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Der Anaesthesist

, Volume 60, Issue 4, pp 343–351 | Cite as

Postpartale Eklampsie und fulminantes HELLP-Syndrom

  • M. SchottEmail author
  • A. Henkelmann
  • Y. Meinköhn
  • J.-P. Jantzen
Kasuistiken

Zusammenfassung

Das Zusammentreffen von HELLP-Syndrom („hemolysis, elevated liver enzymes, low platelet count“) und Eklampsie in der postpartalen Phase ist eine seltene, aber lebensbedrohliche Komplikation für Mutter und Fetus. Bei vorzeitiger Plazentalösung mit neu aufgetretener Hypertonie muss das Auftreten einer schweren postpartalen Gestose und deren Komplikationen in Betracht gezogen werden. Die Differenzialdiagnose eines postpartalen HELLP-Syndroms ist bei rasantem Hämoglobinabfall von einer schweren peripartalen Blutung abzugrenzen. Anhand des Fallberichts einer bis zum Geburtsbeginn symptomfreien 38-jährigen Patientin werden die Pathophysiologie, Differenzialdiagnosen und Behandlungsoptionen für das postpartale Zusammentreffen von fulminatem HELLP-Syndrom und Eklampsie beschrieben.

Schlüsselworte

Hypertension, schwangerschaftsinduziert Abruptio placentae Blutung Anämie Hämolyse 

Postpartum eclampsia and fulminant HELLP syndrome

Abstract

Postpartum onset of eclampsia and HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome is a rare but life-threatening complication for both mother and fetus. A case of a 38-year-old parturient (gravida 2, para 1) who was asymptomatic prior to delivery is reported. Emergency cesarian section had to be performed due to sudden onset of fetal bradycardia as a result of partial placental separation. The perioperative course was characterized by new onset hypertension, nausea and restlessness; within 2 h the patient suffered a generalized seizure which was treated with magnesium sulfate and hydralazine. Despite management in accordance with current guidelines, the condition deteriorated with hypotension, anemia and renal failure. On further examination hematomas in the abdominal cavity and walls were identified and laboratory tests confirmed HELLP syndrome with severe coagulopathy. Explorative laparotomy revealed diffuse bleeding without a significant isolated source or postpartum uterine hemorrhage. Retrospectively, the anemia could be ascribed to severe hemolysis and diffuse bleeding from coagulopathy. The patient required packed red cells, platelets, fresh frozen plasma and prothrombin complex. After admission to the intensive care unit persistent diffuse bleeding mainly caused by hyperfibrinolysis and renal failure occurred, which required blood transfusion, antifibrinolytic (tranexamic acid) and renal replacement therapy (continuous veno-venous hemodiafiltration with citrate) for 6 days. The patient recovered without any sequelae and was discharged 26 days later. Placental separation with new onset peripartum hypertension is to be interpreted as a precursor of severe gestosis and associated complications, especially dissiminated intravascular coagulation (DIC), acute renal failure and pleural effusion. A differentiation between a rapid drop in hemoglobin concentration secondary to hemolysis in postpartum HELLP syndrome rather than postpartum hemorrhage can be challenging. In addition, HELLP syndrome can lead to rapidly developing, fulminant hyperfibrinolysis in the context of DIC. Keys to successful management of postpartum gestosis and associated complications are early detection and perception of clinical and laboratory warning signs, a multidisciplinary approach with rapid and consistent targeted symptomatic therapy to save the mother and fetus.

Keywords

Hypertension, pregnancy-induced Abruptio placentae Bleeding Anemia Hemolysis 

Notes

Danksagung

Die Autoren danken Prof. Dr. Kienast, Universität Münster, für seinen Rat und wertvolle Hinweise.

Interessenkonflikt

Der korrespondierende Autor gibt an, dass kein Interessenkonflikt besteht.

Literatur

  1. 1.
    Bolton TJ, Randall K, Yentis SM (2003) Effect of the confidential enquiries into maternal deaths on the use of syntocinon at caesarean section in the UK. Anaesthesia 58:277–279PubMedCrossRefGoogle Scholar
  2. 2.
    Borzychowski AM, Sargent IL, Redman CWG (2006) Inflammation and pre-eclampsia. Semin Fetal Neonatal Med 11:309–316PubMedCrossRefGoogle Scholar
  3. 3.
    Douglas KA, Redman CW (1994) Eclampsia in the United Kingdom. BMJ 309:1395–1400PubMedGoogle Scholar
  4. 4.
    Dubé L, Grany JC (2003) The therapeutic use of magnesium in anesthesiology, intensive care and emergency medicine: a review. Can J Anesth 50:732–746PubMedCrossRefGoogle Scholar
  5. 5.
    Charbit B, Mandelbrot L, Samain E et al (2007) The decrease of fibrinogen is an early predictor of the severity of postpartum hemorrhage. J Thromb Haemost 5:266–273PubMedCrossRefGoogle Scholar
  6. 6.
    Gammill HS, Arundhathi J (2005) Acute renal failure in pregnancy. Crit Care Med 33 (Suppl):S372–S384PubMedCrossRefGoogle Scholar
  7. 7.
    Fetsch NI, Bremerich DH (2008) Anästhesie bei Patientinnen mit Präeklampsie und Eklampsie. Anaesthesist 57:87–102PubMedCrossRefGoogle Scholar
  8. 8.
    Hofer S, Schreckenberger R, Heindl B et al (2007) Blutungen während der Schwangerschaft. Anaesthesist 56:1075–1090PubMedCrossRefGoogle Scholar
  9. 9.
    Keiser SD, Owens MY, Parrish MR et al (2010) HELLP syndrome with and without eclampsia. Am J Perinatol, doi 10.1055/s-0030-1266155Google Scholar
  10. 10.
    Joshi D, James A, Quaglia A et al (2010) Liver disease in pregnancy. Lancet 375:594–605PubMedCrossRefGoogle Scholar
  11. 11.
    Martini WZ, Pusateri AE, Uscilowicz JM et al (2005) Independent contributions of hypothermia and acidosis to coagulopathy in swine. J Trauma 58:1002–1009PubMedCrossRefGoogle Scholar
  12. 12.
    Matchaba P, Moodley J (2004) Corticosteroids for HELLP syndrome in pregnancy. Cochrane Database Syst Rev (1):CD002076Google Scholar
  13. 13.
    Neilson J (2007) Pre-eclampsia and eclampsia. In: Lewis G (Hrsg) The Seventh Report of Confidential Enquiries into Maternal Death in the United Kingdom (2003–2005) Chapt. 3. CEMACH, London, S 72–77. http://www.cemach.org.ukGoogle Scholar
  14. 14.
    Panchal S, Arria AM, Harris AP (2000) Intensive care utilization during hospital admission for delivery: prevalence, risk factors, and outcomes in a statewide population. Anesthesiology 92:1537–1544PubMedCrossRefGoogle Scholar
  15. 15.
    Pfanner G, Kilgert K (2006) Geburtshilfliche Blutungskomplikationen. Hamostaseologie 26:S56–63PubMedGoogle Scholar
  16. 16.
    Rath W, Fischer T, Klockenbusch W (2008) Diagnostik und Therapie hypertensiver Schwangerschaftserkrankungen. Leitlinie der Arbeitsgemeinschaft Schwangerschaftshochdruck/Gestose der Deutschen Gesellschaft für Gynäkologie und Geburtshilfe e.V. (DGGG). AWMF-Leitlinien-Register Nr. 015/018, letzte Aktualisierung 05/2008Google Scholar
  17. 17.
    Rath W, Gogarten W (2008) Oxytocin und Methylergotamin nach der Geburt – Vorsicht bei der Anwendung! Frauenarzt 49:498–502Google Scholar
  18. 18.
    Rath W, Surbek D, Kainer F et al (2008) Diagnostik und Therapie peripartaler Blutungen. Leitlinie der Deutschen Gesellschaft für Gynäkologie und Geburtshilfe (DGGG). Interdisziplinäre Expertengruppe. AWMF-Leitlinien-Register Nr. 015/063, letzte Aktualisierung 06/2008Google Scholar
  19. 19.
    Redman CWG, Sargent IL (2009) Placental stress and pre-eclampsia: a revised view. Placenta 23:S38–S42CrossRefGoogle Scholar
  20. 20.
    Sibai BM, Ramadan MK, Usta I et al (1993) Maternal morbidity and mortality in 442 pregnancies with hemolysis, elevated liver enzymes, and low platelets (HELLP syndrome). Am J Obstet Gynecol 169:1000–1006PubMedGoogle Scholar
  21. 21.
    Weinstein L (1982) Syndrome of hemolysis, elevated liver enzymes and low platelet count: a severe consequence of hypertension in pregnancy. Am J Obstet Gynecol 142:159–167PubMedGoogle Scholar
  22. 22.
    Wong DW, Mishkin FS, Tanaka TT (1980) The effects of bicarbonate on blood coagulation. JAMA 244:61–66PubMedCrossRefGoogle Scholar
  23. 23.
    Woudstra DM, Chandra S, Hofmeyr GJ, Dowswell T (2010) Corticosteroids for HELPP (hemolysis, elevated liver enzymes, low platelets) syndrome in pregnancy. Cochrane Database Syst Rev (9):CD008148Google Scholar

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  • M. Schott
    • 1
    Email author
  • A. Henkelmann
    • 1
  • Y. Meinköhn
    • 1
  • J.-P. Jantzen
    • 1
  1. 1.Klinik für Anaesthesiologie, Intensivmedizin und SchmerztherapieKlinikum Nordstadt, Klinikum Region HannoverHannoverDeutschland

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