Introduction: HELLP syndrome is a variant of preeclampsia that evolves with hemolysis, elevated transaminases and bilirubin as well as thrombocytopenia, being able to generate severe complications during gestation.

Objective and Methodology: We did a retrospective study over a period of 6 years (2013-2018) on incidence, timing and complications generated by HELLP syndrome. At a total of 14,883 births, we reported 12 cases of HELLP syndrome representing 0.08%. At the same time it represents 5.06% of preeclampsia cases and 1.36% of the total pregnancies that have evolved with pregnancy-induced hypertension. At a number of 877 tasks that evolved with the HTA induced by pregnancy, preeclampsia cases were in the number of 238 (27.13%), and those with HELLP syndrome in the number of 12 (1.36%).

Results: All 12 cases OF HELLP syndrome were born prematurely by disrupting the course of pregnancy through the predominantly performed Caesarean section, in the percentage of 75% in maternal interest and 25% in the fetal interest resulting only in grade III and IV premature who died 2, both antepartum.

Conclusions: Hepatic impairment by cytolysis, secondary anemia, thrombocytopenia, cause the syndrome to be the determining factor of premature birth and chronic fetal suffering.

Pregnancy, Preeclampsia, Prematurity

George D, Maria APM, Casiana B, Mirela F, AdrianG, et al. (2023) The Incidence of HELLP Syndrome as a Complication of Preeclampsia and As a Determining Factor of Premature Birth. Ann Clin Exp Hypertension 8(1): 1062.

One of the high blood pressure (HBP) induced complications of pregnancy is also the HELLP syndrome. It was first observed in 1954 by Pritchard [1-3] and is defined by Weinstein as the association of 3 biological disorders with preeclampsia [4-7]:

1. Hemolysis H

2. levated Liver enzymes EL

3. Low Platelets LP

Over time, each of these symptoms underwent changes in fracture limits, with the exception of thrombocytopenia whose diagnostic value remained constant, ie the platelet count was below 100,000 / ml [8] (Table 1).

Table 1: Representing the studied lot according to incidence of HELLP syndrome, preeclampsia and pregnancy-induced HTA-induced pregnancies.

Although some authors consider HELLP syndrome to be a simple syndrome, its association with preeclampsia makes us consider it a complication of pregnancy-induced hypertension, although mortality up to 24% is not always related to the syndrome but rather preeclampsia [4,5].

The name of the syndrome results from the acronym of the main HELLP symptoms. Mac Kaena rated the frequency in 12% of cases of eclampsia [9] compared to other authors who considered an incidence of 10-14% in preeclampsia patients and 30% in those with eclampsia. It is also estimated that in 69% of cases, the syndrome occurs antepartum and 30% postpartum in the early hours [6,10].

At present, it is estimated that within the syndrome thrombocytopenia is below 100,000 / ml [11], hemolytic anemia characterized by the presence of schizocytes in peripheral blood smear, decreased haptoglobin, bilirubin binding greater than 12 mg / l and lactate hydrogenease (LDH) values above 600 U / l and cytolysis characterized by increased transaminases (GOT and GPT) greater than 70 U / l [12-14,6,2,3,15].

Perinatal mortality varies between 7.7 and 60%, fetal intrauterine death being estimated at 19.3%, fetal mortality not related to common syndrome [16,17].

 HELLP syndrome may be associated with an increased risk of abruption of normal inserted placenta [18,10], hepatic subcapsular hematoma, renal failure [16,19,15], pulmonary edema, CID [4,13,20,21], AVC, premature birth [22,23] fetal death in utero and maternal death [24].

There is a risk of post-operative bleeding and tendency to form wound hematomas, especially abdominal, in these pregnant women.

Clinical symptoms are nonspecific, consisting of:

- Epigastric papules

- Dyspeptic phenomena

- Pseudogripal phenomenon

Sometimes elevated blood pressure (BP) may be missing from the clinical picture [10,16,8]. Pregnancy with HELLP syndrome will be treated as a pregnant woman with severe preeclampsia, a particular focus being on treating coagulation problems [25,26].

Management of HELLP syndrome treatment should assess the preferred birth-time decision point to over 34 weeks of gestation [22,25,27]. Prior to 34 weeks of gestation, it may be tempting to go through this gestational age to receive a steroid cure for lung maturation and prophylaxis of respiratory distress syndrome [26,24]. This is done through strict echographic, cardiotocographic and blood pressure monitoring.

At the base of the HELLP syndrome, there is preeclampsia, which at its origin has acute hypertension occurring in the last trimester of pregnancy, with the exception of glomerulonephrites [10,16]. Sibai was the one who resumed the initial criteria he had completed [2,3]. In the cytopathogenicity of preeclampsia there are a number of placental changes that generate placental ischemia [4,5,18,17,19,21,29,30,15].

We conducted a 6-year retrospective study (2013-2018) looking at maternal-fetal incidence, treatment, progression and prognosis in these particularly serious cases with regard to the HELLP syndrome.

In a total of 14,883 births that occurred during the 6 years studied, 12 cases of HELLP syndrome were reported, representing 0.08%. At the same time, this represents 5.06% of cases of preeclampsia and 1.36% of all pregnancies that have evolved with pregnancy-induced HBP. The incidence of all pregnancies evolved with pregnancy-induced HBP, including preeclampsia and HELLP syndrome, was 877 cases, representing 5.89%. Of these, preeclampsia cases were 238 (27.13%), and those with HELLP syndrome 12 (1.36%) .

The 12 cases of HELLP syndrome occurred in 5 cases (41.66%), in 4 cases (33.33%) secondary and in 3 cases (25%) in multiple gaps. At the same time after parity in 6 (50%) cases occurred in primipara, in 5 (41.66%) secundipara and in one case (8.33%) multipara (Table 1-3), showing the group studied after gestation.

Table 2: Representing the Studied Lot According To Gestation

Table 3: Representing the Studied Lot According To Parity

After the residence area, 9 cases (75%) were from the urban area and 3 (28%) from the rural area. From the total number of cases that evolved with HELLP syndrome, one (8.33%) was a twin pregnancy. Thus, from the pregnancies that developed HELLP syndrome, 13 newborns resulted, 12 of which had a weight of less than 2500 g, all premature, of which in 6 (50%), the birth weight was between 500-1000 g, and in 6 (50%) of cases the birth weight was between 1001-1500 g, hence the HELLP syndrome is involved as the decisive factor in the premature birth etiology, all 12 cases having premature birth, of which they have premature third and fourth grade results. All of these births were resolved by cesarean section performed in maternal and fetal interest. Of the newborns resulting from these pregnancies, two girls died, one (8.33%) being born dead and one (8.33%) with Apgar 2 at birth. We mention that there were 168 premature births from pregnancies that evolved with PIH, preeclampsia and HELLP syndrome, accounting for 19.15% of them (Table 4-7).

Table 4: presenting the distribution of premature births to evolved cases that evolved with PIH, preeclampsia HELLP Syndrome.

Table 5: Presenting the Premature Births Associated With PIH

Table 6: Presenting the Studied Lot According To Age

Table 7: Presenting the Studied Lot According To The Apgar Score Associated With Hellp Syndrome

After the age of pregnant women who developed HELLP syndrome, I found that 91.65% were under the age of 30 and only one case (8.33%) was 35 years. The mean age of the studied lot was 28 years 8 months 3 days.

After gestational age 7 (78.33%) had gestational age below 28 weeks, 4 (33.32%) with 29-30 weeks and 1 case (8.33%) 35 weeks (Graph 1-6).

After the prematurity of newborns resulting from pregnancies that evolved with PIH, preeclampsia and HELLP syndrome, the situation was the following (Table 8-10):

Table 8: Representing the Studied Lot According To the Gender of the Newborns Resulted From Pregnancies Complicated With Hellp Syndrome

Table 9: Representing the Studied Lot According To platelet Count

Table 10: representing the studied lot according to transaminase value

-prematurity gr.I 2001-2500g 67 cases (39.88%)

-Prematurity gr.II 1501-2000g 40 cases (23.80%)

-Prematurity gr.III 1001-1500g 30 cases (19.04%)

-Prematurity gr.VI 500-1000g 29 cases (17.26%) Total 168 cases (99.98%)

Out of the total of 1631 premature births, representing a 10.95% prematurity, 877 (53.77%) were premature births resulting from pregnancies that evolved with PIH regardless of form.

According to APGAR score at birth, 10 (83.33%) newborns had APGAR 0-6 and only 2 (16.66%) cases had an APGAR score of 7-8. This proves an advanced degree of the antepartum fetal suffering of these girls.

Without any special significance, we mention that 8 (66.66%) were male and 4 (33.33%) female.

HELLP syndrome is a clinical but especially laboratory syndrome that complicates about 20% of cases of severe preeclampsia [15] on our lot of 5.06%. From this point of view, 5 (41.66%) of the cases presented thrombocytopenia with a platelet count of 20,000-50,000, in 4 (33.33%) with a value between 50,000-60,000 / mm3 and in 3 cases (25%) with a value between 60,000 to 80,000 / mm3.

Even if the value of the transaminases oscillated, they were increased, sometimes even exaggerated, with 74.99% having values above 100 (Table 11,12).

Tabel 11: Representing the Evolution of Hepatic Parameters during Pregnancy [30]

Tabel 12: Representing the Evolution of Other Factors during Pregnancies Associated With Hellp Syndrome

Proteinuria had elevated levels between 3-5 g and a total proteinemia generally lower between 4.5-6 g%. Also in all cases we found a decrease in fibrinogen below 100 mg / ml.

The clinical symptoms encountered by us on the studied group were as follows:

- Epigastria pain commonly found in all cases -dyspeptic simptoms in 75% of cases

- Pseudogripal phenomenon - we did not notice our lot

- Increased values of arterial tension can be missed sometimes, but we have not met any cases in the lot we studied

From a clinical point of view, arterial blood tension values were increased with diastolic TA at least 110 mmHg and maximum 180-200 mmHg rebels to treatment. Symptomatically, pregnant women accused of headache, epigastralgia, pain in the right hippocampus, icteric coloration of sclera and tegument, anorexiaand fatigue.

f pregnancy, which reveals the role of placenta in the etiopathogenesis of the syndrome [21,28,29,15].

HELLP syndrome can cause a number of complications, even the risk of postoperative bleeding occurring in a disseminated intravascular coagulation syndrome or afibrinogenemia. In assessing changes in some parameters during HELLP syndrome, we must also keep in mind the physiological changes of some liver parameters that occur during pregnancy [30].

In comparison with these parameters, the following changes are observed in HELLP syndrome:

The perinatal mortality of newborns resulting from pregnancies that evolved with HELLP syndrome was 2 cases, representing 16.66% of all fetal deaths, of which one case (8.33%) occurred antepartum. This, along with the APGAR index at birth, proves the involvement of the syndrome in the occurrence of fetal distress.

1. HELLP syndrome is a variant of preeclampsia with fetal distress, haemolysis, elevated transaminase and bilirubin levels, and a decrease in thrombocytes in luckily being rare

2. The incidence of HELLP syndrome on the group we studied was 0.08% of all pregnancies and in 1.36% of pregnancies that evolved with PIH

3. Currently the role of placenta is well defined in the etiopathogenesis of the syndrome, the placental ischemia phenomena having a determinant role

4. HELLP Syndrome is a determinant of premature birth in all cases studied by us resulting in premature newborns of Grade III and IV

5. Hepatic impairment, by cytolysis, secondary anemia and thrombocytopenia make the syndrome a determinant of premature birth and fetal suffering

6. Coagulation disorders caused by severe thrombocytopenia and decreased fibrinogen value are the basis for the occurrence of disseminated intravascular coagulation syndrome which may worsen both maternal and fetal prognosis 7. In preterm newborns of third and fourth grade in our group resulting from pregnancies that evolved with HELLP syndrome, the mortality was 2 cases (16.66%) of which a death was anepartum 8. The incidence of premature birth in pregnancies that evolved with HTAIS is double compared with the pregnancies that evolved without HTAIS that means 20.75% versus 10.95

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