Investigating the impact of different strategies for endometrial preparation in frozen cycles considering normal responders undergoing IVF/ICSI cycles: a multicenter retrospective cohort study.

Uncertainty exists concerning the type, adjunct, or dose of regimen to offer in frozen cycles in infertile women undergoing IVF/ICSI. Current systematic reviews have failed to identify one method of endometrial preparation as being more effective than another, whereas many IVF Units use variable and mixed protocols mainly based on their experience and convenience of use. Thus, we performed a four-center two-arm retrospective cohort study, encompassing 439 cycles in 311 women. The modalities analyzed were: Modified natural cycle without and with luteal support (Groups 1,2) and Hormone Replacement cycle (HRC) with and without GnRHa suppression (Groups 3,4). Various schemes of progesterone and estradiol were used and compared. χ2 tests for categorical data and t-tests for continuous data were employed, stratifying by exposure, along with univariate and multivariable Logistic Regression models and subgroup analyses, according to the number of embryos transferred (1 vs. ≥2) and day of transfer (d2 vs. d5). Group 3 presented with statistically significant higher live birth and miscarriage rates in comparison to Group 4 (RR = 5.87, 95%CI: 2.44-14.14 and RR = 0.19, 95%CI: 0.06-0.60, respectively), findings that persisted in subgroup analyses according to the day of transfer and the number of embryos transferred. Progesterone administration through the combination of vaginal tabs and gel was associated with lower clinical pregnancy rates when compared to tabs (RR = 0.19, 95%CI: 0.05-0.71). The stable estrogen protocol compared to increasing estrogen at day 5 was associated with a higher positive hCG test and clinical pregnancy rate, while the progesterone through vaginal tabs was linked with lower miscarriages compared either with gel or combinations. In conclusion, HRC with GnRHa appears to be superior to HRC without GnRHa, concerning live birth and miscarriage, especially when the number of embryos transferred are ≥2 and irrespective of day of transfer. The use of progesterone vaginal tabs compared to gel or combinations is associated with better outcomes. Age is a significant predictor of a negative hCG test and clinical pregnancy rates. A properly conducted RCT is needed to evaluate the optimal frozen embryo transfer preparation strategy.Abbreviations: SD: standard deviation; BMI: body mass index; PCOS: polycystic ovarian syndrome; IQR: interquartile range; FSH: follicle-stimulating hormone; LH: luteinizing hormone; TSH: thyroid-stimulating hormone.

Administration of low-molecular-weight heparin in patients with two or more unsuccessful IVF/ICSI cycles: a multicenter cohort study.

To compare the effects of the administration of low-molecular-weight heparin (LMWH) in subfertile patients with two or more unsuccessful IVF/ICSI cycles. In this six-center two-arm retrospective cohort study, the study population (230 women) underwent a GnRH-antagonist protocol and was classified into two groups, according to the couse of LMWH or not. Groups were compared regarding the clinical and IVF/ICSI cycle characteristics and reproductive outcomes, whereas clinical pregnancy and miscarriage constituted the primary endpoints. Logistic regression analysis was performed to determine the potential predictors of clinical pregnancy, miscarriage and live birth rates using the Enter method. Baseline characteristics were comparable in the two groups. There was no statistically significant difference between the two study groups with regard neither to clinical pregnancy and miscarriage rates (33/133 vs. 20/97, p = .456 and 15/133 vs. 9/97, p = .624, respectively), nor to the secondary outcomes preset for this study (all p values >.05). Logistic regression revealed that age of the woman and ICSI and dose of gonadotrophins used were predictors of clinical pregnancy and live birth, respectively. In conclusion, there is no evidence to support the standard addition of LMWH in patients with two or more unsuccessful IVF/ICSI cycles.

Circulating adipokines and mRNA expression in adipose tissue and the placenta in women with gestational diabetes mellitus.

Maternal adipose tissue and the placenta secrete various molecules commonly called adipokines such as chemerin, omentin-1, visfatin, adiponectin, and leptin that are important players in the pathogenesis of insulin resistance. Gestational diabetes mellitus (GDM) is defined as a state of glucose intolerance characterized by ß-cell dysfunction and insulin resistance. To examine whether circulating adipokines and their mRNA expression in the adipose tissue and the placenta are altered in GDM pregnancy, we compared 15 GDM women [obese (BMI > 30) and non-obese (BMI < 30)] to 23 NGT (normal glucose tolerance) women [obese and non-obese], at the time of the Cesarean section. Circulating chemerin and leptin were higher (p = 0.009 and p = 0.005, respectively) and circulating omentin-1, visfatin, as well as the adiponectin/leptin ratio were lower (p = 0.039, p = 0.007 and p = 0.011, respectively) in GDM-obese compared to NGT-non-obese women. Chemerin and leptin correlated positively with BMI and HOMA-IR and omentin-1 correlated negatively with BMI. Serum TNF-α was significantly elevated in all obese compared to non-obese pregnant women and correlated positively with BMI. Adiponectin levels were reduced -although not significantly- in GDM- and NGT-obese women compared to their non-obese counterparts. Resistin, RPB4 and IL-6 levels did not differ significantly between groups. Chemerin mRNA expression in subcutaneous adipose tissue (SAT) and visceral adipose tissue (VAT) was significantly higher compared to placenta in all women (6-to 24-times, p < 0.05). Chemerin-VAT mRNA expression in GDM-obese tended to be significantly higher compared to NGT-non-obese women (3-times, p = 0.005). Omentin-1 mRNA expression was significantly higher in VAT compared to SAT (50- to 100-times, p < 0.01) and its expression in placenta was negligible in all women. Although, leptin was expressed significantly higher in SAT compared to VAT and the placenta in all women (5- to 46-times, p < 0.05), only its mRNA expression in VAT of obese (GDM and NGT) differed significantly when compared to NGT-non-obese women (3-times higher, p < 0.02). Visfatin mRNA expression was comparable in all tissues. In conclusion, chemerin and leptin are elevated and omentin-1 and visfatin levels are decreased in GDM women complicated by obesity. This finding together with the positive association of chemerin and leptin with markers of insulin resistance, suggests that these adipokines and more especially chemerin and leptin accompanied by their adipose tissue expression could contribute to the increased insulin resistance and low grade inflammation that characterizes GDM-obese women.

Administration of prednisolone and low molecular weight heparin in patients with repeated implantation failures: a cohort study.

Conflicting results exist for low molecular weight heparin (LMWH) and prednisolone when tested as separate adjuncts for the improvement of the clinical outcomes in patients with repeated implantation failures (RIF) undergoing IVF/ICSI treatment. Through a cohort study, we evaluated the combined effect of both drugs on pregnancy parameters in 115 women with RIF. Clinical pregnancy rate was the primary end point while the sample size was calculated through the results of a pilot study. Clinical and IVF cycle characteristics were also compared between the groups. Baseline and cycle characteristics were comparable between groups. Biochemical and clinical pregnancy rates were similar in both groups [23/57 (40.4%) vs. 14/58 (24.1%), and 17/57 (29.8%) vs. 11/58 (19%), p = .063, and .175, respectively]. Similarly, miscarriage rates were comparable between the groups (35.7% vs. 34.8%), as well as live birth rates [15/57 (26.3%) vs. 9/58 (15.5%), p = .154]. In conclusion, the administration of LMWH with prednizolone in subfertile women with RIF seems not to improve clinical pregnancy rates, but a full-scaled RCT would definitely be more accurate.

Mild versus conventional antagonist ovarian stimulation protocols in expected normal responders undergoing IVF/ICSI: a case-control study.

Mild controlled ovarian hyperstimulation (COH) protocols combining clomiphene citrate (CC) or letrozole with gonadotropins were introduced as an effective alternative of conventional COH in normal responders undergoing IVF/ICSI. In this case-control study, we compared 41 participants treated with a mild stimulation protocol receiving gonadotropins combined with either CC (n = 24) or letrozole (n = 17) with 71 subfertile participants with matching baseline characteristics, conforming with the same inclusion criteria and treated with a conventional antagonist protocol. Live birth was determined in reduced rates in the study group compared to the control group, reaching marginal statistical significance [4/41 versus 19/71, p = 0.050], as also in the respective number of clinical pregnancies [6/41 versus 22/71, p = 0.054], although the incidence of miscarriage was similar for both groups [2/41 versus 5/71, p = 0.714]. Most of the secondary parameters examined, favored the conventional antagonist protocol. There was no difference in any of the outcomes reported between the three different stimulation groups in post-hoc analysis. Mild stimulation regimens with the aid of either CC or letrozole employing GnRH antagonists do not seem to constitute an equally effective method as compared to the conventional antagonist protocol to be offered in good prognosis subfertile women seeking an induced cycle toward IVF/ICSI.

Mild Versus Conventional Ovarian Stimulation for Poor Responders Undergoing IVF/ICSI.

BACKGROUND/AIM: Mild stimulation protocols have been implemented to be offered to subfertile patients who respond poorly to ovarian stimulation. We aimed to compare the efficacy of mild versus conventional gonadotropin-releasing hormone (GnRH)-agonist and antagonist protocols in poor responders undergoing in vitro fertilization/intra-cytoplasmic sperm injection (IVF/ICSI) cycles. PATIENTS AND METHODS: A total of 58 poorly-responding patients were divided into two groups: mild group (n=33), receiving clomiphene citrate 100 mg and 0.25 mg of cetrorelix with 150 IU of gonadotrophins daily; conventional group (n=25), undergoing the long GnRH-agonist or -antagonist protocols. The primary outcome was the number of cumulus oocyte complexes (COCs) retrieved. RESULTS: A lower number of COCs [median (range)=1 (0-4) vs. 3 (0-8.4), p<0.001] was retrieved in the mild stimulation compared to the conventional group. Secondary outcomes favored the conventional group, whereas live birth (9.1% vs. 12%), clinical pregnancy (12.1% vs. 20%) and miscarriage rate (40% vs. 40%) were similar in the two groups. CONCLUSION: Mild ovarian stimulation is inferior to conventional regimes when applied to poor responders undergoing IVF/ICSI, in terms of the numbers of retrieved COCs.

Risk of hypertensive disorders in pregnancy following assisted reproductive technology: overview and meta-analysis.

The extent of the increased risk of pregnancy hypertensive disorders following assisted reproductive technology (ART) was investigated. PubMed and the Cochrane Collaboration Library were used as data sources to identify and select longitudinal cohorts comparing pregnancies following ART with spontaneously conceived pregnancies, between 1978 and June 2016. Risk ratios and 95% confidence intervals (CIs) of three outcomes, ie, gestational hypertension (GH), preeclampsia (PE), and their sum (PHD), were calculated. Stratification of results by gestation order (singletons and nonsingletons) was pursued, but a separate "all orders" mixed stratification was considered. Sixty-six longitudinal studies (7 038 029 pregnancies; 203 375 following any ART) were eligible. All outcomes independent of gestation order ("all orders") were increased following any invasive ART: GH (+79% [95% CI, 24%-157%]) and PE (+75% [95% CI, 50%-103%]) to a greater extent, with smaller increases in PHD (+54% [95% CI, 39%-70%]). The risk of PHD following ART steadily increased independent of gestation order.

Estradiol Pretreatment in an Ultrashort GnRH Combined with a GnRH Antagonist Protocol in A Cohort of Poor Responders Undergoing IVF/ICSI: A Case-control Study.

AIM: To provide results of the use of estradiol pretreatment in a combination of an ultrashort gonadotropin-releasing hormone (GnRH) agonist and antagonist protocol, in an attempt to improve the clinical outcomes in "poor responders", according to the Bologna criteria, undergoing in vitro fertilization (IVF). PATIENTS AND METHODS: We applied estradiol pretreatment to 20 participants before the initiation of a combination of an ultrashort GnRH agonist plus an GnRH antagonist protocol followed by high doses of gonadotropins; the control group consisted of 20 subfertile participants with matching age, body mass index (BMI), basal follicle-stimulating hormone (FSH) and anti-Müllerian hormone (AMH), antral follicle count (AFC) and cause of subfertility, conforming with the same inclusion criteria and treated with a fixed GnRH antagonist protocol. The primary outcome measure was live birth, while the secondary outcomes included embryological and cycle parameters. RESULTS: Live birth was determined in reduced rates in the study compared to the control group (0/20 vs. 3/20, p=0.231) as also in the respective number of clinical pregnancies (2/20 vs. 5/20, p=0.407) and cancellations (10/20 vs. 6/20, p=0.197), but none of these differences reached statistical significance. Also, most of the secondary parameters studied were similar for both groups. CONCLUSION: The study protocol does not seem to constitute an equally effective method compared to the GnRH antagonist protocol in the selected study population. The presented dissimilar results with those reported so far in the literature are possibly attributed to the small sample size and the strict criteria applied when labeling participants as "poor responders".

Morphokinetic parameters of early embryo development via time lapse monitoring and their effect on embryo selection and ICSI outcomes: a prospective cohort study.

PURPOSE: To compare the outcomes of embryos selected via time lapse monitoring (TLM) versus those selected with conventional methods of selection in subfertile women undergoing ICSI. METHODS: The study population (239 women) was classified into two groups, based on the monitoring method used: Group 1 (TLM) and Group 2 (conventional monitoring). Groups were compared according to the clinical and ICSI cycle characteristics and reproductive outcomes, while transfers were performed at day 2 or 3. Subgroup analyses were performed, in women of both groups according to age and clinical parameters, and in embryos of Group 1 based on their cellular events. RESULTS: There was a statistically significant difference between the two study groups with regard to the outcome parameters, favoring Group 1 and especially in women >40 years of age. No differences were found in subgroup analyses in participants of both groups, regarding the stimulation protocol used, number of the oocytes retrieved and type of subfertility, while in Group 1 the percentages of "in range" cellular events were higher in certain divisions in ages 35-40, non-smokers, and the GnRH-agonist group, and in embryos that resulted in pregnancy. CONCLUSION: Morphokinetic parameters of early embryo development via TLM are related to the characteristics of subfertile patients and associated with ICSI outcomes.

Granulocyte macrophage colony stimulating factor supplementation in culture media for subfertile women undergoing assisted reproduction technologies: a systematic review.

Granulocyte macrophage colony stimulating factor (GM-CSF) is a cytokine/growth factor produced by epithelial cells that exerts embryotrophic effects during the early stages of embryo development. We performed a systematic review, and six studies that were performed in humans undergoing assisted reproduction technologies (ART) were located. We wanted to evaluate if embryo culture media supplementation with GM-CSF could improve success rates. As the type of studies and the outcome parameters investigated were heterogeneous, we decided not to perform a meta-analysis. Most of them had a trend favoring the supplementation with GM-CSF, when outcomes were measured in terms of increased percentage of good-quality embryos reaching the blastocyst stage, improved hatching initiation and number of cells in the blastocyst, and reduction of cell death. However, no statistically significant differences were found in implantation and pregnancy rates in all apart from one large multicenter trial, which reported favorable outcomes, in terms of implantation and live birth rates. We propose properly conducted and adequately powered randomized controlled trials (RCTs) to further validate and extrapolate the current findings with the live birth rate to be the primary outcome measure.

Alterations in the cellular component of the maternal immune system in a murine preterm delivery model.

OBJECTIVE: Investigate changes in the cellular component of maternal immune system in a murine preterm delivery (PTD) model. METHODS: C57BL/6 J mice were mated and on day 14.5 after plugging either whole blood was harvested or Escherichia coli lipopolysaccharide (LPS) was intraperitoneally injected. PTD resulted within 24 h. Ten to twelve hours after LPS injection (initiation of labor), whole blood was harvested. Annexin-V, CD3, CD4, CD8, CD80 and CD86 were counted after running through flow cytometer with gating for mononuclear cells. Control group consisted of non-pregnant mice. RESULTS: Rate of apoptosis of monocytes and lymphocytes and expression of CD80(+) and CD86(+) was increased in non-pregnant mice after LPS injection (p = 0.009, p = 0.002, p < 0.001 and p = 0.005, respectively), but remained unaltered in pregnant mice. Expression of CD3(+)/4(+) and CD3(+)/8(+) on lymphocytes was increased after LPS injection in both pregnant (p = 0.001, p = 0.011, respectively) and non-pregnant mice (p = 0.008, p < 0.001, respectively). CONCLUSIONS: Cellular component of maternal non-specific immune system is remain suppressed in pregnant mice, whereas specific immune responses of pregnant mice to infection are similar to these of non-pregnant mice.

Reproducibility study of crown-rump length and biparietal diameter measurements in the first trimester.

OBJECTIVE: This study aims to investigate the intra-observer and inter-observer variability of crown-rump length (CRL) and biparietal diameter (BPD) measurements in the first trimester. METHODS: A prospective observational study on 592 fetuses between 8 and 14 gestational weeks was conducted. Intra-class correlation coefficients (ICCs) were computed, and Bland-Altman analysis was carried out. RESULTS: The ICCs (95% confidence interval) and the 95% limits of agreement, expressed as a percentage of the average, for CRL's intra-observer and inter-observer variability were 0.979 (0.974-0.982, p < 0.001), +8.53% to -8.376%, and 0.968 (0.952-0.978, p < 0.001), +9.06% to -7.69%, respectively. The corresponding figures for BPD were 0.981 (0.977-0.984, p < 0.001), +7.41% to -7.51%, and 0.968 (0.952-0.978, p < 0.001), +6.65% to -7.25%. After conversion in days, the ICCs and 95% limits of agreement for CRL's intra-observer and inter-observer variability were 0.983 (0.980-0.986, p < 0.001), +2.88% to -2.84%, and 0.971 (0.957-0.980, p < 0.001), 2.83% to -2.60%, respectively. The corresponding figures for BPD were 0.982 (0.979-0.986, p < 0.001), +3.36% to -3.40%, and 0.968 (0.953-0.978, p < 0.001), +3.06% to -3.38%. CRL's standard deviation of the differences increased with gestation for intra-observer (r = 0.289, p < 0.001) and inter-observer (r = 0.197, p = 0.023) variability. CONCLUSION: The BPD and CRL are highly reproducible measurements. CRL's measurement error increased with the magnitude of CRL, whereas BPD's reproducibility was not affected by gestational age.

Cardiotocography alone versus cardiotocography plus Doppler evaluation of the fetal middle cerebral and umbilical artery for intrapartum fetal monitoring: a Greek prospective controlled trial.

OBJECTIVE: The present study was designed to assess the utility of Doppler velocimetry in the setting of non-reassuring cardiotocography tracings. METHODS: Two hundred fifty six women with term singleton pregnancies were enrolled in a controlled trial. Patients received either routine cardiotocograpic (CTG) monitoring, or CTG with the addition of Doppler velocimetry in cases of non-reassuring CTG tracings. The results were analyzed according to protocol. RESULTS: In the CTG+Doppler group, there was a trend toward lower risk of neonatal metabolic acidosis than in the CTG group, although the incidence was rare. The CTG+Doppler group had significantly lower rates of cesarean section for fetal distress, and improved neonatal outcomes. CONCLUSIONS: We conclude that intrapartum fetal Doppler velocimetry, when combined with CTG, increases the clinicians' ability to accurately identify fetal hypoxia, and decreases the rate of Cesarean section.

Cervical length changes from the first to second trimester of pregnancy, and prediction of preterm birth by first-trimester sonographic cervical measurement.

OBJECTIVES: The purpose of this study was to examine the evolution of cervical length from the first to second trimester of pregnancy and the value of first-trimester cervical measurement in the prediction of preterm delivery. METHODS: We conducted a longitudinal prospective study. Cervical length was measured by transvaginal sonography at 11 to 14 weeks (Cx1), 16 to 19 weeks (Cx2), and 20 to 24 weeks (Cx3). RESULTS: Eight hundred singleton pregnancies were studied. The median cervical lengths were 33 mm for Cx1 and 31 mm for Cx2 and Cx3. Significant independent predictors for cervical length were maternal weight, height, and history of cervical surgery for Cx1, maternal height, history of cervical surgery, and history of preterm delivery for Cx2, and history of cervical surgery, history of first-trimester miscarriage, and history of spontaneous preterm delivery for Cx3. Mean cervical length shortening was 2.36 mm between Cx1 and Cx3. In the subgroups of women with previous cervical surgery and history of previous preterm birth, cervical shortening was significantly more prominent. The median Cx1 was significantly shorter in the women who subsequently delivered preterm; Cx1 predicted preterm delivery before 34 weeks (odds ratio, 0.746; 95% confidence interval, 0.649-0.869) and preterm delivery before 32 weeks (odds ratio, 0.734; 95% confidence interval, 0.637-0.912). CONCLUSIONS: Cervical length in the first trimester depends on maternal characteristics and a history of cervical surgery. The cervix exhibits minimal changes from 11 to 24 weeks for most women, although the shortening is more prominent in women with a history of cervical surgery or preterm delivery. First-trimester cervical length measurement can predict preterm delivery.

The role of the post-anaesthesia care unit in the management of high-risk obstetric patients.

INTRODUCTION: High-risk obstetric patients in the immediate postpartum period are frequently admitted to the intensive care unit, but the necessity of this practice has recently been doubted. Herein we describe the efficiency of utilizing the post-anaesthesia care unit (PACU) as an intermediate intensive care facility for those patients. MATERIAL AND METHODS: We retrospectively described the reasons for admission, duration of stay, the anaesthetic used, main interventions and outcome for all obstetric admissions in the PACU during a period of 4 years in a university hospital. RESULTS: During the 4-year period 47 women were admitted to the PACU after delivery. The frequency of admission to the PACU was 15.3 per 1000 deliveries, while obstetric cases represented 4.4 per 1000 admissions to the PACU. The majority represented caesarean sections (81%). The main reasons for admission to the PACU were haemorrhage (49%), cardiovascular problems (19%) and preeclampsia/eclampsia (17%). Mean length of stay in the PACU was 14.5 ±11.6 h, being significantly less in women having received epidural anaesthesia (8.2 ±5.6 h) compared to those who delivered with general anaesthesia (19.0 ±13.6 h, p < 0.05). General anaesthesia was used in 85% of cases in which emergency delivery was indicated, but only in 27% of cases without emergency indications for delivery (p < 0.01). No death or admission to the intensive care unit occurred during the study period. CONCLUSIONS: The PACU can offer an intermediate intensive care facility for high-risk obstetric patients, thus reducing unnecessary admissions to the intensive care unit.

Office hysteroscopy: current trends and potential applications: a critical review.

Office hysteroscopy is an excellent method of identifying and treating intracavitary uterine lesions. It has become easy to learn and perform; as an aid of modern technological applications, it is safe, accurate, provides immediate results under direct visualisation, and offers the additional benefit of histological confirmation and the discomfort of patients is minimal. We applied an extended literature search to explore the special features and details of the technique itself, as it evolved since it first appeared 30 years back. Our initial goal was to examine potential changes/improvements of the modality, in terms of the instrumentation used and the technique itself, the indications of use, its incorporation in daily practice, and patients' and clinicians' acceptability.

The prevalence of non-classical congenital adrenal hyperplasia due to 21-hydroxylase deficiency in Greek women with hirsutism and polycystic ovary syndrome.

UNLABELLED: The study was aimed to find out the prevalence of non-classical congenital adrenal hyperplasia (NC-CAH) due to 21-hydroxylase deficiency (21-OHdef) among Greek women with hirsutism and polycystic ovary syndrome (PCOS) and to compare the results of ACTH stimulated 17-hydroxyprogesterone 60 min (17-OHP60) values, with human leukocyte antigens (HLA) phenotypes, in any patient diagnosed as having NC-CAH. One hundred and seven women with hirsutism and PCOS were included in the study. All were presented at the Reproductive Endocrinology Outpatient Clinic with hirsutism and PCOS. After ACTH stimulation test, 10 women were diagnosed as having NC-CAH because of high 17-OHP60 values >or=36 nmol/l, and 97 as having PCOS. Ten (10.3%) of the 97 women presented hormonal findings compatible with adrenal hyper-response due to ACTH testing, because of hyperstimulated 17-OHP60 values >or=21 nmol/l and <32 nmol/l. The HLA typing of 10 patients with NC-CAH revealed the phenotypes B14, DR1, B35, B7 and B44 which present positively genetic linkage disequilibrium with 21-OHdef, as reported in the literature. IN CONCLUSION: In Greek women with hirsutism and PCOS we have found that: a. The prevalence of NC-CAH among these women is relatively high and reaches at 10%. b. The HLA phenotypes B(14), DR(1), B(35), B(7) and B44 were found in high frequency in these NC-CAH patients. c. Adrenal NC-CAH due to 21-OHdef as well as adrenal hyperactivity, revealed after ACTH testing, constitutes an important reason of hirsutism and PCOS in these Greek women and both reach a rate of 20%.

Antiphospholipid syndrome: a predisposing factor for early onset HELLP syndrome.

Hemolysis elevated liver enzymes low platelets syndrome (HELLP) is a relatively rare pregnancy-related thrombotic microangiopathic disorder, usually observed during the third trimester. Its incidence seems to be increased in patients with antiphospholipid syndrome (APS). In this report, we describe a 33-year-old pregnant woman with previously known primary APS who developed early onset HELLP syndrome during the 15th week of gestation. We also review the literature about this interesting relationship between APS and HELLP.