Ethnic, geographical and altitude considerations and maternal mortality associated with HELLP syndrome in Ecuador: a population-based cohort study.

BACKGROUND: Eclampsia and pre-eclampsia rank as the third leading causes of maternal death in Ecuador, following pre-existing chronic diseases and postpartum haemorrhage, as reported by the Ecuadorian National Institute of Statistics and Census (INEC). In contrast, HELLP (Haemolysis, Elevated Liver enzymes, Low Platelet count) syndrome remains underexplored epidemiologically, not only in Latin America but globally. This study marks the first population-based investigation into HELLP syndrome incidence and mortality in Ecuador, examining geographical variations, altitude influences and ethnic backgrounds. METHODS: Conducted as a retrospective population-based cohort study from 2015 to 2017, this research delves into the incidence, risk factors and maternal mortality associated with HELLP syndrome in Ecuador. Utilising data from INEC and the Ecuadorian Ministry of Health, we identified HELLP syndrome cases through ICD-10 (International Classification of Diseases, tenth revision) coding in hospitalised individuals. Logistic regression analysis was employed to explore association, whilst geospatial statistical analysis focused on cantons to identify significant spatial clusters. Primary outcome measures include HELLP syndrome incidence and maternal mortality, supplying crucial insights into the syndrome's impact on maternal health in Ecuador. RESULTS: The incidence of HELLP syndrome is 0.76 (0.69-0.84)/ 1000 deliveries. Afro-Ecuadorian communities have a higher risk (Odds Ratio (OR) = 2.18 (1.03-4.63)) compared to Indigenous Ecuadorian communities. Living at mid-level or high altitude is a significant risk factor OR of 2.79 (2.19-3.55) and an OR 3.61 (2.58-5.03), respectively. Being an older mother was also identified as a risk factor. Women living more than 20 km from the obstetric unit have an OR of 2.55 (2.05-3.18). Moreover, we found that cantons with higher crude HELLP syndrome incidence also have lower numbers of physicians (R = 0.503, p-value < 0.001). The mortality incidence of women with HELLP syndrome is 21.22 (12.05-20.59)/1000 deliveries with HELLP syndrome diagnoses. CONCLUSIONS: High altitude, advanced maternal age and geographical distance between residence and health centres are risk factors for HELLP syndrome. Maternal mortality in women with HELLP syndrome is higher than pre-eclampsia and eclampsia but comparable with previous reports in other countries.

Prevalence of Preeclampsia in Brazil: An Integrative Review.

OBJECTIVE: To review literature and estimate the occurrence of preeclampsia and its complications in Brazil. METHODS: We performed an integrative review of the literature, and included observational studies published until August 2021 on the SciELO and PubMed databases that evaluated preeclampsia among pregnant women in Brazil. Other variables of interests were maternal death, neonatal death, hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome, and eclampsia. Three independent reviewers evaluated all retrieved studies and selected those that met inclusion criteria. A metanalysis of the prevalence of preeclampsia and eclampsia was also performed, to estimate a pooled frequency of those conditions among the studies included. RESULTS: We retrieved 304 studies after the initial search; of those, 10 were included in the final analysis, with a total of 52,986 women considered. The pooled prevalence of preeclampsia was of 6.7%, with a total of 2,988 cases reported. The frequency of eclampsia ranged from 1.7% to 6.2%, while the occurrence of HELLP syndrome was underreported. Prematurity associated to hypertensive disorders ranged from 0.5% to 1.72%. CONCLUSION: The frequency of preeclampsia was similar to that reported in other international studies, and it is increasing in Brazil, probably due to the adoption of new diagnostic criteria. The development of a national surveillance network would be essential to understand the problem of hypertensive disorders of pregnancy in Brazil.

OBJETIVO: Revisar a literatura e estimar a ocorrência de pré-eclâmpsia e suas complicações no Brasil. MéTODOS: Foi realizada uma revisão integrativa da literatura, com a inclusão de estudos observacionais publicados até agosto de 2021, nas bases de dados PubMed e SciELO, que avaliavam pré-eclâmpsia em mulheres brasileiras. Outras variáveis de interesse foram morte materna, morte neonatal, síndrome de hemólise, enzimas hepáticas elevadas e plaquetopenia (hemolysis, elevated liver enzymes, and low platelet count, HELLP, em inglês) e eclâmpsia. Três revisores independentes avaliaram os estudos identificados e selecionaram aqueles que preenchiam os critérios de inclusão. Foi realizada uma meta-análise da prevalência de pré-eclâmpsia e eclâmpsia, para estimar sua frequência acumulada com relação aos estudos incluídos. RESULTADOS: Foram identificados 304 estudos, 10 dos quais foram incluídos na análise final, num total de 52.986 mulheres. A frequência acumulada de pré-eclâmpsia foi de 6,7%, com um total de 2.988 casos. A frequência de eclâmpsia variou de 1,7% a 6,2%, ao passo que a ocorrência de síndrome de HELLP foi pouco relatada. A prematuridade associada a hipertensão foi de 0,5% a 1,7%. CONCLUSãO: A frequência de pré-eclâmpsia foi similar à de estudos internacionais; no entanto, ao longo dos últimos anos, ela vem aumentando no Brasil, possivelmente como reflexo da adoção de novos critérios diagnósticos. A criação de uma rede nacional de vigilância seria fundamental para entender o problema da hipertensão na gestação no país.

Genetic association of ERAP1 and ERAP2 with eclampsia and preeclampsia in northeastern Brazilian women.

The clinical spectrum of hypertensive disorders of pregnancy (HDP) is determined by the interplay between environmental and genetic factors, most of which remains unknown. ERAP1, ERAP2 and LNPEP genes code for multifunctional aminopeptidases involved with antigen processing and degradation of small peptides such as angiotensin II (Ang II), vasopressin and oxytocin. We aimed to test for associations between genetic variants in aminopeptidases and HDP. A total of 1282 pregnant women (normotensive controls, n = 693; preeclampsia, n = 342; chronic hypertension with superimposed preeclampsia, n = 61; eclampsia, n = 74; and HELLP syndrome, n = 112) were genotyped for variants in LNPEP (rs27300, rs38034, rs2303138), ERAP1 (rs27044, rs30187) and ERAP2 (rs2549796 rs2927609 rs11135484). We also evaluated the effect of ERAP1 rs30187 on plasma Ang II levels in an additional cohort of 65 pregnant women. The genotype C/C, in ERAP1 rs30187 variant (c.1583 T > C, p.Lys528Arg), was associated with increased risk of eclampsia (OR = 1.85, p = 0.019) whereas ERAP2 haplotype rs2549796(C)-rs2927609(C)-rs11135484(G) was associated with preeclampsia (OR = 1.96, corrected p-value = 0.01). Ang II plasma levels did not differ across rs30187 genotypic groups (p = 0.895). In conclusion, ERAP1 gene is associated with eclampsia whereas ERAP2 is associated with preeclampsia, although the mechanism by which genetic variants in ERAPs influence the risk of preeclampsia and eclampsia remain to be elucidated.

Validation of the fullPIERS model for prediction of adverse outcomes in preeclampsia at a referral center.

OBJECTIVES: To validate the use of fullPIERS to predict maternal and perinatal adverse outcomes in a referral center. METHODS: Cross-sectional study including all pregnant women with preeclampsia (PE) at a referral center in southeast Brazil. The prevalence of PE and adverse outcomes were assessed. The fullPIERS score was tested on three composites of adverse outcomes: maternal adverse outcome; fetal adverse outcomes; and the combination of these two. Furthermore, the fullPIERS risk calculator, was considered to define the cutoff that better estimates adverse outcomes. RESULTS: 2839 women were screened in a one year period, with 208 (7.3%) cases of PE; most were preterm (56.7%); with severe features (74.5%). HELLP syndrome (6.7%), eclampsia (3.8%) and placental abruption (2.4%) were the most frequent complications. FullPIERS assessement had a median of 1.2% (0.45 - 2.3%) and the score had an excelent performance to predict adverse maternal outcome (AUC = 0.845, confidence interval 0.776 - 0.914, p-value < 0.01). For perinatal adverse outcomes (AUC = 0.699, confidence interval 0.581 - 0.816, p-value < 0.01) and the composite of maternal and perinatal adverse outcome (AUC = 0.804, confidence interval 0.736 - 0.872, p-vale < 0.01), fullPIERS score had a suboptimal performance. The cutoff value that best performed for the assessment of maternal adverse outcome was 2.15% (sensitivity of 75% and specificity of 83%). CONCLUSION: Preeclampsia was a significant complication during pregnancy. The fullPIERS model was an excellent tool to predict maternal adverse outcomes; with a cutoff value of 2.15% in the tested population.

Epidemiology and maternal prognosis of hypertension disorders of pregnancy in French Guiana.

BACKGROUND: Hypertensive disorders of pregnancy (HDP) are responsible for high maternal mortality and morbidity worldwide. OBJECTIVE: Our primary objective was to report the epidemiological and clinical features of HDP in Cayenne General Hospital. Our secondary objectives were to search for factors associated to preeclampsia (PE) and to severe PE in patients with HDP. METHODS: Our study was observational and non-interventional. It was conducted over 4-month period (January to April 2019) in the Obstetrics and Gynaecology Unit of the Cayenne General Hospital. We included all pregnant women after 20 weeks of gestation (WG), who gave birth and who presented HDP and/or PE. RESULTS: During the study period 1243 patients gave birth in our unit. Among them, 156 were diagnosed with HDP (12.6%). The median age was 33 years (IQR 28 - 38 years). The most frequent medical histories were diabetes (27.5%) and chronic hypertension (23.5%). The socioeconomic status was low in 31% of patients. Ninety-four patients (61.4%) developed PE with a severe form in 80.9% of cases. HELLP syndrome was diagnosed in 6.5% and nephropathy in 3.3% of cases. Delivery was by cesarean in 49.7% of cases. The median gestational age at delivery was 37 WG (IQR: 35-39). Multivariate analysis showed no independent factors associated with the occurrence of PE or severe PE in patients with HDP. CONCLUSION: Our study shows a high prevalence of PE in patients with HDP. Hospitalization and repeated clinical evaluation are needed to screen for women exposed to develop PE or severe PE.

Desenlaces materno-fetales de los embarazos con trastornos hipertensivos: un estudio transversal / Maternal and fetal outcomes of pregnancies with hypertensive disorders: a cross-sectional study

INTRODUCCIÓN Y OBJETIVO: Los trastornos hipertensivos asociados al embarazo son considerados un problema de salud pública. Se busca describir las características clínicas y desenlaces materno-fetales de las pacientes con esta patología, atendidas en el Hospital Universitario de Santander (HUS) durante el primer semestre de 2017. MÉTODOS: Estudio observacional retrospectivo de corte transversal. Se incluyeron las pacientes en estado de embarazo o puerperio con diagnóstico o sospecha de trastorno hipertensivo; se excluyeron aquellas que no pudieron ser clasificadas o no correspondían a éstos. RESULTADOS: Se analizaron 181 historias clínicas; la edad de las pacientes osciló entre 14 y 44 años; el 43,7% eran primigestantes; el 40,3% tuvo un control prenatal inadecuado y el 27,5% tenía antecedente de trastorno hipertensivo en gestaciones previas. El 75,1% de las pacientes fueron clasificadas como preeclampsia, 18,2% con hipertensión gestacional, 4,4% con hipertensión más preeclampsia sobreagregada y 2,2% con hipertensión crónica. El 16,9% de las pacientes con preeclampsia debutaron antes de la semana 34, de las cuales el 91,3% tenían criterios de severidad; mientras que entre las demás, el 84% presentaron criterios de severidad. CONCLUSIONES: La preeclampsia fue el trastorno hipertensivo más frecuente, predominó la presentación tardía y severa con importantes tasas de complicación maternas y fetales. Mediante la implementación de estrategias de detección temprana y adecuada atención de los trastornos hipertensivos asociados al embarazo podrían mejorarse los desenlaces materno-fetales.

BACKGROUND AND OBJECTIVE: Hypertensive disorders of pregnancy are considered a public health issue. The aim is to describe the clinical features, maternal - fetal outcomes of patients with this disease, who were admitted at the University Hospital of Santander (Bucaramanga, Colombia) during the first half of 2017. METHOD: Cross-sectional retrospective observational study. Patients in pregnancy or puerperium with diagnosis of hypertensive disorder were included; those who could not be classified or did not correspond were excluded. RESULTS: 181 clinical charts were analyzed, the age of the patients ranged between 14 and 44 years, 43.7% were nulliparous, 40.3% had an inadequate prenatal control and 27.5% had history of hypertensive disorder in previous pregnancies. 75.1% were classified as preeclampsia, 18.2% as gestational hypertension, 4.4% as hypertension and superimposed preeclampsia and 2.2% with chronic hypertension; 16.9% of the patients were of an early-onset preeclampsia before week 34, of which 91.3% had criteria of severity; among the others, 84% presented criteria of severity. CONCLUSION: Preeclampsia was the most frequent hypertensive disorder, late and severe presentation prevailed with important maternal and fetal complication rates. Through the implementation of early detection strategies and adequate care of hypertensive disorders associated with pregnancy maternal and fetal outcomes could be improved.

Dexamethasone in HELLP syndrome: experience in Bolivia.

Objective: To demonstrate the utility of dexamethasone, used according to the criteria of the attending physician, in patients with HELLP syndrome.Methods: This cross-sectional study was conducted in patients with HELLP syndrome and was based on the daily, real-life management of HELLP syndrome. Patients who received dexamethasone had it administered immediately after giving birth at a dosage of 8 mg every 8 hours for 72 hours, for a total of 72 mg. The analysis was conducted between patients who received corticosteroids and those who did not, with complete or partial HELLP.Results: There were 97 women who suffered complications from HELLP syndrome, there were 43 (44.3%) received dexamethasone. The groups were comparable except for the initial platelet count because this was the criterion used to divide the groups. In addition, the group without corticosteroids comprised more patients with partial HELLP. The platelet count shows that on the third day was similar in both groups, following a difference of more than 40,000 at the beginning of the study. The average platelet increase was 27,448 in the group without corticosteroids and 88,408 in the corticosteroid group; p = .001.Conclusions: This study demonstrates that the administration of postpartum dexamethasone at a dosage of 8 mg every 8 hours for 72 hours in HELLP syndrome is associated with a significant increase in platelet count.

Liver disease in pregnancy: Medical aspects and their implications for mother and child.

Liver disease during pregnancy is more common than expected and may require specialized intervention. It is important to determine if changes in liver physiology may develop into liver disease, to assure early diagnosis. For adequate surveillance of mother-fetus health outcome, liver disease during pregnancy might require intervention from a hepatologist. Liver diseases have a prevalence of at least 3% of all pregnancies in developed countries, and they are classified into two main categories: related to pregnancy; and those non- related that are present de novo or are preexisting chronic liver diseases. In this review we describe and discuss the main characteristics of those liver diseases associated with pregnancy and only some frequent pre-existing and co-incidental in pregnancy are considered. In addition to the literature review, we compiled the data of liver disease occurring during pregnancies attended at the National Institute of Perinatology in Mexico City in a three-year period. In our tertiary referral women hospital, liver disease was present in 11.24 % of all pregnancies. Associated liver disease was found in 10.8% of all pregnancies, mainly those related to pre-eclampsia (9.9% of pregnancies). Only 0.56% was due to liver disease that was co-incidental or preexisting; the acute or chronic hepatitis C virus was the most frequent in this group (0.12%). When managing pregnancy in referral hospitals in Latin America, it is important to discard liver alterations early for adequate follow up of the disease and to prevent adverse consequences for the mother and child.

Prevalencia de Síndrome de Hellp en el servicio de ginecología y obstetricia del Hospital Central del Instituto de Previsión Social. 2017 / Prevalence of Hellp Syndrome in the gynecology and obstetrics service of the Central Hospital of the Instituto de Previsión Social

Introducción: En la actualidad, la mortalidad materna va aumentando, debido a ciertas complicaciones producidas durante la gestación, una de ellas es el Síndrome de HELLP que es considerada una de las complicaciones más severas de las enfermedades hipertensivas del embarazo que mayoritariamente se presenta en embarazadas que cursan con preeclampsia. Objetivo: Determinar la prevalencia de Síndrome de HELLP en el Servicio de Ginecología y Obstetricia del Hospital Central del Instituto de Previsión Social durante el año 2017. Materiales y método: Estudio observacional descriptivo de corte transversal, muestreo probabilístico aleatorio simple. Fueron incluidas las fichas clínicas de las embarazadas que acudieron al servicio de Ginecología y Obstetricia del Hospital Central del Instituto de Previsión Social desde enero a diciembre del 2017. Resultados: Fueron incluidas en el estudio 177 embarazadas; de las cuales el 14,2% presentó Síndrome de HELLP. La mediana de edad fue de 28 años; el estado civil predominante fue unión libre en un 49,15%; el 62,71% de las gestantes procedieron de áreas urbanas, mayoritariamente del departamento Central y el 33,90% de ellas son ama de casa. La edad gestacional estuvo comprendida predominantemente entre las 33,2 a 37,6 semanas; la mediana del número de controles prenatales fue de 5. Con respecto a las enfermedades hipertensivas del embarazo la mayor parte de las gestantes presentaron preeclampsia. Conclusión: La prevalencia de Síndrome de HELLP en las embarazadas que acudieron al servicio de Ginecología y Obstetricia en el Hospital Central del Instituto de Previsión Social durante el año 2017 fue del 14,2%; dato similar a otros estudios realizados.

Ingresos a Unidad de Cuidados Intensivos de mujeres durante el embarazo y periodo puerperal / Admission of women to an intensive care unit during pregnancy or the postpartum period

Introducción: las complicaciones del embarazo y parto constituyen las principales causas de muerte entre las mujeres en edad reproductiva. Las embarazadas o puérperas que ingresan a Unidad de Cuidados Intensivos (UCI) son en su mayoría casos agudos críticos con riesgo de muerte, que necesitan tratamiento especializa do y complejo. Constituyen un grupo significativo de la práctica obstétrica. Objetivo: determinar las características clínicas y demográficas de las pacientes gestantes o puérperas que ingresaron a UCI del Hospital Nacional de Itauguá durante 5 años (2011-2015) Materiales y métodos: diseño observacional descriptivo de corte trasverso. Fueron incluidas gestantes y puérperas que requirieron ingreso a UCI por complicaciones obstétricas y no obstétricas, descompensación materna, con y sin morbilidad previa. Resultados: necesitaron ingreso a UCI 135 pacientes (0,48%). La edad media fue 27 ± 6,7 años. La muestra estuvo conformada por 21 gestantes (15,5%), 85 puérperas (63%), 27 mujeres con post aborto (20%) y 2 con embarazo ectópico (1,5 %). La complicación obstétrica más frecuente que motivó el ingreso a UCI fue la sepsis y entre las no obstétricas la cardiopatía descompensada. El tiempo medio de internación en la UCI fue 6,47 ± 8,5 días y 50 pacientes (37,03%) necesitaron asistencia respiratoria mecánica. Hubo 19 óbitos (14%) Conclusiones: el ingreso a UCI se observó en 0,48%. La mortalidad en UCI fue 14%.

Introduction: complications of pregnancy and childbirth are the main causes of death among women of childbearing age. Pregnant women or postpartum women entering the Intensive Care Unit (ICU) are mostly acute cases with a high risk of death, which require specialized and complex treatment. They constitute a significant group of obstetric practice. Objective: to determine the clinical and demographic characteristics of the pregnant or puerperal patients who entered the ICU of the National Hospital of Itauguá for 5 years (2011-2015) Materials and methods: descriptive observational cross-sectional design. Pregnant women and postpartum women who required admission to the ICU due to obstetric and non-obstetric complications, maternal decompensation, with and without prior morbidity were included. Results: 135 patients required admission to the ICU. The mean age was 27 ± 6.7 years. The sample consisted of 21 pregnant women (15.5%), 85 postpartum women (63%), 27 women with post abortion (20%) and 2 with ectopic pregnancy (1.5%). The most frequent obstetric complication that led to ICU admission was sepsis and non-obstetric heart disease was decompensated. The mean ICU admission time was 6.47 ± 8.5 days and 50 patients (37.03%) required mechanical ventilation. There were 19 deaths (14%) Conclusions: ICU admission was observed at 0.48%. Mortality in ICU was 14%.

Caracterización de las pacientes con síndrome HELLP / Characterization of patients with HELLP syndrome

Introducción: el síndrome HELLP es una complicación de los trastornos hipertensivos del embarazo. Objetivo: identificar las características de las pacientes que padecen este trastorno. Métodos: se realizó un estudio descriptivo de corte transversal y retrospectivo en el Hospital Osio de Cua, Municipio Urdaneta, estado Miranda en la República Bolivariana de Venezuela desde la creación de la Unidad de Cuidados Intensivos (UCI), periodo comprendido desde Septiembre del 2010 hasta Junio del 2012. La muestra la integraron 35 pacientes que ingresaron en la unidad con diagnóstico de Síndrome HELLP o que durante su estadía fueron diagnosticadas con esta patología. La fuente primaria de obtención de datos fue la historia clínica y registro de la Unidad de Cuidados Intensivos. Resultados: encontramos como factores predominantes la edad materna entre 20 y 29 años (57,14 por ciento); la edad gestacional al momento de la interrupción del embarazo entre 28 y 34 semanas (42,87 por ciento). Los motivos del ingreso que más se hallaron fueron la epigastralgia y cifras tensionales elevadas. Por el conteo de plaquetas (48, 58 por ciento) el HELLP tipo II fue el más frecuente, en 80 por ciento de las pacientes, las cifras de hemoglobina fueron inferiores a 100g/l y 88,58 por ciento tuvo los niveles de transaminasas elevadas, también 82,85 por ciento de los valores del perfil renal se comportó por encima de lo normal. Durante el embarazo la enfermedad se presentó en 75 por ciento de las mujeres. Conclusión: el Síndrome HELLP es un proceso patológico que puede presentarse en el embarazo o en el puerperio(AU)

Introduction: HELLP syndrome is a complication of hypertensive disorders in pregnancy. Objective: To identify the characteristics of patients who suffer it. Methods: A retrospective, cross-sectional and descriptive study was carried out in Hospital Osio de Cua, Urdaneta municipality, state of Miranda in the Bolivarian Republic of Venezuela since the creation of the intensive care unit in the period of September 2010 through June 2012. The sample was made up of 35 patients who were admitted to the unit with diagnosis of HELLP syndrome or were so diagnosed during their stay at hospital. The primary data source was the medical history and the intensive care unit records. Results: The predominant factors were found to be maternal age of 20 to 29 years (57.14 percent) and gestational age of 28 to 34 weeks (42.87percent) at the time of pregnancy cessation. The most frequent causes of admission were epigastralgia and high blood pressure figures. According to the platelet count (48.58 percent), the most common type was HELLP II; 80 percent of patients showed hemoglobin values lower than 100g/l and 88.58 percent had high transaminase levels whereas 82.85 percent of the renal profile values were over the normal figures. During pregnancy, the disease affected 75 percent of studied females. Conclusions: HELLP syndrome is a pathological process that may occur in pregnancy or in puerperium(AU)

Prevalencia del síndrome de HELLP en gestantes críticas: Maternidad "Dr. Armando Castillo Plaza", Maracaibo, Venezuela / Prevalence of HELLP syndrome in critical pregnant women: Maternity "Dr. Armando Castillo Plaza", Maracaibo, Venezuela

OBJETIVO: Determinar la prevalencia de síndrome de HELLP (SH) en gestantes críticamente enfermas ingresadas a la Unidad de Cuidados Intensivos Obstétricos (UCIO) de la Maternidad "Dr. Armando Castillo Plaza", de Maracaibo, estado Zulia, Venezuela, periodo 2011 a 2015. MÉTODOS: Investigación descriptiva con diseño retrospectivo, donde se revisaron las historias clínicas de gestantes ingresadas a la UCIO con diagnóstico de SH, analizándo sus características clínicas y epidemiológicas. RESULTADOS: Hubo una prevalencia del 13,60% (111/816), tasa de letalidad de 1,23% (10/8l6) y tasa de mortalidad materna específica de 15,08/100.000 nacidos vivos. Las características clínicas más prevalentes fueron: edad 25,8 ± 6,9 años, estancia en UCIO 4,76 ± 4,46 días, embarazos pretérminos 69,37%, antecedentes de abortos 24,32%, primíparas 42,34%, control prenatal ausente o inadecuado, embarazos simples 95,5%, preeclámpticas 67,57%, antecedentes de condiciones preexistentes 47,75%, sin hábitos como tabaco o alcohol 81,99%, ingresaron embarazadas 89,19% y cesárea 74,77%. Se diagnosticaron mayoritariamente casos de SH incompleto (56,76%), siendo las complicaciones más observadas la disfunción hematológica (98,2%), disfunción hepática (91,9%) y disfunción renal (70,3%). CONCLUSIÓN: La prevalencia de SH resultó más elevada que lo reportada en estudios nacionales e internacionales, presentando características clínicas y epidemiológicas que deben ser consideradas para su prevención y diagnóstico precoz.

AIMS: To determinate the prevalence of HELLP syndrome (HS) in critical pregnant women admitted to the Obstetrics Intensive Care Unit (OICU) of the "Maternidad Dr. Armando Castillo Plaza", in Maracaibo, Zulia state, Venezuela, during 2011 to 2015. METHODS: A descriptive research with retrospective design was due, in which were reviewed the clinical files of all pregnant admit into the OICU complicated with HS, was analyzed establish the clinical and epidemiological features. RESULTS: We found a prevalence of 13.60% (111/816), fatality rate of 1.23% (10/816) and specific maternal mortality rate of 15.08/100,000 live births. The most prevalent clinical characteristics were: age 25.8 ± 6.9 years, stay in UCIO 4.76 ± 4.46 days, pre-terms pregnancies (69.37%), history of abortions (24.32%), primiparous (42.34%), absent or inadequate prenatal care, singleton pregnancies (95.50%), preeclampsia (67.57%), history of pre-existing conditions (47.75%), without habits such as tobacco or alcohol (81.99%), admitted pregnant (89.19%) and cesarean section (74.77%). Also, were mainly diagnosed cases of incomplete HS (56.76%); the most observed com-plications were hematologic dysfunction (98.2%), liver dysfunction (91.9%) and renal dysfunction (70.3%). CONCLUSION: The prevalence of HELLP syndrome was higher than reported in national and international studies, presenting clinical and epidemiological characteristics that should be considered for prevention and early diagnosis.

Near miss materno em unidade de terapia intensiva: aspectos clínicos e epidemiológicos / Maternal near miss in the intensive care unit: clinical and epidemiological aspects

RESUMOObjetivos:Analisar o perfil clínico epidemiológico de mulheres com near miss materno segundo os novos critérios da Organização Mundial da Saúde.Métodos:Foi realizado um estudo descritivo, tipo corte transversal, analisando- se os prontuários das pacientes admitidas na unidade de terapia intensiva obstétrica de um hospital terciário do Recife (Brasil), em um período de quatro anos. Foram incluídas as mulheres que apresentavam pelo menos um dos critérios de near miss. As variáveis estudadas foram: idade, raça/cor, estado civil, escolaridade, procedência, número de gestações e consultas de pré-natal, complicações e procedimentos realizados, via de parto, idade gestacional no parto e critérios de near miss materno. A análise descritiva foi executada utilizando-se o programa Epi-Info 3.5.1.Resultados:Foram identificados 255 casos de near miss materno, totalizando uma razão de near miss materno de 12,8/1.000 nascidos vivos. Dentre esses casos, 43,2% das mulheres apresentavam ensino fundamental incompleto; 44,7% eram primigestas e 20,5% tinham realizado cesariana prévia. Quanto aos diagnósticos específicos, houve predominância dos distúrbios hipertensivos (62,7%), sendo que muitos deles foram complicados pela síndrome HELLP (41,2%). Os critérios laboratoriais de near miss foram os mais observados (59,6%), em função, principalmente, da elevada frequência de plaquetopenia aguda (32,5%).Conclusões:Evidenciou-se uma frequência elevada de mulheres com baixa escolaridade e primigestas. Com os novos critérios propostos pela Organização Mundial da Saúde, os distúrbios hipertensivos da gestação continuam sendo os mais comuns entre os casos de near miss materno. Destaca-se ainda a elevada frequência da síndrome HELLP, o que contribuiu para que a trombocitopenia aguda fosse o critério mais frequente de near miss.

ABSTRACTObjective:To analyze the epidemiological clinical profile of women with maternal near miss according to the new World Health Organization criteria.Methods:A descriptive crosssectional study was conducted, in which the records of patients admitted to the obstetric intensive care unit of a tertiary hospital in Recife (Brazil) over a period of four years were analyzed. Women who presented at least one near miss criterion were included. The variables studied were age, race/color, civil status, education, place of origin, number of pregnancies and prenatal consultations, complications and procedures performed, mode of delivery, gestational age at delivery, and maternal near miss criteria. The descriptive analysis was performed using the program Epi-Info 3.5.1.Results:Two hundred fifty-five cases of maternal near miss were identified, with an overall ratio of maternal near miss of 12.8/1,000 live births. Among these cases, 43.2% of the women had incomplete primary education, 44.7% were primiparous, and 20.5% had undergone a previous cesarean section. Regarding specific diagnoses, there was a predominance of hypertensive disorders (62.7%), many of which were complicated by HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome (41.2%). The laboratory near miss criteria were the most often observed (59.6%), due mainly to the high frequency of acute thrombocytopenia (32.5%).Conclusions:A high frequency of women who had a low level of education and who were primiparous was observed. According to the new criteria proposed by the World Health Organization, hypertensive pregnancy disorders are still the most common among maternal near miss cases. The high frequency of HELLP syndrome was also striking, which contributed to acute thrombocytopenia being the most frequent near miss criterion.

Maternal near miss in the intensive care unit: clinical and epidemiological aspects.

OBJECTIVE: To analyze the epidemiological clinical profile of women with maternal near miss according to the new World Health Organization criteria. METHODS: A descriptive cross-sectional study was conducted, in which the records of patients admitted to the obstetric intensive care unit of a tertiary hospital in Recife (Brazil) over a period of four years were analyzed. Women who presented at least one near miss criterion were included. The variables studied were age, race/color, civil status, education, place of origin, number of pregnancies and prenatal consultations, complications and procedures performed, mode of delivery, gestational age at delivery, and maternal near miss criteria. The descriptive analysis was performed using the program Epi-Info 3.5.1. RESULTS: Two hundred fifty-five cases of maternal near miss were identified, with an overall ratio of maternal near miss of 12.8/1,000 live births. Among these cases, 43.2% of the women had incomplete primary education, 44.7% were primiparous, and 20.5% had undergone a previous cesarean section. Regarding specific diagnoses, there was a predominance of hypertensive disorders (62.7%), many of which were complicated by HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome (41.2%). The laboratory near miss criteria were the most often observed (59.6%), due mainly to the high frequency of acute thrombocytopenia (32.5%). CONCLUSIONS: A high frequency of women who had a low level of education and who were primiparous was observed. According to the new criteria proposed by the World Health Organization, hypertensive pregnancy disorders are still the most common among maternal near miss cases. The high frequency of HELLP syndrome was also striking, which contributed to acute thrombocytopenia being the most frequent near miss criterion.

Characterization of Atypical Preeclampsia.

OBJECTIVE: To characterize patients with atypical preeclampsia (PE), in relation to socio-demographic characteristics, clinical presentation, maternal complications and perinatal outcome. MATERIALS AND METHODS: Between July 1, 2011 and November 30, 2013, a cohort was created of women attended at a Obstetric High-dependency Unit who met criteria for atypical PE: gestational hypertension with severe hypertension or symptoms or laboratory signs suggestive of microangiopathy/hemolysis; normotensive proteinuria with the presence of symptoms or laboratory signs suggestive of microangiopathy/hemolysis; presence of PE or eclampsia or HELLP syndrome appearing after 48 h postpartum, and, PE or eclampsia appearing before 20 weeks of pregnancy. RESULTS: A total of 200 women fulfilling criteria for atypical PE, were included: 61.5% corresponded to non-proteinuric gestational hypertension, 35.5% to normotensive proteinuria and 3% to PE/eclampsia in late postpartum. Criteria for severe maternal morbidity were present in 12% of the cases and there were no maternal deaths. There were 6 perinatal deaths. CONCLUSION: Atypical preeclampsia is a type of preeclampsia not fully recognized that is associated with maternal and neonatal morbidity, mainly related to smallness-for-gestational-age and low birth weight. Vasospasm symptoms are a key element to detect this condition.

Maternal outcomes according to mode of delivery in women with severe preeclampsia: a cohort study.

OBJECTIVE: To determine the association between mode of delivery and maternal complications in patients with severe preeclampsia. METHODS: A prospective cohort study was conducted with 500 pregnant women with severe preeclampsia. The mode of delivery, vaginal or caesarean section, was considered the exposure, while the postpartum maternal complications and severe maternal morbidity were the outcomes. Logistic regression analysis was performed to determine the adjusted risk and 95% confidence intervals (95% CI) of maternal morbidity. RESULTS: Labour was spontaneous in 22.0% and induced in 28.2%, while 49.8% had an elective caesarean section. Ninety-five (67.4%) of the patients in whom labour was induced delivered vaginally. Total Caesarean rate was 68.2%. The risk of severe maternal morbidity was significantly greater in patients submitted to Caesarean section (54.0% versus 32.7%) irrespective of the presence of labour. Factors that remained associated with severe maternal morbidity following multivariate analysis were a diagnosis of HELLP syndrome after delivery (OR = 3.73; 95% CI: 1.55-9.88) and having a caesarean (OR = 1.91; 95% CI: 1.52-4.57). CONCLUSIONS: Caesareans are often performed in patients with severe preeclampsia and are associated with significant postpartum maternal morbidity. Induction of labour should be considered a feasible option in these patients.

Association between ACVR2A and early-onset preeclampsia: replication study in a Northeastern Brazilian population.

INTRODUCTION: Preeclampsia is a complex and heterogeneous disease with increased risk of maternal mortality, especially for earlier gestational onset. There is a great inconsistency regarding the genetics of preeclampsia across the literature. The gene Activin A receptor, type IIA (ACVR2A), was reported as associated to preeclampsia in Australian/New Zealand and Norwegian populations. The goal of this study was to validate this genetic association in a Brazilian population. METHODS: We performed a case-control study using 693 controls and 613 cases (443 preeclampsia, 64 eclampsia and 106 HELLP syndrome), from a Northeastern Brazilian population. Five single nucleotide polymorphisms (SNPs) in ACVR2A were tested for association through multiple logistic regression models. RESULTS: There was no statistical association with preeclampsia (per se), eclampsia or HELLP. However, by grouping preeclampsia in accordance to the gestational age at delivery, SNPs rs1424954 (OR = 1.86; 95% CI, 1.25-2.78; p = 0.002) and rs1014064 (OR = 1.77; 95% CI, 1.21-2.60; p = 0.004) were significantly associated with early onset preeclampsia (gestational age ≤ 34 weeks). The risk haplotype had a frequency of 0.468 in early preeclampsia compared to 0.316 in controls (p = 0.0008 and permuted p = 0.002). DISCUSSION: Activin A receptors are important in decidualization, trophoblast invasion and placentation processes during pregnancy. The gene ACVR2A was associated with the more severe early onset preeclampsia. This finding supports the hypothesis of different pathogenic mechanisms contributing to the early- and late-onset preeclampsia.

Características clínico-epidemiológicas y morbi-mortalidad materno-perinatal en pacientes con Síndrome de Hellp, atendidas en el Hospital Nacional Hipólito Unanue, 2009-2011 / Clinical-epidemiological characteristics and maternal-perinatal morbidity and mortality in patients with HELLP Syndrome, attended in the National Hospital Hipolito Unanue, 2009-2011

OBJETIVO: Determinar las características clínico-epidemiológicas y morbimortalidad materno perinatal en pacientes con síndrome de Hellp atendidas en el Hospital Nacional Hipólito Unanue, 2009-2011. METODOLOGIA: El tipo de estudio es observacional, descriptivo, retrospectivo, de corte transversal. Se trabajó con 24 pacientes con el diagnóstico de síndrome de Hellp atendidas en el Hospital Nacional Hipólito Unanue 2009-2011. Se estimaron las frecuencias absolutas y relativas de las principales variables de estudio. RESULTADOS: Se observó una edad promedio de 28.8±7 años y de manera predomínate edades con rango de 19 a 35 años (79.2 por ciento), siendo en su mayoría nulíparas (37.5 por ciento), en la mayoría de casos sin controles prenatales (66.7 por ciento). Con un promedio edad gestacional al momento del parto de 35.3±3.l semanas, con rangos que oscilan entre 35 a 42 semanas (62.5 por ciento). Asimismo las principales características clínicas observadas en el mayor porcentaje de casos se fueron: hipertensión (91.7 por ciento), Cefalea (83.3 por ciento), epigastralgia (41.7 por ciento), náuseas y vómitos (12.5 por ciento), sin embargo un 87.5 por ciento se encontró estable al ingreso por emergencia. En cuanto a los hallazgos de laboratorio más relevantes, en promedio se observó: una hemoglobina de 10.9±2.9 gr/dl, plaquetas de 119821±78911 cel/mm3, proteínas de 572±1379 mg/dl, Transaminasa Glutámico Pirúvica (TGP) de 157±154 u/l, Transaminasa Glutámico Oxalacética (TGO) de 312±462 u/l, Láctico deshidrogenasa (LDH) de 862±66.82 u/l y creatinina de 1.06±0.80 mg/dl. En consecuencia el 79.2 por ciento tuvieron plaquetopenia (<150,000 cel/mm3), un 91.7 por ciento y 66.7 por ciento tuvieron elevados los valores de TGP y TGO respectivamente, mientras que solo en el 29.2 por ciento de casos se observó presencia de proteínas en orina (ASS). Entre las complicaciones observadas en mayor porcentaje se encontraron: ascitis (41.7 por ciento), eclampsia (20.8 por ciento)...

OBJECTIVE: To determine the clinical and epidemiological characteristics maternal and perinatal morbidity and mortality in patients with HELLP syndrome treated at the National Hospital Hipolito Unanue 2009-2011. METHODOLOGY: The type of study is observational, descriptive, retrospective, cross-sectional. We worked with 24 patients with the diagnosis of HELLP syndrome treated at the National Hospital Hipolito Unanue 2009-2011. Absolute and relative major study variables were estimated frequencies. RESULTS: Mean age 28.8±7 years and ages predominate way with the rank of 19-35 years (79.2 per cent), and in its most nulliparous (37.5 per cent), in most cases without prenatal care (66.7 per cent) was observed. With an average gestational age at delivery of 35.3±3.1 weeks, with ranks ranging from 35 to 42 weeks (62.5 per cent). Also the main clinical features observed in the highest percentage of cases were hypertension (91.7 per cent), headache (83.3 per cent), epigastric pain (41.7 per cent), nausea and vomiting (12.5 per cent), however 87.5 per cent were found stable emergency admission. Regarding laboratory findings most relevant, on average was observed: hemoglobin 10.9±2.9 g/dl, platelets of 119821±78911 cells/mm3, proteins of 572±1379 mg/dl, transaminase, glutamic pyruvic transaminase (SGPT) of 157±154 u/L, glutamic oxaloacetic transaminase (SGOT) of 312±462 u/l, lactic dehydrogenase (LDH) of 862±66.82 u/l and creatinine 1.06±0.80 mg/dl. Accordingly 79.2 per cent had thrombocytopenia (<150,000 cells/mm3), 91.7 per cent and 66.7 per cent had elevated values of SGPT and SGOT, respectively, while only 29.2 per cent of cases were observed the presence of proteins in urine (ASS). Complications observed in a higher percentage were found: ascites (41.7 per cent), eclampsia (20.8 per cent), placental abruption (12.5 per cent) and acute renal failure (12.5 per cent) finally CID and pleural effusion (4.2 per cent for both cases). As treatment received methyldopa...