Download PDF
CC BY-NC-ND 4.0 · Geburtshilfe Frauenheilkd 2024; 84(07): 635-645
DOI: 10.1055/a-2308-9698
GebFra Science
Original Article

The Role of Hypertension for Maternal Outcomes of Women with HELLP Syndrome – a Retrospective Study from a Tertiary Obstetric Center

Die Rolle der Hypertonie für das mütterliche Outcome von Frauen mit HELLP-Syndrom – eine retrospektive Untersuchung aus einem geburtshilflichen Zentrum der Maximalversorgung
Linda-Marie Müller
1   Department of Obstetrics and Gynecology, University Hospital Münster, Münster, Germany
,
Maria Eveslage
2   Institute of Biostatistics and Clinical Research, University of Münster, Münster, Germany (Ringgold ID: RIN9185)
,
Helen Ann Köster
3   Clinic for Gynecology and Obstetrics, Frauenarztpraxis am Mexikoplatz, Berlin, Germany
,
Kevin Willy 
4   Department of Cardiology, University Hospital Münster, Münster, Germany (Ringgold ID: RIN39069)
,
Mareike Möllers
1   Department of Obstetrics and Gynecology, University Hospital Münster, Münster, Germany
,
Ralf Schmitz
1   Department of Obstetrics and Gynecology, University Hospital Münster, Münster, Germany
,
Kathrin Oelmeier
1   Department of Obstetrics and Gynecology, University Hospital Münster, Münster, Germany
,
Daniela Willy
1   Department of Obstetrics and Gynecology, University Hospital Münster, Münster, Germany
› Author Affiliations
› Further Information
Also available at
  Permissions and Reprints

Abstract

Introduction

HELLP syndrome is a serious disorder that can occur in pregnancy; it has many possible complications and is associated with adverse maternal outcome. Due to the lack of predictive parameters for HELLP syndrome, finding the right time for delivery is challenging. In contrast to preeclampsia, hypertension is not an essential part of the diagnosis; nevertheless, many women with HELLP syndrome are hypertensive. The role and possible implications of hypertension in HELLP syndrome are not fully understood.

Material and Methods

In this retrospective cohort study, we analyzed the maternal outcomes of 59 patients diagnosed with HELLP syndrome. The patients were divided into three groups according to their blood pressure levels during their stay in hospital. These three groups were compared in terms of patient characteristics and maternal outcomes. A combined endpoint for adverse maternal outcome was defined which included blood pressure and antihypertensive medication at discharge from hospital, severe postpartum anemia, and eclampsia.

Results

Women with hypertensive crises had an unfavorable outcome compared to women with lower blood pressure levels. Patients with higher blood pressure during pregnancy were more likely to be hypertensive at discharge and needed a combination of antihypertensive agents significantly more often. The risk of an adverse maternal outcome increased with the severity of hypertension. An increase in systolic blood pressure by 10 mmHg raised the risk of an adverse outcome by 74% (95% CI: 1.22–2.66).

Conclusion

Hypertension not only plays an important role in preeclampsia but also affects the outcomes of patients with HELLP syndrome. These patients need to be identified quickly and treated accordingly as they are at risk of cardiovascular impairment. Patients should be followed up closely after delivery to reduce cardiovascular morbidity.

Zusammenfassung

Einleitung

Das HELLP-Syndrom stellt eine ernsthafte Schwangerschaftserkrankung dar; es ist mit vielen potenziellen Komplikationen behaftet und geht mit ungünstigen mütterlichen Outcomes einher. Da es an prädiktiven Parametern für das HELLP-Syndrom fehlt, ist es schwierig, den richtigen Zeitpunkt für die Entbindung zu ermitteln. Im Gegensatz zur Präeklampsie stellt das Auftreten einer Hypertonie keinen Bestandteil der Diagnose HELLP-Syndrom dar, dennoch haben viele Frauen mit HELLP-Syndrom Bluthochdruck. Die Rolle und die möglichen Implikationen einer Hypertonie beim HELLP-Syndrom sind noch nicht vollständig erforscht.

Material und Methoden

In dieser retrospektiven Kohortenstudie haben wir die mütterlichen Outcomes von 59 Patientinnen mit HELLP-Syndrom analysiert. Die Patientinnen wurden in 3 Gruppen unterteilt entsprechend ihrem jeweiligen Blutdruckniveau während ihres Aufenthalts im Krankenhaus. Die 3 Gruppen wurden bezüglich ihrer Patientencharakteristika und mütterlichen Outcomes verglichen. Es wurde ein kombinierter Endpunkt für ungünstiges mütterliches Outcome definiert, welcher den Blutdruck der Patientin und die Einnahme blutdrucksenkender Medikamente bei der Entlassung aus dem Krankenhaus, starke Anämie postpartal sowie das Auftreten einer Eklampsie einschloss.

Ergebnisse

Frauen mit hypertensiven Krisen hatten ein ungünstigeres mütterliches Outcome verglichen mit Frauen mit niedrigerem Blutdruck. Patientinnen mit Bluthochdruck während der Schwangerschaft hatten eher Bluthochdruck und benötigten signifikant häufiger eine Kombination blutdrucksenkender Mittel bei der Entlassung aus dem Krankenhaus. Das Risiko eines ungünstigen mütterlichen Outcomes nahm mit dem Schweregrad der Hypertonie zu. Eine Erhöhung des systolischen Blutdrucks um 10mmHg erhöhte das Risiko eines ungünstigen Ergebnisses um 74% (95%-KI [1.22–2.66]).

Schlussfolgerung

Die Hypertonie spielt nicht nur bei der Präeklampsie eine wichtige Rolle, sie beeinflusst auch das Outcome von Patientinnen mit HELLP-Syndrom. Diese Patientinnen müssen schnell identifiziert und entsprechend behandelt werden, da sie ein höheres Risiko für kardiovaskuläre Schäden haben. Ein engmaschiges Programm zur Überwachung dieser Patientinnen nach der Entbindung sollte eingeführt werden, um die kardiovaskuläre Morbidität zu senken.

Keywords

HELLP syndrome - arterial hypertension - hypertensive crisis - cardiovascular risk - hypertension in pregnancy

Schlüsselwörter

HELLP-Syndrom - arterielle Hypertonie - hypertensive Krise - kardiovaskuläres Risiko - Hypertonie in der Schwangerschaft

Supplementary Material



Publication History

Received: 18 January 2024

Accepted after revision: 17 April 2024

Article published online:
17 May 2024

© 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Sibai BM, Ramadan MK, Usta I. et al. Maternal morbidity and mortality in 442 pregnancies with hemolysis, elevated liver enzymes, and low platelets (HELLP syndrome). Am J Obstet Gynecol 1993; 169: 1000-1006
    CrossrefPubMedSearch in Google Scholar
  • 2 Sibai BM. Diagnosis, controversies, and management of the syndrome of hemolysis, elevated liver enzymes, and low platelet count. Obstet Gynecol 2004; 103: 981-991
    CrossrefPubMedSearch in Google Scholar
  • 3 Gasem T, Al Jama FE, Burshaid S. et al. Maternal and fetal outcome of pregnancy complicated by HELLP syndrome. J Matern Fetal Neonatal Med 2009; 22: 1140-1143
    CrossrefPubMedSearch in Google Scholar
  • 4 [Anonym]. Hypertensive Pregnancy Disorders: Diagnosis and Therapy. Guidline of the German Society of Gynecology and Obstetrics (S2k-Level, AWMF-Registry No. 015/018, March 2019). Accessed January 18, 2024 at: https://register.awmf.org/de/leitlinien/detail/015-018
    PubMed
  • 5 Petca A, Miron BC, Pacu I. et al. HELLP Syndrome-Holistic Insight into Pathophysiology. Medicina (Kaunas) 2022; 58: 326
    CrossrefPubMedSearch in Google Scholar
  • 6 Haram K, Svendsen E, Abildgaard U. The HELLP syndrome: clinical issues and management. A Review. BMC Pregnancy Childbirth 2009; 9: 8
    CrossrefPubMedSearch in Google Scholar
  • 7 Abildgaard U, Heimdal K. Pathogenesis of the syndrome of hemolysis, elevated liver enzymes, and low platelet count (HELLP): a review. Eur J Obstet Gynecol Reprod Biol 2013; 166: 117-123
    CrossrefPubMedSearch in Google Scholar
  • 8 Stepan H, Kuse-Föhl S, Klockenbusch W. et al. Diagnosis and Treatment of Hypertensive Pregnancy Disorders. Guideline of DGGG (S1-Level, AWMF Registry No. 015/018, December 2013). Geburtshilfe Frauenheilkd 2015; 75: 900-914
    Thieme ConnectPubMedSearch in Google Scholar
  • 9 Wallace K, Harris S, Addison A. et al. HELLP Syndrome: Pathophysiology and Current Therapies. Curr Pharm Biotechnol 2018; 19: 816-826
    CrossrefPubMedSearch in Google Scholar
  • 10 Cavkaytar S, Ugurlu EN, Karaer A. et al. Are clinical symptoms more predictive than laboratory parameters for adverse maternal outcome in HELLP syndrome?. Acta Obstet Gynecol Scand 2007; 86: 648-651
    CrossrefPubMedSearch in Google Scholar
  • 11 Bezircioğlu I, Baloğlu A, Cetinkaya B. et al. Do clinical and laboratory parameters effect maternal and fetal outcomes in pregnancies complicated with hemolysis, elevated liver enzymes, and low platelet count syndrome?. J Turk Ger Gynecol Assoc 2012; 13: 1-7
    CrossrefPubMedSearch in Google Scholar
  • 12 Willy D, Willy K, Köster H-A. et al. Blood Pressure Levels and Maternal Outcome in Women with Preeclampsia – a Retrospective Study from a Large Tertiary Obstetric Centre. Geburtshilfe Frauenheilkd 2022; 82: 528-534
    Thieme ConnectPubMedSearch in Google Scholar
  • 13 Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy. Obstet Gynecol [Anonym]. 2013; 122: 1122-1131
    CrossrefPubMedSearch in Google Scholar
  • 14 Williams B, Mancia G, Spiering W. et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension. J Hypertens 2018; 36: 1953-2041
    CrossrefPubMedSearch in Google Scholar
  • 15 Marcus R, Peritz E, Gabriel KR. On closed testing procedures with special reference to ordered analysis of variance. Biometrika 1976; 63: 655-660
    CrossrefPubMedSearch in Google Scholar
  • 16 Tita AT, Szychowski JM, Boggess K. et al. Treatment for Mild Chronic Hypertension during Pregnancy. N Engl J Med 2022; 386: 1781-1792
    CrossrefPubMedSearch in Google Scholar
  • 17 Aziz N, Kumar S. Clinical symptoms and laboratory parameters do not predict adverse maternal and fetal outcomes in HELLP. Pregnancy Hypertens 2011; 1: 132-136
    CrossrefPubMedSearch in Google Scholar
  • 18 Miranda ML, Vallejo-Vaz AJ, Cerrillo L. et al. The HELLP syndrome (hemolysis, elevated liver enzymes and low platelets): Clinical characteristics and maternal-fetal outcome in 172 patients. Pregnancy Hypertens 2011; 1: 164-169
    CrossrefPubMedSearch in Google Scholar
  • 19 Lind Malte A, Uldbjerg N, Wright D. et al. Prediction of severe pre-eclampsia/HELLP syndrome by combination of sFlt-1, CT-pro-ET-1 and blood pressure: exploratory study. Ultrasound Obstet Gynecol 2018; 51: 768-774
    CrossrefPubMedSearch in Google Scholar
  • 20 Verlohren S, Brennecke SP, Galindo A. et al. Clinical interpretation and implementation of the sFlt-1/PlGF ratio in the prediction, diagnosis and management of preeclampsia. Pregnancy Hypertens 2022; 27: 42-50
    CrossrefPubMedSearch in Google Scholar
  • 21 Huang H, Liu B, Gao X. et al. Clinical Classification, Pregnancy Outcomes and Risk Factors Analysis of Severe Preeclampsia Complicated With HELLP Syndrome. Front Surg 2022; 9: 859180
    CrossrefPubMedSearch in Google Scholar
  • 22 Riemer M, Schulze S, Wagner L. et al. Cardiovascular Risk Reduction in Women Following Hypertensive Disorders of Pregnancy – a Prospective, Randomised, Controlled Interventional Study. Geburtshilfe Frauenheilkd 2021; 81: 966-978
    Thieme ConnectPubMedSearch in Google Scholar
  • 23 Chames MC, Haddad B, Barton JR. et al. Subsequent pregnancy outcome in women with a history of HELLP syndrome at < or = 28 weeks of gestation. Am J Obstet Gynecol 2003; 188: 1504-1507
    CrossrefPubMedSearch in Google Scholar
  • 24 van Oostwaard MF, Langenveld J, Schuit E. et al. Recurrence of hypertensive disorders of pregnancy: an individual patient data metaanalysis. Am J Obstet Gynecol 2015; 212: 624.e1-624.e17
    CrossrefPubMedSearch in Google Scholar
  • 25 Sibai BM, Ramadan MK, Chari RS. et al. Pregnancies complicated by HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets): subsequent pregnancy outcome and long-term prognosis. Am J Obstet Gynecol 1995; 172: 125-129
    CrossrefPubMedSearch in Google Scholar
  • 26 Orabona R, Vizzardi E, Sciatti E. et al. Maternal cardiac function after HELLP syndrome: an echocardiography study. Ultrasound Obstet Gynecol 2017; 50: 507-513
    CrossrefPubMedSearch in Google Scholar
  • 27 Sciatti E, Mohseni Z, Orabona R. et al. Maternal myocardial dysfunction after hemolysis, elevated liver enzymes, and low platelets syndrome: a speckle-tracking study. J Hypertens 2021; 39: 1956-1963
    CrossrefPubMedSearch in Google Scholar
  • 28 Sciatti E, Orabona R, Prefumo F. et al. Elastic properties of ascending aorta and ventricular-arterial coupling in women with previous pregnancy complicated by HELLP syndrome. J Hypertens 2019; 37: 356-364
    CrossrefPubMedSearch in Google Scholar
  • 29 Schausberger CE, Jacobs VR, Bogner G. et al. Hypertensive Disorders of Pregnancy – A Life-Long Risk?!. Geburtshilfe Frauenheilkd 2013; 73: 47-52
    Thieme ConnectPubMedSearch in Google Scholar
  • 30 Riemer M, Schulze S, Wagner L. et al. Cardiovascular Risk Reduction in Women Following Hypertensive Disorders of Pregnancy – a Prospective, Randomised, Controlled Interventional Study. Geburtshilfe Frauenheilkd 2021; 81: 966-978
    Thieme ConnectPubMedSearch in Google Scholar
  • 31 Li B, Yang H. Comparison of clinical features and pregnancy outcomes in early- and late-onset preeclampsia with HELLP syndrome: a 10-year retrospective study from a tertiary hospital and referral center in China. BMC Pregnancy Childbirth 2022; 22: 186
    CrossrefPubMedSearch in Google Scholar