Maternal risk factors and adverse birth outcomes associated with HELLP syndrome: a population‐based study (original) (raw)

Abstract

Population: Mothers with a singleton hospital live birth or stillbirth at ≥24 weeks gestation (N=1,078,323). Methods: HELLP syndrome was identified using ICD-10-CA diagnostic code from delivery hospitalization data. We used logistic regression to identify independent risk factors for HELLP syndrome by obtaining adjusted odds ratios (AOR) and 95% confidence intervals (CI), and to assess the associations with adverse outcomes. Main Outcome Measures: Adverse maternal (e.g., eclampsia) and fetal/neonatal outcomes (e.g., intraventricular hemorrhage, perinatal death). Results: The incidence of HELLP syndrome was 2.5 per 1,000 singleton deliveries (n=2,663). Risk factors included: age ≥35 years, rural residence, nulliparity, parity ≥4, pre-pregnancy and gestational hypertension and diabetes, assisted reproduction, chronic cardiac conditions, systemic lupus erythematosus, obesity, chronic hepatic conditions, placental disorders (e.g., fetomaternal transfusion), and congenital anomalies; PROM and age <25 years were inversely associated with HELLP syndrome (p-values <0.05). Women with syndrome had a 10-fold higher maternal mortality (95% CI 1.6-84.3) and elevated severe maternal morbidity (9.6 vs. 121.7 per 1,000; AOR=12.5, 95% CI 11.1-14.1); and higher perinatal mortality (4.3 vs. 21.0 per 1,000; AOR=4.5, 95%CI 3.5-5.9) and perinatal mortality/severe neonatal morbidity (21.2 vs 202.4 per 1,000; AOR=10.7, 95% CI 9.7-11.8). Conclusion: HELLP syndrome is associated with specific pre-pregnancy and pregnancy risk factors, higher rates of maternal death, and substantially higher severe maternal morbidity, perinatal mortality and severe neonatal morbidity.

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References (37)

  1. Weinstein L. Syndrome of hemolysis, elevated liver enzymes, and low platelet count: a severe consequence of hypertension in pregnancy. Am J Obstet Gynecol 1982;142:159-67.
  2. Sibai BM. Diagnosis, controversies, and management of the syndrome of hemolysis, elevated liver enzymes, and low platelet count. Obstet Gynecol 2004;103:981-91.
  3. Sibai BM. The HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets): much ado about nothing? Am J Obstet Gynecol 1990;162:311-6.
  4. Fitzpatick KE, Hinshaw K, Kurinczuk JJ, Knight M. Risk Factors, Management, and Outcomes of Hemolysis, Elevated Liver Enzymes, and Low Platelets Syndrome and Elevated Liver Enzymes, Low Platelets Syndrome. Obstet Gynecol 2014;123:618-27.
  5. Abraham KA, Connolly G, Farrell J, Walshe JJ. The HELLP syndrome, a prospective study. Ren Fail 2001;23:705-13.
  6. Waterstone M, Bewley S, Wolfe C. Incidence and predictors of severe obstetric morbidity: case-control study. BMJ 2001;322:1089-93.
  7. Martin JN Jr, Rinehart BK, May WL, Magann EF, Terrone DA, Blake PG. The spectrum of severe preeclampsia: comparative analysis by HELLP (hemolysis, elevated liver enzyme levels, and low platelet count) syndrome classification. Am J Obstet Gynecol 1999;180:1373-84.
  8. Haram K, Svendsen E, Abildgaard U. The HELLP syndrome: Clinical issues and management. BMC Pregnancy Childbirth 2009;9(8).
  9. Murray, D. O'Riordan M, Geary M, Phillips R, Clarke T, McKenna P. The HELLP syndrome: maternal and perinatal outcome. Ir Med J 2001;94: 16-18.
  10. Martin JN Jr, Brewer JM, Wallace K, Sunesara I, Canizaro A, Blake PG, et al. Hellp syndrome composite major maternal morbidity: importance of Mississippi classification system. J Mater Fet Neonat Med 2013;26(12):1201-1206, DOI: 10.3109/14767058.2013.773308.
  11. Sibai BM, Ramadan MK, Usta I, Salama M, Mercer BM, Friedman SA. Maternal morbidity and mortality in 442 pregnancies with hemolysis, elevated liver enzymes, and low platelets (HELLP syndrome). Am J Obstet Gynecol 1993;169:1000-6.
  12. Accepted Article 12. Sibai BM, Taslimi MM, El-Nazer A, Amon E, Mabie BC, Ryan GM. Maternal-perinatal outcome associated with the syndrome of hemolysis, elevated liver enzymes, and low platelets in severe preeclampsia. Am J Obstet Gynecol 1986;155:501-9.
  13. Reubinoff BE, Schenker JG. HELLP syndrome-a syndrome of hemolysis, elevated liver enzymes and low platelet count-complicating preeclampsia-eclampsia. Int J Gynecol Obstet 1991;36:95-102.
  14. Vigil-De Gracia P. Pregnancy complicated by pre-eclampsia-eclampsia with HELLP syndrome. Int J Gynecol Obstet 2001;72:17-23.
  15. Martin JN Jr, Blake PG, Perry KG, McCaul JF, Hess LW, Martin RW. The natural history of HELLP syndrome: patterns of disease progression and regression. Am J Obstet Gynecol 1991;164:1500-13.
  16. Canadian Institute for Health Information. Ottawa. Canadian Classification of Health Interventions. https://www.cihi.ca/en/data-and-standards/standards/classification-andcoding/icd- 10-ca-cci-implementation-schedule. Accessed June, 2019.
  17. Data Quality Documentation for External Users: Discharge Abstract Database, 2010-2011. Canadian Institute for Health Information 2011. Ottawa (http://www.cihi.ca/CIHI-ext- portal/pdf/internet/DAD_EXECUTIVE_SUM_10_11_EN). Accessed June, 2019.
  18. Statistics Canada. Postal code conversion file (PDDF), reference guide. 2004. Ottawa, Ontario, Canada: Statistics Canada; 2005. Catalogue no. 92F0153GIE. Available at: http://dsp- psd.pwgsc.gc.ca/Collection/Statcan/92F0153GIE/92F0153GIE2005001.pdf. Accessed Sept 30, 2019.
  19. Structure and Change in Canada's Rural Demography: An Update to 2006 with Provincial
  20. Wen SW, Liu S, Marcoux S, Fowler D. Uses and limitations of routine hospital admission/separation records for perinatal surveillance. Chronic Dis Can. 1997;18:113-9.
  21. Joseph KS, Fahey J. Validation of perinatal data in the Canadian Institute for Health Information's Discharge Abstract Database. Chron Dis Can 2009;29:96-100.
  22. Juurlink D, Preyra C, Croxford R, Chong A, Austin P, Tu J, et al. Canadian Institute for Health Information Discharge Abstract Database: A Validation Study. Toronto: Institute for Clinical Evaluative Sciences; 2006. file:///C:/Users/slisonkova/Downloads/Full%20report%20(1).pdf. Accessed July 2019.
  23. Bateman BT, Mhyre JM, Hernandez-Diaz S, Huybrechts KF, Fischer MA, Creanga AA, et al. Development of a comorbidity index for use in obstetric patients. Obstet Gynecol 2013;122:957-65.
  24. Metcalfe A, Lix LM, Johnson J-A, Currie G, Lyon AW, Bernier F, et al. Validation of an obstetric comorbidity index in an external population. BJOG 2015;122:1748-1755.
  25. Dzakpasu S, Rinker P, Arbour L, Darling EK, Kramer MS, Shiliang Liu S, et al. Severe Maternal Morbidity in Canada: Temporal Trends and Regional Variations, 2003-2016 J Obstet Gynaecol Can 2019;000(000):1-10. https://doi.org/10.1016/j.jogc.2019.02.014
  26. Perinatal Services BC. British Columbia Perinatal Data Registry. Years Provided: (2012/13 to 2015/16). Resource Type: tabulated data. Data provided for planning purposes on 2020.
  27. Butalia S, Audibert F, Cote AM, Firoz T, Logan AG, Magee LA et al. Hypertension Canada's 2018 Guidelines for the Management of Hypertension in Pregnancy. Can J Cardiology 2018;34:526-531..
  28. VanderWeele TJ. Commentary: Resolutions of the birthweight paradox: competing explanations and analytical insights. Int J Epidemiol 2014, 1368-1373. doi: 10.1093/ije/dyu162.
  29. Joseph KS. Incidence-based measures of birth, growth restriction, and death can free perinatal epidemiology from erroneous concepts of risk. J Clin Epidemiol 2004; 57(9):889-897.
  30. Holmes LB, Nasri H, Beroukhim R, Hunt A, Roberts DJ, Toufaily MH, et al. Stillborn Infants: Associated Malformations. Birth Defects Research 2018;110: 114-121. doi:10.1002/bdr2.1097.
  31. Malmstrom O, Morken NH. HELLP syndrome, risk factors in first and second pregnancy: a population based cohort study. Acta Obstet Gynecol Scand 2018; 97:709-716.
  32. Lisonkova S, Haslam M, Dahlgren L, Chen I, Synnes A, Lim K. Maternal morbidity among women in rural versus urban areas: a residence-based approach. CMAJ 2016; 188:E456-E465. doi: 10.1503/cmaj.151382.
  33. Glanville T, Walker J. HELLP syndrome. Review. The Obstetrician and Gynaecologist 2003;5:149-154.
  34. Martin JN, Rose CH, Briery CM. Understanding and managing HELLP syndrome: The integral role of aggressive glucocorticoids for mother and child. Am J Obstet Gynecol 2006;195:914-34.
  35. Purwosunu Y, Sekizawa A, Yoshimura S, Farina A, Wibowo N, Nakamura M, et al. Expression of angiogenesis related genes in the cellular component of the blood of preeclamptic women. Reproduction Science 2009;16:857-64.
  36. Haram K, Mortensen JH, Nagy B. Genetic aspects of preeclampsia and the HELLP syndrome. J Pregnancy 2014, 910751.
  37. Hutcheon J, Lisonkova S, Magee L, von Dadelszen P, Woo H, Liu S, et al. Optimal timing of delivery in pregnancies with pre-existing hypertension. BJOG 2011;118:49-54.