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Hantavirus and dengue virus infections lead to diseases causing economic and public health concerns. Acute hantavirus infections can lead to similar clinical haemorrhagic signs as other endemic diseases including dengue and leptospirosis. Using a retrospective case analysis of pregnant dengue and hantavirus disease patients with clinical reports and compatible clinical laboratory information during pregnancy, we report the first evidence of dengue and hantavirus infections and a case of dual dengue and hantavirus infection among pregnant women in the Caribbean. Laboratory testing by enzyme-linked immunosorbent assay (ELISA) and non-structural protein 1 (NS1) for DENV and for hantavirus infection pseudotype focus reduction neutralisation tests (pFRNT), ELISA and immunochromatographic (ICG) strips. Four pregnant cases with acute DENV infections were identified; however, only one out of the four cases (25%) had a detailed medical record to permit abstraction of clinical data. Six hantavirus infected pregnant cases were identified with gestation periods ranged from 36 to 39 weeks; none of the reported patients exhibited previous pregnancy complications prior to hospitalisation and infection. Acute liver damage was observed in three of the six cases (AST readings) who were subsequently diagnosed with hepatitis in pregnancy and variable clinical outcomes were observed with term and pre-term deliveries. Whilst hantavirus infection in pregnancy is rare, consideration should be given to differential diagnosis with fever, kidney involvement, liver involvement, haemorrhagic symptoms and thrombocytopenia in endemic areas with clinically similar diseases such as dengue and leptospirosis. First recorded case of hantavirus and dengue co-infection in a pregnant woman. First detailed report of clinical hantavirus infection in pregnant women in the Caribbean. First published report of clinical dengue infection in pregnant woman in the Caribbean. Possible complications of pregnancy following hantavirus infection. Pre-term birth and low birth weights. Clinical course of hantavirus infection in a Caribbean population. [ABSTRACT FROM AUTHOR]

Thrombotic microangiopathies (TMAs) comprise a distinct group of diseases with different manifestations that can occur in both pediatric and adult patients. They can be hereditary or acquired, with subtle onset or a rapidly progressive course, and they are particularly known for their morbidity and mortality. Pregnancy is a high-risk time for the development of several types of thrombotic microangiopathies. The three major syndromes are hemolysis, elevated liver function tests, and low platelets (HELLP); hemolytic uremic syndrome (HUS); and thrombotic thrombocytopenic purpura (TTP). Because of their rarity, clinical information and therapeutic results related to these conditions are often obtained from case reports, small series, registries, and reviews. The collection of individual observations, the evolution of diagnostic laboratories that have identified autoimmune and/or genetic abnormalities using von Willebrand factor post-secretion processing or genetic–functional alterations in the regulation of alternative complement pathways in some of these TMAs, and, most importantly, the introduction of advanced treatments, have enabled the preservation of affected organs and improved survival rates. Although TMAs may show different etiopathogenesis routes, they all show the presence of pathological lesions, which are characterized by endothelial damage and the formation of thrombi rich in platelets at the microvascular level, as a common denominator, and thrombotic damage to microcirculation pathways induces "mechanical" (microangiopathic) hemolytic anemia, the consumption of platelets, and ischemic organ damage. In this review, we highlight the current knowledge about the diagnosis and management of these complications during pregnancy. [ABSTRACT FROM AUTHOR]

This study aimed to evaluate the association between human chorionic gonadotropin and adverse pregnancy outcomes. Medline, Embase, PubMed, and Cochrane were searched in November 2021 using Medical Subject Headings (MeSH) and relevant key words. This analysis included published full-text studies of pregnant women with serum human chorionic gonadotropin testing between 8 and 28 weeks of gestation, investigating fetal outcomes (fetal death in utero, small for gestational age, preterm birth) or maternal factors (hypertension in pregnancy: preeclampsia, pregnancy-induced hypertension, placental abruption, HELLP syndrome, gestational diabetes mellitus). Studies were extracted using REDCap software. The Newcastle–Ottawa scale was used to assess for risk of bias. Final meta-analyses underwent further quality assessment using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) method. A total of 185 studies were included in the final review, including the outcomes of fetal death in utero (45), small for gestational age (79), preterm delivery (62), hypertension in pregnancy (107), gestational diabetes mellitus (29), placental abruption (17), and HELLP syndrome (2). Data were analyzed separately on the basis of categorical measurement of human chorionic gonadotropin and human chorionic gonadotropin measured on a continuous scale. Eligible studies underwent meta-analysis to generate a pooled odds ratio (categorical human chorionic gonadotropin level) or difference in medians (human chorionic gonadotropin continuous scale) between outcome groups. First-trimester low human chorionic gonadotropin levels were associated with preeclampsia and fetal death in utero, whereas high human chorionic gonadotropin levels were associated with preeclampsia. Second-trimester high human chorionic gonadotropin levels were associated with fetal death in utero and preeclampsia. Human chorionic gonadotropin levels are associated with placenta-mediated adverse pregnancy outcomes. Both high and low human chorionic gonadotropin levels in the first trimester of pregnancy can be early warning signs of adverse outcomes. Further analysis of human chorionic gonadotropin subtypes and pregnancy outcomes is required to determine the diagnostic utility of these findings in reference to specific cutoff values. [ABSTRACT FROM AUTHOR]

Objective: To determine the etiologies and outcomes of liver disease in pregnancy in a developing country. Method: A total of 336 consecutive pregnant women with liver disease were included in this prospective cohort study conducted at the Department of Gastroenterology, Jinnah Postgraduate Medical Center, Karachi from August 2019 to August 2021. Patients' baseline demographic, clinical, and laboratory data and outcomes were collected on a pre-designed questionnaire. Results: Among all the pregnant females, the most common liver disease was acute hepatitis E virus (HEV) infection (37.2%), followed by preeclampsia (PEC)/eclampsia (EC), hemolysis, elevated liver enzymes & low platelets (HELLP) syndrome, and hyperemesis gravidarum (HG). The most common maternal complications were fulminant hepatic failure (FHF) in 14.9% and placental abruption in 11.0%. Fetal complications included intrauterine death (IUD) in 20.8% and preterm birth in 8.6%. The maternal and neonatal mortality rates were 11.6% and 39.6%, respectively. Among the predictors, low maternal weight, low body mass index (BMI), and low hemoglobin (Hb) were associated with increased maternal mortality. Low fetal weight, height, maternal systolic blood pressure (SBP), and low maternal Hb were independent predictors of fetal mortality. Conclusion: In our cohort of pregnant females in a tertiary care medical center, acute HEV was the most common liver disease, followed by PEC/EC, HELLP, and HG. Maternal and fetal deaths were alarming in this group of patients and demanded careful management. [ABSTRACT FROM AUTHOR]

To compare risk factors, biochemical parameters, maternal and fetal health parameters of Early onset preeclampsia and Late onset preeclampsia in Central India at tertiary care centre. Methods: At a tertiary care institute in Central India, a prospective study was conducted. 75 women in each, EOP and LOP, were studied based on development of preeclampsia before and after 34 weeks of gestation respectively. Risk factors, biochemical parameters, maternal and perinatal outcomes were compared between the groups to get a better idea in understanding etiopathogenesis and its implications on Indian Population. Results: The results concluded that Mean Gestational age in EOP was 31.8 weeks than 37.9 in LOP. 50.67% and 37.3% ICU admissions were seen in EOP and LOP respectively due to more incidence of maternal morbidities in EOP. In EOP and LOP still births were 21.3% and 9.3% respectively. More number of NICU admissions were seen in EOP than LOP; 30.7% and 8% respectively. Conclusion: The results concluded that Early onset preeclampsia is comparatively associated with more severe maternal and perinatal outcomes, which was statistically significant. Biochemical parameters were more deranged in Early onset preeclampsia. Inconclusive results were found on comparison of known risk factors of preeclampsia between both groups. [ABSTRACT FROM AUTHOR]

Introduction: Hypertensive disorders are the most common medical disorders encountered in pregnancy approximately 7% to 10% of all pregnancies. Hypertensive disorders are associated with foetal growth restriction, perinatal asphyxia, Iatrogenic prematurity, still births, preterm delivery, perinatal death, neonatal mortality and affects vital maternal organ system such as hepatic, renal, cardiorespiratory, cerebral and haematologic leading to maternal morbidity and mortality. The aim of the study was to assess the prevalence of severe pre-eclampsia, eclampsia and HELLP syndrome in our Hospital and its maternal and foetal outcome. Materials and Methods: This is retrospective study done in Department of Obstetrics and Gynaecology, Government General Hospital, Guntur over a period of six months (July 2023 to December 2023). All women presenting with severe pre-eclampsia, pre-eclampsia with imminent features, eclampsia and HELLP syndrome attending Labour room, Government General hospital Guntur were included in this study. Women with gestational HTN, nonsevere pre-eclampsia, chronic HTN were excluded. Ethical approval was obtained from institutional ethical committee. Out of all the total deliveries, 130 were studied. All detailed data such as demographic data, maternal age, parity, mode of delivery, obstetrical history, obstetric outcome, maternal complications, and foetal outcome were recorded. Results: 130 cases were recorded out of 3007deliveries. Among these, 66 cases were severe pre-eclampsia (50.76%),33 cases were imminent eclampsia(25.38%), 27 cases were Eclampsia(20.76%), four cases were HELLP syndrome(3%). The total prevalence was4.32% in our study. Majority of them were primigravida(61.53%) and belong to an age group of 20 to 25 (60%). Majority of them were delivered by caesarean section (67.69%). Most complications were seen in the eclampsia group. Prematurity was seen in 60.75% and LBW seen in 40.57%. 10 cases were IUD and 15 were neonatal deaths. Conclusion: It is one of the important causes of maternal and perinatal morbidity and mortality probably resulting from inadequate and suboptimal antenatal care and lack of education and awareness amongst people belonging to low socio-economic status. The high prevalence of hypertensive disorders complicates the maternal and foetal outcome. Antenatal surveillance, early detection, prompt treatment and early intervention and timely termination of pregnancy could reduce the maternal morbidity and mortality. [ABSTRACT FROM AUTHOR]

Abstract Background HELLP syndrome refers to a group of clinical syndromes characterized by hemolysis, elevated liver enzymes and low platelet, and the evidence on the association between proteinuria and the severity of HELLP and its maternal and neonatal outcomes is rare. Methods 106 pregnant women were assigned to the proteinuric group (24-hUPro ≥ 0.3 g, 79 cases) and the non-proteinuric group (24-hUPro

There is currently little known about the complex interaction between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and pregnancy. Past data from MERS-CoV and SARS-CoV-1 indicated that infection was associated with an adverse neonatal outcome. A 20-year-old primigravida presented at 23 weeks gestation and was found to have severe pre-eclampsia complicated by HELLP syndrome (haemolysis, elevated liver enzymes, low platelets) and acute fatty liver of pregnancy (AFLP). She had no respiratory symptoms and only one documented elevated body temperature from the referring facility. She was subsequently found to be COVID-19 positive. Within several hours of admission, she had an intrauterine demise. Following delivery, her condition steadily improved. COVID-19 may worsen pre-eclampsia leading to an adverse outcome. Obstetricians should be aware of the possible negative impact of COVID-19 on hypertensive disorders of pregnancy and the need for further research on this complex relationship.

ABSTRACTBackground HELLP syndrome, featuring hemolysis, elevated liver enzymes, and thrombocytopenia, is life-threatening disease of pregnancy that triggers comorbidities in both pregnant women and the fetus/newborn. This study provides an updated systematic review and meta-analysis of relevant studies to assess the therapeutic efficacy of corticosteroids in maternal and neonatal outcomes.Methods Randomized control trials (RCTs) regarding the use of corticosteroids in the HELLP population from three electronic databases, including Ovid MEDLINE, Ovid EMBASE, andCochrane Central Register of Controlled Trials, were searched from database inception to 23 March 202323 March 2023.Results A total of 485 patients treated with corticosteroids from 7 RCTs were included. Compared to placebo, corticosteroids therapy failed to significantly improve the maternal outcomes regard to maternal morbidity (RR = 1.36, 95%CI [0.45, 4.10]), eclampsia (RR = 1.16, 95%CI [0.76, 1.77]), acute renal failure (RR = 0.71, 95%CI [0.41, 1.22]), pulmonary edema (RR = 0.34, 95%CI [0.10, 1.15]) and oliguria (RR = 1.08, 95%CI [0.75, 1.54]). In addition, pooled data showed that it wasn’t significant differences between corticosteroids therapy and placebo regarding neonatal outcomes.Conclusions This study compared the efficacy of corticosteroids in patients with HELLP syndrome, revealing that corticosteroids did not provide any significant benefit in clinical outcomes for pregnant women and newborns with HELLP. The conclusions of this study must be verified by a larger sample of high-quality RCTs.

Background: Current knowledge regarding the association between trimester-specific changes during pregnancy and COVID-19 infection is limited. We utilized the National Inpatient Sample (NIS) database to investigate trimester-specific outcomes among hospitalized pregnant women diagnosed with COVID-19. Results: Out of 3,447,771 pregnant women identified, those with COVID-19 exhibited higher in-hospital mortality rates in their third trimester compared with those without the virus. Notably, rates of mechanical ventilation, acute kidney injury, renal replacement therapy, and perinatal complications (preeclampsia, HELLP syndrome, and preterm birth) were significantly elevated across all trimesters for COVID-19 patients. COVID-19 was found to be more prevalent among low-income, Hispanic pregnant women. Conclusions: Our findings suggest that COVID-19 during pregnancy is associated with increased risk of maternal mortality and complications, particularly in the third trimester. Furthermore, we observed significant racial and socioeconomic disparities in both COVID-19 prevalence and pregnancy outcomes. These findings emphasize the need for equitable healthcare strategies to improve care for diverse and socioeconomically marginalized groups, ultimately aiming to reduce adverse COVID-19-associated maternal and fetal outcomes. [ABSTRACT FROM AUTHOR]

HELLP syndrome is characterized by hemolysis, elevated liver enzymes, and a low platelet count and poses an increased risk to the pregnant woman and the unborn child. Individual risk factors such as obesity may alter immunocompetence and influence the course of preeclampsia (PE) or HELLP syndrome. Blood samples were collected from 21 pregnant women (7 healthy, 6 with PE, and 8 with HELLP syndrome) and polymorphonuclear neutrophils (PMNs) were subsequently isolated. Production of radical oxygen species (ROS), cell movement, and NETosis were assessed by live-cell imaging. Surface protein expression and oxidative burst were analyzed by flow cytometry. PE and HELLP patients had significantly higher BMI compared to the healthy control group. Depending on the expression of CD11b, CD62L, and CD66b on PMNs, a surface protein activation sum scale (SPASS) was calculated. PMNs from patients with high SPASS values showed prolonged and more targeted migration with delayed ROS production and NETosis. Obesity is associated with a chronic inflammatory state, which in combination with immunological triggers during pregnancy could modulate PMN functions. Pregnant women with higher BMI tend to have higher SPASS values, indicating activation of the innate immune system that could co-trigger PE or HELLP syndrome. [ABSTRACT FROM AUTHOR]

Synopsis: Not only AFLP but also HELLP and acute liver failure due to viruses in pregnancy meet the Swansea criteria, meriting a reappraisal and a reevaluation of the criteria. [ABSTRACT FROM AUTHOR]

Background: HELLP syndrome refers to a group of clinical syndromes characterized by hemolysis, elevated liver enzymes and low platelet, and the evidence on the association between proteinuria and the severity of HELLP and its maternal and neonatal outcomes is rare. Methods: 106 pregnant women were assigned to the proteinuric group (24-hUPro ≥ 0.3 g, 79 cases) and the non-proteinuric group (24-hUPro < 0.3 g, 27 cases). The proteinuric group was further divided into three subgroups: mild group (24-hUPro:0.3-2.0 g, 33 cases), moderate group (24-hUPro:2.0-5.0 g, 21 cases) and severe group (24-hUPro: ≥5.0 g, 25 cases). The general clinical data, laboratory indexes, complications and pregnancy outcome and adverse neonatal outcomes of HELLP with or without proteinuric were analyzed. Results: Compared with proteinuric group, the non-albuminuric group or in the three proteinuric subgroups of HELLP pregnant women's, increased proteinuria was associated with earlier onset gestations, higher incidence of abdominal pain, skin jaundice, headache, blurred vision (p < 0.05 respectively), and also the higher levels of ALT, AST, LDH, Fib, APTT, ATII, proportions of tubular urine and lower levels of ALB, PLT (p < 0.05 respectively). In the three subgroups of the proteinuric group, the ratio of fetal growth restriction, cesarean section and postpartum hemorrhage were compared, and the difference was statistically significant (p < 0.05 respectively). Compared with the proteinuric group, the non-proteinuric group had higher birth weight, birth length, and lower SGA, admission rate in NICU (p < 0.05 respectively). In the three subgroups of the proteinuric group, significant differences were identified in the adverse outcomes of newborns (p < 0.05 respectively), and the incidence of adverse outcomes in neonates tended to be higher. Significant differences were identified in birth weight, birth length, and lower SGA and NICU occupancy rate among the three subgroups (p < 0.05 respectively). Conclusions: HELLP syndrome is a severe complication of pregnancy, involving multiple systems of the whole body. It has posed a great challenge to obstetricians for its acute onset, dangerous condition, rapid progress, and great harm. Thus, insights into HELLP syndrome should be gained, and early diagnosis, early treatment and timely termination of pregnancy should be conducted to reduce the incidence of maternal and fetal adverse outcomes and improve maternal and fetal prognosis. [ABSTRACT FROM AUTHOR]

One of the main causes of maternal and neonatal morbidity and mortality is pre-eclampsia. It is characterized by a high sFlt1/PlGF ratio, according to prior research. Pregestational diseases in mothers may increase the risk of developing pre-eclampsia. Only a few studies have looked at the connection between maternal comorbidities before conception and the sFlt1/PlGF ratio. The most recent information regarding the association between maternal pregestational diseases and the ratio of sFlt1/PlGF is described in this review. The paper also examines current research suggesting that changes in pregnancy hormones and metabolites are related to a high sFlt1/PlGF ratio. Certain maternal disorders have been found to dramatically raise sFlt-1 and sFlt1/PlGF levels, according to an analysis of the literature. There is still debate about the data on the association between the sFlt1/PlGF ratio and maternal disorders such as HIV, acute coronary syndromes, cardiovascular function in the mother between 19 and 23 weeks of pregnancy, thyroid hormones, diabetes, and cancer. Additional research is needed to confirm these findings. [ABSTRACT FROM AUTHOR]

OBJECTIVE: In this study, we investigated the immunohistochemical staining of cited-1 and caspase-6 expression in the placentas of pregnant women with HELLP syndrome. PATIENTS AND METHODS: Placentas of 20 normotensive patients and 20 women with HELLP syndrome were processed for routine histological tissue processing. The biochemical and clinical parameters of patients were recorded. Placentas were stained with hematoxylin-eosin and cited-1 and caspase-6 immunostaining. RESULTS: Placentas of normotensive patients showed normal histology. Placentas of women with HELLP syndrome showed degenerated cells, hyalinization and vacuolization. Cited-1 expression was negative in normotensive group; however, it was increased in HELLP group, especially in decidual cells, endothelial cells and other placental cells. Caspase-6 expression was negative in placental structures of normotensive groups. However, it was intense in decidual cells, vacuolar and hyalinized areas, inflammatory cells and connective tissue cells in HELLP group. CONCLUSIONS: Cited-1 and caspase-6 are a marker in determining the severity of HELLP syndrome. [ABSTRACT FROM AUTHOR]

Thrombotic microangiopathies (TMAs) comprise a distinct group of diseases with different manifestations that can occur in both pediatric and adult patients. They can be hereditary or acquired, with subtle onset or a rapidly progressive course, and they are particularly known for their morbidity and mortality. Pregnancy is a high-risk time for the development of several types of thrombotic microangiopathies. The three major syndromes are hemolysis, elevated liver function tests, and low platelets (HELLP); hemolytic uremic syndrome (HUS); and thrombotic thrombocytopenic purpura (TTP). Because of their rarity, clinical information and therapeutic results related to these conditions are often obtained from case reports, small series, registries, and reviews. The collection of individual observations, the evolution of diagnostic laboratories that have identified autoimmune and/or genetic abnormalities using von Willebrand factor post-secretion processing or genetic–functional alterations in the regulation of alternative complement pathways in some of these TMAs, and, most importantly, the introduction of advanced treatments, have enabled the preservation of affected organs and improved survival rates. Although TMAs may show different etiopathogenesis routes, they all show the presence of pathological lesions, which are characterized by endothelial damage and the formation of thrombi rich in platelets at the microvascular level, as a common denominator, and thrombotic damage to microcirculation pathways induces “mechanical” (microangiopathic) hemolytic anemia, the consumption of platelets, and ischemic organ damage. In this review, we highlight the current knowledge about the diagnosis and management of these complications during pregnancy.

HELLP syndrome, featuring hemolysis, elevated liver enzymes, and thrombocytopenia, is life-threatening disease of pregnancy that triggers comorbidities in both pregnant women and the fetus/newborn. This study provides an updated systematic review and meta-analysis of relevant studies to assess the therapeutic efficacy of corticosteroids in maternal and neonatal outcomes. Randomized control trials (RCTs) regarding the use of corticosteroids in the HELLP population from three electronic databases, including Ovid MEDLINE, Ovid EMBASE, andCochrane Central Register of Controlled Trials, were searched from database inception to 23 March 202323 March 2023. A total of 485 patients treated with corticosteroids from 7 RCTs were included. Compared to placebo, corticosteroids therapy failed to significantly improve the maternal outcomes regard to maternal morbidity (RR = 1.36, 95%CI [0.45, 4.10]), eclampsia (RR = 1.16, 95%CI [0.76, 1.77]), acute renal failure (RR = 0.71, 95%CI [0.41, 1.22]), pulmonary edema (RR = 0.34, 95%CI [0.10, 1.15]) and oliguria (RR = 1.08, 95%CI [0.75, 1.54]). In addition, pooled data showed that it wasn't significant differences between corticosteroids therapy and placebo regarding neonatal outcomes. This study compared the efficacy of corticosteroids in patients with HELLP syndrome, revealing that corticosteroids did not provide any significant benefit in clinical outcomes for pregnant women and newborns with HELLP. The conclusions of this study must be verified by a larger sample of high-quality RCTs. [ABSTRACT FROM AUTHOR]

Pregnancy associated atypical hemolytic uremic syndrome (p-aHUS) is a rare condition of thrombotic microangiopathy (TMA) which causes an increase of fetal and maternal morbidity and mortality. It presents typically with a triad of microangiopathic hemolytic anemia (MAHA), thrombocytopenia and acute progressive renal failure. Differential diagnoses of HELLP (Hemolysis, Elevated Liver enzymes, and Low Platelets) syndrome, preeclampsia, thrombotic thrombocytopenic purpura (TTP), and disseminated intravascular coagulation (DIC) syndrome must be considered. In the following case report, presented is a 32-year-old, 38 weeks pregnant Caucasian woman admitted to Eberswalde Hospital with signs of preeclampsia and HELLP Syndrome. Caesarean Section was performed due to HELLP syndrome and fetal distress. Acute renal failure occurs shortly after a successful delivery. After a diagnosis of p-aHUS is established, the patient was given Eculizumab, which yielded significant improvements. A 32-year-old, 38 week pregnant Caucasian woman was admitted to Eberswalde Hospital with upper right abdominal pain. After a laboratory examination, a diagnosis of HELLP syndrome was established and a Caesarean Section was performed. The follow-up examination revealed deterioration of clinical signs with the patient experiencing dyspnea, oliguria, and oedema, as well as aggravation of laboratory values, ranging from severe thrombocytopenia, hemolytic anemia, liver injury, and acute kidney injury. After excluding other possible causes of TMA, a diagnosis of p-aHUS was established and a treatment with Eculizumab was administered. Clinical and laboratory signs of hemolysis and kidney functions were found to improve gradually after two administrations of Eculizumab. The patient was discharged after 20 days of hospitalization with significantly improved condition and hematological values. A successful treatment of p-aHUS requires a comprehensive assessment and a prompt diagnosis, which can be confounded by multiple similar differential diagnoses. Treatment with Eculizumab was found to significantly improve the outcome of the patient, but more studies are required to decide on a standardized regiment for p-aHUS. [ABSTRACT FROM AUTHOR]

Purpose: HELLP syndrome is a relatively uncommon pregnancy-related condition characterized by hemolysis, elevated liver function tests, and low platelets. It can be accompanied by lifethreatening hepatic complications including hepatic infarction, hematoma formation, and hepatic rupture. HELLP syndrome occurs in approximately 0.2% of pregnancies. Major hepatic complications occur in less than 1% of HELLP patients suggesting an incidence of 1/50,000. The pathogenesis is incompletely understood and in particular, it is difficult to understand a disorder with both major thrombotic and bleeding manifestations. Methods: Literature review. Results: On the basis of reports in the published literature, and our own clinical experience, we suggest that vasospasm is one of the principal drivers with hepatic ischemia, infarction, and hemorrhage as secondary events. It is known that vasoactive substances are released by the failing placenta. We suggest these cause severe vasospasm, most likely affecting the small postsinusoidal hepatic venules. This leads to patchy or confluent hepatic ischemia and/or necrosis with a resultant increase in circulating liver enzymes. Reperfusion is associated with a fall in platelet count and microvascular hemorrhage if the microvasculature is infarcted. Blood tracks to the subcapsular space causing hematoma formation. If the hematoma ruptures the patient presents with severe abdominal pain, intra-abdominal hemorrhage, and shock. Conclusions: We suggest that hepatic and other complications associated with HELLP syndrome including placental abruption, acute renal failure, and posterior reversible encephalopathy syndrome (PRES) may also be due to regional vasospasm. [ABSTRACT FROM AUTHOR]

Ebubekir Arslan Mogadishu Somalia Turkish Training and Research Hospital, Mogadishu, 2526, SomaliaCorrespondence: Ebubekir Arslan, Tel +905317936501, Email ebuarslan@hotmail.comPurpose: There are still many unexplained points about how COVID-19 affects pregnant women and what kind of clinical and laboratory findings it reveals. These findings can become clinical conun drums when there is significant overlap with known and serious syndromes in pregnancy. The aim of this study is to report a case with a laboratory-proven diagnosis of COVID-19 and HELLP syndrome hypothesis.Case Presentation: A 30-year-old multigravida (g3p2, repeated cesarean section) 32-week pregnant patient reported to the emergency service with complaints of chills, cough and shortness of breath that started 6 days ago. Following comprehensive screening tests for the differential diagnosis of lymphopenia, high liver enzymes, low platelets, abnormal coagulation panel, high D-dimer, high total bilirubin, high LDH and HELLP syndrome in the laboratory examinations of the patient, the patient’s laboratory findings were evaluated as compatible with HELLP syndrome. Emergency cesarean section was performed on the patient because of maternal hypoxemia. The finalization of the microbiological diagnosis of COVID-19 resulted to start conventional COVID-19 treatment. The fetus was also confirmed to be positive for COVID-19, and the newborn died on the 5th postnatal day. Unfortunately, our mother patient died on the 10th day of her hospitalization.Conclusion: This report describes a case of multigravida, 30 years old, who presented with respiratory tract infection symptoms and hypothesized HELLP syndrome, who later tested positive for the novel coronavirus. The distinction between these two etiologies and onset times is extremely difficult. However, given the sequence of events in this case, it is reasonable to consider that COVID-19 may be an etiological factor associated with the pathophysiology of HELLP, despite the lack of conclusive evidence.Keywords: COVID-19, pregnancy complication, HELLP, overlapping clinics, preeclampsia

HELLP syndrome is characterized by hemolysis, elevated liver enzymes, and a low platelet count and poses an increased risk to the pregnant woman and the unborn child. Individual risk factors such as obesity may alter immunocompetence and influence the course of preeclampsia (PE) or HELLP syndrome. Blood samples were collected from 21 pregnant women (7 healthy, 6 with PE, and 8 with HELLP syndrome) and polymorphonuclear neutrophils (PMNs) were subsequently isolated. Production of radical oxygen species (ROS), cell movement, and NETosis were assessed by live-cell imaging. Surface protein expression and oxidative burst were analyzed by flow cytometry. PE and HELLP patients had significantly higher BMI compared to the healthy control group. Depending on the expression of CD11b, CD62L, and CD66b on PMNs, a surface protein activation sum scale (SPASS) was calculated. PMNs from patients with high SPASS values showed prolonged and more targeted migration with delayed ROS production and NETosis. Obesity is associated with a chronic inflammatory state, which in combination with immunological triggers during pregnancy could modulate PMN functions. Pregnant women with higher BMI tend to have higher SPASS values, indicating activation of the innate immune system that could co-trigger PE or HELLP syndrome.

Objective: Liver diseases constitute a family of diseases in pregnancy which are less often studied individually. Spectrum of liver diseases directly or indirectly related to pregnancy comprise 3% of all pregnancies. The biggest challenge is to arrive at a diagnosis in such cases. With this study we aimed to study the prevalence of different Liver diseases in pregnancy in our population and its effect on fetomaternal outcome. Material and Methods: This was a prospective observational study carried out from March 2018 to March 2020. A total of 184 pregnant women with diagnosis of some form of liver disease as evident from their symptoms, signs or biochemical investigations were included in study cohort. Result: Primigravida accounted for majority of study cohort (44.02%). Approximately 90.21% belonged to 20-35 yrs. Age group. Intrahepatic cholestasis of pregnancy (IHCP) was the most common liver ailment (66.84%) followed by viral hepatitis (10.32%), Hyperemesis gravidarum (7.06%) and HELLP syndrome (6.52%). There was one case of Acute fatty liver of pregnancy (0.54%), four cases of Pre-eclampsia with liver dysfunction (2.17%), seven cases of Jaundice in pregnancy (3.80%) and 3 cases of pre-existing liver diseases (1.63%). 5 cases (2.71%) of antepartum eclampsia, 5 cases (2.71%) of postpartum eclampsia and 1 case (0.54%) of post-partum HELLP was seen. 33.33% patients were delivered early by induction or caesarean section because of liver dysfunction.14.67% required blood or blood products transfusion.1.63% had postpartum hemorrhage.1.08% mothers required intensive care admissions. Neonatal outcome was poor with 6.41% being growth restricted, 9.61% premature, 8.97% were intrauterine dead fetuses, 2.56% had early neonatal deaths and 7.05% needed neonatal intensive care unit admissions. Conclusion: Timely admission, quick diagnosis and appropriate management of patients with liver diseases in pregnancy can make a significant difference in mortality and morbidity rates due to liver ailments in pregnancy.

Preeclampsia is one of the leading causes of maternal and fetal morbidity and mortality. The objective of our study was to study risk factors and complications associated with severe preeclampsia requiring intensive care unit (ICU) admission Retrospective comparative study over a period from 1st of January 2015 to 1st of January 2019 in the University's maternity unit of South Reunion (Indian Ocean). Our sampling included all preeclamptic patients who delivered in the Southern part of the island. Patients admitted to intensive care unit (ICU) and those who remained in the maternity unit (controls) were reviewed. Out of 482 preeclampsia cases, 94 women (19.5%) needed a transfer in ICU, of which only 21 (4.3%) needed invasive intensive care. Mean length of stay was 2.4 ± 2.1 days. ICU admission was associated with HELLP syndrome (OR 8.5 [4.9–14.9], p<.001), severe post-partum hemorrhage (OR 5.86 [1.29–26.70], p=.01) and early onset of preeclampsia (<34 weeks gestation), 2.97 [1.9-4.7], p<.001), leading to higher rate of C-section (OR 2.83 [1.67–4.78], p<.001). There were three patients with a history of eclampsia and no case of maternal death was reported. Fetal prognosis was much poorer in maternal ICU admissions than in controls, with outcomes including lower birth weight (1776 vs. 2304 g, p<.001) and higher perinatal morbidity (infant respiratory distress syndrome 3.70 [1.94–7.05], p<.001) and mortality (<.001). Women needing invasive ICU represented 4.3% of preeclampsia cases. This experience is of interest for lower resource settings such as in countries like Madagascar where very intensive ICU means are very poor, but simpler ICU surveillance is possible. Fetal prognosis was poor though no maternal death was reported. Thus, a multidisciplinary approach of patients with preeclampsia should be encouraged; admission into ICU should be facilitated, as soon as any sign of severity and complications appears. [ABSTRACT FROM AUTHOR]

Background Due to the increasing prevalence of Kawasaki Disease (KD) in adulthood, the number of women considering pregnancy is growing. There are limited data on the course of pregnancy in KD with coronary artery involvement. Case summary We report on the pregnancy outcome of a 30-year-old woman with KD who was successfully resuscitated for ventricular tachycardia 3 years before. At that time, bypass surgery and later implantable cardioverter-defibrillator implantation were performed because of thrombotically occluded calcified giant coronary aneurysms. The pregnancy course was initially uncomplicated, however, at 31 weeks of gestation, left-sided breast cancer was diagnosed. Weighing maximum therapeutic efficacy against acceptable foetal and maternal cardiotoxic risk, our multidisciplinary team decided on neoadjuvant chemotherapy. The mother and foetus tolerated the therapy well. However, at 36 weeks of gestation, due to HELLP (haemolysis, elevated liver, low platelets) syndrome, a caesarean section had to be performed. The newborn was healthy with good APGAR (appearance, pulse, grimace, activity, respiration) scores. Three weeks after delivery, chemotherapy was restarted and at Week 4 after the caesarean section, the tumour was no more detectable. Discussion We discuss data on pregnancy and KD and outline that pregnancy can be considered if the clinical condition is good and left ventricular function is preserved. We also address possible therapeutic approaches and care for breast cancer in pregnancy and coexisting cardiovascular disease. The extraordinary importance of interdisciplinary cooperation between different disciplines in such complex clinical disease conditions is emphasized. [ABSTRACT FROM AUTHOR]

Aim: The aim of this study to determine the maternal outcomes in women given a modest dosage of magnesium sulphate. Materials and methods: This research was conducted at the Department of Obstetrics and Gynecology, with clearance from the institute's ethical committee. Eclampsia patients were placed into two equal groups of 200. Groups 1 (Dhaka regime) and 2 (Pritchard regime). The trial excluded patients with myasthenia gravis, hepatic coma with danger of renal failure, and magnesium hypersensitivity. Results: There was no recurrence in 92% of the cases, 3 recurrences in 3% of the cases, and more than 2 recurrences in 3% of the cases. In group 1, there were only two recurrences in 2% of the cases, and there were none in 98% of the instances. In group 2, there were one and one recurrence in 1% of the cases, respectively. Maternal problems were noted in 25% of the patients overall. HELLP syndrome and abruption were recorded in 9% of the cases each, DIC in 5% of the cases, PPH and CVA in 1% of the cases each in group 1, and total maternal problems in 33% of the cases. Abruption was recorded in 11% of the patients, HELLP syndrome in 8%, and DIC in 6%. Renal failure and PPH were observed in 3% of the patients, respectively, and CVA in 1% of the cases in Group 2. Maternal mortality was 3% overall. In 1% of the cases, CVA, DIC, and pulmonary oedema were the causes of death. Overall maternal mortality was 8% in groups 1 and 2. In 3% of instances, DIC and acute renal failure were the causes of maternal death, whereas pulmonary oedema and CVA were the causes of mortality in 1% of cases. Conclusion: There was no statistically significant difference between the groups in the rates of maternal complications or maternal death. Women in India tend to have a lower body mass index than their Western counterparts, thus a reduced dosage may be ideal for them. Due to its comparability in efficacy and safety to the Pritchard protocol, this research indicates that low-dose magnesium sulphate should be used instead. [ABSTRACT FROM AUTHOR]

Objective: Liver diseases constitute a family of diseases in pregnancy which are less often studied individually. Spectrum of liver diseases directly or indirectly related to pregnancy comprise 3% of all pregnancies. The biggest challenge is to arrive at a diagnosis in such cases. With this study we aimed to study the prevalence of different Liver diseases in pregnancy in our population and its effect on fetomaternal outcome. Material and Methods: This was a prospective observational study carried out from March 2018 to March 2020. A total of 184 pregnant women with diagnosis of some form of liver disease as evident from their symptoms, signs or biochemical investigations were included in study cohort. Result: Primigravida accounted for majority of study cohort (44.02%). Approximately 90.21% belonged to 20-35 yrs. Age group. Intrahepatic cholestasis of pregnancy (IHCP) was the most common liver ailment (66.84%) followed by viral hepatitis (10.32%), Hyperemesis gravidarum (7.06%) and HELLP syndrome (6.52%). There was one case of Acute fatty liver of pregnancy (0.54%), four cases of Pre-eclampsia with liver dysfunction (2.17%), seven cases of Jaundice in pregnancy (3.80%) and 3 cases of pre-existing liver diseases (1.63%). 5 cases (2.71%) of antepartum eclampsia, 5 cases (2.71%) of postpartum eclampsia and 1 case (0.54%) of post-partum HELLP was seen. 33.33% patients were delivered early by induction or caesarean section because of liver dysfunction.14.67% required blood or blood products transfusion.1.63% had postpartum hemorrhage.1.08% mothers required intensive care admissions. Neonatal outcome was poor with 6.41% being growth restricted, 9.61% premature, 8.97% were intrauterine dead fetuses, 2.56% had early neonatal deaths and 7.05% needed neonatal intensive care unit admissions. Conclusion: Timely admission, quick diagnosis and appropriate management of patients with liver diseases in pregnancy can make a significant difference in mortality and morbidity rates due to liver ailments in pregnancy. [ABSTRACT FROM AUTHOR]

Introduction: Preeclampsia is associated with adverse maternal and neonatal outcomes. It is unclear whether multivitamin use reduces the risk of preeclampsia. This systematic review and meta‐analysis aimed to evaluate the association between multivitamin use and the risk of preeclampsia. Material and methods: We searched PubMed, Embase and the Cochrane Library from database inception to July 2021. Randomized controlled trials (RCTs), case–control and cohort studies assessing the association between multivitamin use and risk of preeclampsia were eligible. Studies of treatment with a single micronutrient were excluded. Relative risks and 95% confidence intervals (95% CI) were calculated using random‐effects models. RoB2, the Newcastle Ottawa Scale and GRADE were used to assess risk of bias and quality of evidence. The protocol was registered in PROSPERO (no. CRD42021214153). Results: Six studies were included (33 356 women). Only two RCTs were found, both showing a significantly decreased risk of preeclampsia in multivitamin users. These studies were not compatible for meta‐analysis due to clinical heterogeneity. A meta‐analysis of observational studies using a random‐effects model showed an unchanged risk of preeclampsia following multivitamin use (relative risk 0.85, 95% CI 0.69–1.03). The quality of evidence according to GRADE was very low. Conclusions: Very weak evidence suggests that multivitamin use might reduce the risk of preeclampsia; however, more research is needed. Large RCTs should be prioritized. The results of this review do not allow any final conclusions to be drawn regarding a preventive effect of multivitamin use in relation to preeclampsia. [ABSTRACT FROM AUTHOR]

Introduction: Hemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome is a leading cause of maternal mortality. The emergence of Coronavirus disease 2019 (COVID-19) has led to challenges in diagnosing HELLP syndrome due to overlapping clinical and laboratory presentations. We report a case of HELLP syndrome complicated by COVID-19 infection. Case Description: An otherwise healthy pregnant 31-year-old female presented with fever, myalgia, and headache. She was found to be COVID-positive with laboratory signs of HELLP syndrome. Symptoms and laboratory findings trended toward normal post-partum confirming the diagnosis of HELLP syndrome. Discussion: A prompt diagnosis of HELLP syndrome is essential to avoid maternal and fetal complications. Clinicians should be aware of the similarities in presentation between HELLP syndrome and COVID-19 for timely diagnosis and treatment.

• Expectant management was not associated with maternal or neonatal outcome. • The most severe outcomes were rare and mainly observed in the early delivery group. • Delayed delivery could serve as an option in certain selected cases. Most guidelines recommend induction of labor after 37 weeks of gestation in preeclampsia. This study assessed the effect of interval between diagnosis of preeclampsia and delivery on maternal and perinatal outcomes. A cohort of 1637 women with preeclampsia recruited at five university hospitals in Finland was studied. Outcomes were compared in two groups according to the time interval between diagnosis of PE and delivery: delivery in less than 10 days (the early delivery group) and delivery at 10 days or later after the diagnosis (the delayed delivery group). Maternal outcomes included significantly preterm delivery (delivery before 34 weeks of gestation), placental abruption, eclampsia and maternal intensive care or intensive monitoring for more than 24 h. Neonatal outcomes included small for gestational age, Apgar score of less than seven at the age of five minutes, umbilical artery pH < 7.05 and fetal death. No differences in frequency of preterm deliveries or maternal need for intensive care were observed between groups. Eclampsia and fetal death were rare, and their incidence did not differ between the groups. No maternal deaths were observed. Low Apgar score at five minutes of age was reported more commonly in the early delivery group, but there was no difference in fetal acidemia between groups. Early and delayed delivery lead to comparable outcomes in this cohort. Expectant management could be beneficial in women with an unripe cervix or preterm preeclampsia without severe features. [ABSTRACT FROM AUTHOR]

The causes of thrombotic microangiopathy (TMA), identified during pregnancy, are varied: pregnancy-specific and not specific. The differentiation between a severe preeclampsia/HELLP syndrome (hemolysis, elevated liver enzymes, low platelets), thrombotic thrombocytopenic purpura (TTP) and atypical hemolytic uremic syndrome (aHUS) may be challenging but is critical to ensure the correct management of the pregnant patient as well for future pregnancies, and to institute promptly the treatment, as these are acute conditions with significant morbidity and mortality in untreated patients. [ABSTRACT FROM AUTHOR]

Objective To elucidate patients’ knowledge and counseling perspective on aspirin reducing the risk of hypertensive disorders of pregnancy (HDP). Methods A quantitative survey was performed including women who are members of the patient orgasnization Dutch HELLP Foundation due to a history of HDP. Results Awareness of the risk-reducing effect of aspirin on HDP was present in 51.9% of the 189 women. The majority was informed by their gynecologist (89.8%) and preferred to be informed by a gynecologist (79.4%), at the postpartum checkup (42.3%) or in the consecutive pregnancy (30.7%), both orally and written (62.4%). Conclusion Half of the women with a history of HDP were aware of the risk-reducing effect of aspirin in a consecutive pregnancy.

Background: Jaundice in pregnancy carries a grave prognosis for both the foetus and the mother, and is responsible for 12% of maternal deaths. Liver disease is a rare complication of pregnancy, but when it occurs it may do so in a dramatic and tragic fashion for both the mother and infant. Materials and Methods: Data were collected as prospective Hospital based observational study at tertiary care centre. After the preliminary assessment with regard to the inclusion and exclusion criteria, informed consent was obtained from all patients. Thorough history was taken and physical examination was done. Demographic details of each patient were obtained. Relative investigations were done. Results: Out of 300 patients, 287 were healthy and alive and 13 patients died. The maternal mortality was 4.33%. Out of the total 13 maternal deaths, 4 cases died due to hepatic encephalopathy, 3 due to disseminated-intravascular coagulation and 3 due to sepsis with multiorgan failure. Mortality was due to HELLP- Hemolysis Elevated Liver enzymes and Platelet count in two cases and due to acute fatty liver in one case. In 126 (42%) cases, the mode of delivery was lower segment caesarean section, 138 (46%) cases had normal vaginal delivery, while 36 (12%) cases had undergone abortion. A total of 114 (38%) cases delivered full-term live baby and 78 (26%) cases delivered preterm live baby. Full-term intrauterine foetal death (IUFD) was seen in 15 (5%) cases and preterm IUFD was seen in 69 cases (23%). There was neodeath in 24 (8%) babies. The total perinatal mortality was 36.0%. Conclusion: The present study shows that although liver dysfunction is infrequently seen in pregnancy, it can result in severe maternal and foetal compromise. Jaundice in pregnancy should be managed as a team with the collaboration of the department of obstetrics, internal medicine, gastroenterology, anaesthesia and critical care so that early diagnosis and aggressive management can prevent and reduce foeto–maternal morbidity and mortality.

El Hospital Nacional Dr. Mario Catarino Rivas (hospital de segundo nivel de atención), sirve como centro de atención para embarazos de alto riesgo de la zona noroccidental de Honduras; reportó 1,702 casos de trastornos hipertensivos del embarazo en 2017 y 2,070 casos en 2018. Se caracterizó pacientes con signos y síntomas de trastornos hipertensivos del embarazo agrupadas desde un punto de vista obstétrico, epidemiológico y clínico. Se realizó un estudio, descriptivo de corte transversal en gestantes que presentaron cefalea, cifras tensionales elevadas (≥ 140/90mmHg); registrando ausencia o presencia de proteinuria, atendidas en la emergencia de labor y parto de un hospital nacional de segundo nivel de atención en San Pedro Sula, Honduras, desde junio hasta octubre del 2019. Se incluyeron 110 pacientes de entre 18-43 años, mestizas y amas de casa, la edad gestacional promedio por fecha de ultima menstruación de 37.7 semanas; el 28.2% presentó preeclampsia severa. Las manifestaciones clínicas frecuentes fueron edema de miembros inferiores y cefalea. El 57.3% desarrolló trabajo de parto espontáneo, la resolución del embarazo fue cesárea en el 57.3% de las gestantes. Respecto al producto de la concepción, 66.4% tenían peso normal y talla apropiada para la edad gestacional, un APGAR de 8 al primer minuto y de 9 a los 5 minutos. En este estudio, se reporta una prevalencia del 13.72% con respecto a los trastornos hipertensivos del embarazo. Particularmente en pacientes mayores de 35 años, multípara, con índice de masa corporal ≥ 32 kg/m2, presentando antecedentes de hipertensión arterial, diabetes mellitus y preeclampsia.

Severe preeclampsia is a disorder of pregnancy, characterized by increased blood pressure (>140/90 mmHg) and proteinuria (≥ 300 mg/24 hours) at later than 20 weeks of gestation. Particularly in underdeveloped nations, severe preeclampsia and eclampsia have a significant negative impact on the health of expectant mothers, fetuses, and newborns. The HELLP (hemolysis, increased liver enzymes, low platelets) syndrome is thought to be a subset of preeclampsia, a group of hypertensive disorders of pregnancy that also includes eclampsia. Compared to preeclampsia alone, maternal and fetal problems are more severe in HELLP. There can be a diagnostic dilemma that arises when attempting to differentiate HELLP from its numerous imitators to determine the appropriate course of treatment. Here, we present a rare case of a pregnant woman presenting with preeclampsia complicated by manifestations and investigations suggestive of HELLP syndrome with acute kidney injury (AKI), retinal detachment, and symptoms of DIC (disseminated intravascular coagulation), which can be grievous to the mother as well as the fetus., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Gaikwad et al.)

Subcapsular hematoma of the liver is a potentially fatal complication of pregnancy-related hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome. In turn, HELLP syndrome is one of the most critical complications of preeclampsia. We present a case of a 31-year-old woman who developed a subcapsular liver hematoma in the postpartum period secondary to HELLP syndrome. The diagnosis was made based on the clinical features, radiological investigation, and laboratory values. She was managed with fluids, intravenous steroids, and rigorous monitoring in the intensive care unit before being moved to a tertiary care center with hepatic surgery and interventional radiology capabilities. [ABSTRACT FROM AUTHOR]