The HELLP syndrome is a serious complication in pregnancy characterized by haemolysis, elevated liver enzymes and low platelet count occurring in 0.5 to 0.9% of all pregnancies and in 10–20% of cases with severe preeclampsia. The present review highlights occurrence, diagnosis, complications, surveillance, corticosteroid treatment, mode of delivery and risk of recurrence. Clinical reports and reviews published between 2000 and 2008 were screened using Pub Med and Cochrane databases. About 70% of the cases develop before delivery, the majority between the 27th and 37th gestational weeks; the remainder within 48 hours after delivery. The HELLP syndrome may be complete or incomplete. In the Tennessee Classification System diagnostic criteria for HELLP are haemolysis with increased LDH (> 600 U/L), AST (≥ 70 U/L), and platelets < 100·109/L. The Mississippi Triple-class HELLP System further classifies the disorder by the nadir platelet counts. The syndrome is a progressive condition and serious complications are frequent. Conservative treatment (≥ 48 hours) is controversial but may be considered in selected cases < 34 weeks' gestation. Delivery is indicated if the HELLP syndrome occurs after the 34th gestational week or the foetal and/or maternal conditions deteriorate. Vaginal delivery is preferable. If the cervix is unfavourable, it is reasonable to induce cervical ripening and then labour. In gestational ages between 24 and 34 weeks most authors prefer a single course of corticosteroid therapy for foetal lung maturation, either 2 doses of 12 mg betamethasone 24 hours apart or 6 mg or dexamethasone 12 hours apart before delivery. Standard corticosteroid treatment is, however, of uncertain clinical value in the maternal HELLP syndrome. High-dose treatment and repeated doses should be avoided for fear of long-term adverse effects on the foetal brain. Before 34 weeks' gestation, delivery should be performed if the maternal condition worsens or signs of intrauterine foetal distress occur. Blood pressure should be kept below 155/105 mmHg. Close surveillance of the mother should be continued for at least 48 hours after delivery.

https://link.springer.com/content/pdf/10.1186%2F1471-2393-9-8.pdf

The HELLP syndrome: Clinical issues and management. A Review

Introduction and hypothesis
The aim was to determine the incidence and prevalence of pelvic organ prolapse surgery and describe how outcomes are reported.

Epidemiology and outcome assessment of pelvic organ prolapse.

Objective To examine biomarkers of methylmercury (MeHg) intake in women and infants from seafood-consuming populations globally and characterize the comparative risk of fetal developmental neurotoxicity. Methods A search was conducted of the published literature reporting total mercury (Hg) in hair and blood in women and infants. These biomarkers are validated proxy measures of MeHg, a neurotoxin found primarily in seafood. Average and high-end biomarkers were extracted, stratified by seafood consumption context, and pooled by category. Medians for average and high-end pooled distributions were compared with the reference level established by a joint expert committee of the Food and Agriculture Organization (FAO) and the World Health Organization (WHO). Findings Selection criteria were met by 164 studies of women and infants from 43 countries. Pooled average biomarkers suggest an intake of MeHg several times over the FAO/WHO reference in fish-consuming riparians living near small-scale gold mining and well over the reference in consumers of marine mammals in Arctic regions. In coastal regions of south-eastern Asia, the western Pacific and the Mediterranean, average biomarkers approach the reference. Although the two former groups have a higher risk of neurotoxicity than the latter, coastal regions are home to the largest number at risk. High-end biomarkers across all categories indicate MeHg intake is in excess of the reference value. Conclusion There is a need for policies to reduce Hg exposure among women and infants and for surveillance in high-risk populations, the majority of which live in low-and middle-income countries.

/pdf/global-methylmercury-exposure-from-seafood-consumption-and-3pqb008i6y.pdf

Global methylmercury exposure from seafood consumption and risk of developmental neurotoxicity: a systematic review.

Uterine preservation vs hysterectomy in pelvic organ prolapse surgery: a systematic review with meta-analysis and clinical practice guidelines

Introduction and hypothesis
To review the safety and efficacy of uterine preservation surgery.

Uterine-preserving POP surgery

Effect of cyclosporine, mycophenolic acid, and rapamycin on the proliferation of rat aortic vascular smooth muscle cells: in vitro study.

The present study compares neonatal outcome after preterm delivery of infants in pregnancies complicated by the HELLP syndrome or severe preeclampsia (PS). The maternal and neonatal charts of 71 out of a total of 409 pregnancies that were complicated by hypertensive disorders at Severance hospital between January 1995 and December 2004 were reviewed. Twenty-one pregnancies were complicated by HELLP syndrome and 50 pregnancies were complicated by PS. Fifty normotensive (NT) patients who delivered because of preterm labor comprised the control group. Results were analyzed by the chi-square test and ANOVA. Gestational age and maternal age at delivery were matched among the three groups. The neonatal outcomes of the HELLP syndrome group were compared with the PS and NT groups. There were significant differences between the HELLP syndrome group and the PS group in the incidence of intraventricular hemorrhage (IVH) (61.9% vs. 26%, p = 0.006), sepsis (85.7% vs. 44%, p = 0.003) and mechanical ventilation (MV) rate (81% vs. 54%, p = 0.039). There were significant differences between the HELLP syndrome group and the NT group in the incidence of neonatal death (ND) (19.5% vs. 2.0%, p = 0.034), respiratory distress syndrome (RDS) (38.1% vs. 8%, p = 0.0045), IVH (61.9% vs. 4%, p < 0.0001), sepsis (85.7% vs. 14%, p < 0.0001), intensive care (IC) (85.7% vs. 24%, p < 0.0001) and MV rate (80.1% vs. 14%, p < 0.0001). There were also significant differences between the PS and NT groups in the incidence of ND (20% vs. 2%, p = 0.0192), RDS (30% vs. 8%, p = 0.0085), IVH (26% vs. 4%, p = 0.0070), sepsis (44% vs. 14%, p = 0.0015), IC (78% vs. 24%, p < 0.0001), MV rate (54% vs. 14%, p < 0.0001) and low 5-min APGAR score (50% vs. 16%, p = 0.0005). This study shows increased morbidity in newborns of mothers complicated with HELLP syndrome and indicates that early, regular and high quality management of these patients is essential to improve both maternal and neonatal outcome.

/pdf/neonatal-outcome-after-preterm-delivery-in-hellp-syndrome-x6llyjpbut.pdf

Neonatal outcome after preterm delivery in HELLP syndrome.

In the present study, we examined the relationship between average fish consumption, as well as the type of fish consumed and levels of mercury in the blood of pregnant women. We also performed follow-up studies to determine if blood mercury levels were decreased after counseling and prenatal education. To examine these potential relationships, pregnant women were divided into two groups: a study group was educated to restrict fish intake, whereas a control group did not receive any prenatal education regarding fish consumption. We measured blood mercury level and performed follow-up studies during the third trimester to examine any differences between the two groups. Out of the 63 pregnant women who participated in our study, we performed follow-up studies with 19 pregnant women from the study group and 12 pregnant women from control group. The average initial blood mercury level of both groups was 2.94 µg/L, with a range of 0.14 to 10.75 µg/L. Blood mercury level in the group who ate fish more than four times per month was significantly higher than that of the group who did not consume fish (p = 0.02). In follow-up studies, blood mercury levels were decreased in the study group but slightly increased in the control group (p = 0.014). The maternal blood mercury level in late pregnancy was positively correlated with mercury levels of cord blood (r = 0.58, p = 0.047), which was almost twice the level found in maternal blood. Pregnant women who consume a large amount of fish may have high blood mercury levels. Further, cord blood mercury levels were much higher than that of maternal blood. Because the level of fish intake appears to influence blood mercury level, preconceptual education might be necessary in order decrease fish consumption.

/pdf/the-effect-of-fish-consumption-on-blood-mercury-levels-of-zkk9kbr2f9.pdf

The effect of fish consumption on blood mercury levels of pregnant women

Actual age (29.9 vs. 31.7 years old) and gestational age (34.1 vs. 32.5 weeks) between the normotensive pregnancy and preeclampsia group were controlled (Table 1).



Table 1

Subject Characteristics in Normal Pregnant Women and Women with Preeclampsia



In the preeclampsia group, both plasma renin activity and plasma aldosterone concentration were lower than those in a normotensive, normal pregnancy (Table 1, 35.7 vs. 15.1ng/mL/hr p < 0.001, 453.7 vs. 273.1pg/mL p = 0.08). But, in the preeclampsia group, plasma aldosterone decreased less than plasma renin activity, leading to a significant increase in ARR (Table 1, 16.1 vs. 38.3, p < 0.001). As demonstrated by previous studies, RI value of the uterine artery in the preeclampsia group was also much higher than that of the normotensive pregnant group (Table 1, 0.67 vs. 0.46, p = 0.005).

As gestational age increases, the increase in renin activity also increased but was not statistically significant (Table 2, Fig. 1, r2=0.03, p = 0.11). However, plasma aldosterone levels increase to a statistically significant degree with gestational age (Table 2, Fig. 2, p = 0.003). Aldosterone levels were stimulated by renin in both groups; however the sensitivity of aldosterone to renin was much higher in preeclampsia than in normal pregnancy (Table 3, Fig. 3 and ​and4,4, p = 0.003 vs. 0.04).



Fig. 1

Correlation between gestational age and renin (r=0.18, p = 0.11).





Fig. 2

Correlation between gestational age and aldosterone (r=0.33, p = 0.003).





Fig. 3

Correlation between renin and aldosterone in normal pregnancy (r=0.3, p = 0.04).





Fig. 4

Correlation between renin and aldosterone in preeclampsia (r=0.55, p = 0.003).





Table 2

Correlation between Two Variables





Table 3

Correlation between Plasma Renin Activity and Aldosterone



Most importantly, ARR positively correlates with RI levels of uterine artery (Table 2, Fig. 5, p = 0.048, r2=0.053). However, in each control and preeclampsia group, the correlation was not statistically significant (Fig. 6 and ​and7,7, p = 0.718, p = 0.868, respectively).



Fig. 5

Correlation between RI and ARR (r=0.23, p = 0.048).





Fig. 6

Control group (r=0.052, p = 0.718).





Fig. 7

Preeclampsia group (r=0.033, p = 0.868).

The relationship between aldosterone to renin ratio and RI value of the uterine artery in the preeclamptic patient vs. normal pregnancy.

This study was carried out in order to compare the effects in different surgeries using mesh in pelvic organ prolapse patients whose leading points were C. Thirty-nine patients were categorized into 3 groups: group A pelvic reconstruction with hysterectomy; group B hysterectomy prior to pelvic reconstruction; and group C pelvic reconstruction with uterus preserved. At first visit, POP-Q stage was determined, and age, BMI, admission days, operation time, post-operative stage and complications were observed and results were analyzed and compared. All patients who were operated upon converted to stage one month following the operation, and no further change was observed except in one patient. Group admission days were not significantly different, but tended to be lower in group C. Group average operation times between 'group A and B' and 'group A and C' were statistically different. No significant difference was observed in post-operative complications between the groups, but 3 members of group A developed erosion, whereas no erosion occurred in groups B and C. Pelvic reconstruction using mesh is a highly efficient method of treating pelvic organ prolapse. Improvements in stage and post-operative complications were not significantly different in the groups. However, uteropexy showed a shorter operation time, fewer admission days, and less erosion due to mesh than conventional pelvic reconstruction with hysterectomy.

/pdf/a-comparison-of-different-pelvic-reconstruction-surgeries-1zu6au101n.pdf

Euy Hyuk Kim

Papers

Effect of cyclosporine, mycophenolic acid, and rapamycin on the proliferation of rat aortic vascular smooth muscle cells: in vitro study.

Neonatal outcome after preterm delivery in HELLP syndrome.

The effect of fish consumption on blood mercury levels of pregnant women

The relationship between aldosterone to renin ratio and RI value of the uterine artery in the preeclamptic patient vs. normal pregnancy.

A Comparison of Different Pelvic Reconstruction Surgeries Using Mesh for Pelvic Organ Prolapse Patients