HELLP SYNDROME IN 18-WEEK PREGNANCY: A CASE REPORT

Casanova N. (1), Orellana M. (2), Ahumada H. (2), Hernández K. (3), López I. (4)

(1) Department of Obstetrics and Gynecology, School of Medicine, University of Valparaíso, Chile

(2) Service of Gynecology and Obstetrics, Claudio Vicuña Hospital, San Antonio, Chile

(3) Service of Gynecology and Obstetrics, Gustavo Fricke Hospital, Viña del Mar, Chile

(4) Service of Gynecology and Obstetrics, Carlos Van Buren Hospital, Valparaíso, Chile

 

Objective: To report an atypical presentation at early gestational age of a serious obstetric complication that should be promptly suspected in order to improve maternal-fetal prognosis.

Case report: A 44-year-old woman with a history of chronic hypertension and antisynthetase syndrome with interstitial lung disease was evaluated in the emergency department for elevated blood pressure at 18+4 weeks gestation. Blood pressure >160/110 mmHg and a protein/creatinine ratio of 0.37 were found. The patient developed a hypertensive crisis, intense epigastric pain and neurosensory symptoms, with severity tests reporting: platelets 81x10^3/uL, LDH 517 IU/L and AST/ALT at 175 and 201 IU/L. Management was started with labetalol and intravenous magnesium sulfate. She persists with hypertensive crisis and neurosensory symptoms; control tests: Platelets 66 x10^3/uL, LDH 585 IU/L and AST/ALT at 187/219 IU/L. Pulsatility index Right uterine artery 2.0, left uterine artery 2.0 STLF1/PLGF ratio 115.9. She maintains hypertensive crisis with BP 180/90 mmHg despite pharmacological management. After evaluation by the medical team and with the patient, it is decided to voluntarily terminate the pregnancy.

Discussion: HELLP syndrome is a serious obstetric complication with variable incidence and time of onset, even before fetal viability. The current definition of preeclampsia excludes diagnosis before 20 weeks of gestation, however, there are reports of cases of onset before 20 weeks, including severe cases with Hellp syndrome. Most patients who develop atypical preeclampsia (before 20 weeks) have preexisting comorbidities such as antiphospholipid syndrome, antisynthetase syndrome or arterial hypertension prior to pregnancy. Antisynthetase syndrome is a rare autoimmune disease. The association of autoimmune rheumatic diseases and adverse perinatal outcomes is widely recognized. Several reports have suggested an association between antisynthetase syndrome and vasculitis, which raises the hypothesis that when the disease is active it could lead to vasculitis and inflammatory changes within the blood vessel which would determine poor vascular perfusion and thus poor perfusion of the placental bed.

Conclusion: HELLP syndrome is a serious obstetric complication with infrequent presentation before 20 weeks of pregnancy. The association between autoimmune diseases and hypertensive syndromes has been widely studied, with hypoperfusion of the placental bed being the most reported finding. Preconception counseling is suggested for patients with a history of autoimmune disease in order to plan pregnancy during the inactive phase of the disease, thereby optimizing obstetric and perinatal outcomes.