestation.

A woman at 16 weeks of gestation was admitted to our perinatal center with unspecific abdominal pain. The results from blood samples 12 h after admission revealed a fulminant HELLP-syndrome. After starting i.v. corticosteroid therapy, the woman recovered quickly. CVS was performed because of abnormal findings by ultrasound and a fetal triploidy (69, XXX) was diagnosed. Pregnancy was terminated and histopathological examination of the placental tissue confirmed a partial mole.

Hyperreactio luteinalis could be a risk factor for development of HELLP syndrome: case report.

OBJECTIVE: To report a unique case of hyperreactio luteinalis in pregnancy associated with ovarian torsion and subsequent development of hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. DESIGN: Case report. SETTING: University medical center. PATIENT(S): A 34-year-old primigravida woman with ovarian torsion in 13 weeks of pregnancy and subsequent intrauterine growth restriction (IUGR) and HELLP syndrome. INTERVENTION(S): Laparoscopic salpingo-oophorectomy due to the ovarian torsion and cesarean section (CS) due to the development of HELLP syndrome. MAIN OUTCOME MEASURE(S): HELLP syndrome. RESULT(S): In the first trimester the patient had symptoms of acute abdomen due to the ovarian torsion. Both ovaries were enlarged and multicystic. Hormonal studies confirmed an abnormally elevated level of hCG (192.000 IU/L), mild hyperthireosis, and hyperandrogenemia. Laparoscopic salpingo-oophorectomy was performed. At 30 weeks of pregnancy, IUGR was confirmed sonographically and clinically, and at 33 weeks severe preeclampsia developed. One week later, HELLP syndrome occurred. Emergency CS was preformed, and she delivered a female newborn weighing 1,640 g. Seven days after delivery, blood pressure and hormonal status returned to normal. CONCLUSION(S): Hyperreactio luteinalis due to the abnormally high level of hCG in the first trimester could be a consequence of inappropriate trophoblast invasion and an early sign of subsequently developing preeclampsia, eclampsia, and HELLP syndrome.

CT of pregnancy-related complications.

During pregnancy, the risk of radiation exposure to the fetus is increased so that more than the usual benefit is necessary to justify computed tomography (CT; or other radiation exposure) than in non-pregnant patients. In the setting of a life-threatening illness, CT may be indicated to assess for potentially fatal complications such as hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. After delivery, patients rarely develop serious problems requiring radiologic evaluation. When indicated, however, CT may be invaluable in making the diagnosis or determining the severity of peri- and post-partum complications, including uterine perforation, hemorrhage, endometritis, thrombophlebitis, and abscess formation. At times, CT may be the first to uncover conditions, such as post-partum cardiomyopathy, and heart failure, which are usually diagnosed by other modalities but may explain the symptoms for which the study was ordered. In some centers, CT pulmonary angiography represents the standard of care to diagnose pulmonary thromboembolism. In this article, we illustrate the spectrum of peri-partum and post-partum complications on CT to familiarize the radiologist with the CT features of these potentially life-threatening pregnancy-related complications.

Prediction of HELLP syndrome with assessment of maternal dual hepatic blood supply by using Doppler ultrasound.

OBJECTIVE: Early structural and functional changes in the systemic vasculature have been proposed to play a major pathogenetic role in HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome. Our objective was to assess whether the evaluation of maternal hepatic blood supply is instructive to the prediction of onset of HELLP syndrome. DESIGN: Prospective observation study. POPULATION: Fifty-eight women with severe preeclampsia and 60 healthy pregnant controls at 25-36 weeks gestation. METHODS: Angle-corrected time-averaged flow velocity and the cross-sectional area of common hepatic artery and portal vein were measured by using Doppler ultrasonography in 58 women with severe preeclampsia and in 60 healthy pregnant controls at 25-36 weeks gestation. Intravascular flow volumes were calculated from the product of the time-averaged velocity and the cross-sectional area. The total liver blood flow was taken as the sum of flow volumes in the hepatic artery and portal vein. RESULTS: The total liver blood flow decreased significantly to about 40% of control in 9 women with severe preeclampsia who developed HELLP syndrome within 4 days after the examination, but not in 49 women with severe preeclampsia without HELLP syndrome. CONCLUSION: The results indicated that the decrease in dual hepatic blood supply preceded the onset of HELLP syndrome.