386 SPO Abstracts

320 A DECADE OF EXPERIENCE WITH PlASMA EXCHANGE THERAPY IN PATIENTS WITH PREECLAMPSIA/ECLAMPSIA. J.N. Martin, Jr., J.C. Fl1esx, P.G. BlakeX, P.H. Normanx, J.e. MOrrison, R.W. Martin, K.G. Perry, Jr. Dept. Ob/Gyn, University of Mississippi Medical Center, Jackson, MS. OBJECTIVE: To (1) review our cumulative experience with plasma exchange (PEX) for selected patients with preecl alllPsl a; and (2) summarize the major findings of these studies relative to recommendations for contemporary utilization of this process. STUDY DESIGN: Since July 1982 there have been 25 patients with preeclampsia/eclampsia/HELlP syndrome who underwent some fOI1ll of perlpartal PEX In our hospital. Among these were 7 patients with severe pretenn preeclampsia (without HELLP syndrome) who underwent single or serial partial PEX to unsuccessfully arrest the disease process and forestall dell very. The other 18 parturlents with severe preeclampsia and HELLP syndrome underwent emergent perlpartal (+ 24 hours of deli very) PEX (N • 4) or delayed PEX (H .~4) remote from delivery (3-8 days) when spontaneous recovery fall ed to occur. The IBM Cell Separator System was utilized throughout the series with a variety of fluid replacement regimens. RESULTS: I n the absence of HELLP syndrome, the undelivered severely preeclamptic patient benefited only tranSiently from/artlal PEX (mixed replacement fluids) before a reboun response with worsening of disease parailleters was observed. I n the presence of HEllP syndrome, the use of single or serial PEX with at least a 3-1lter volume of fresh frozen plas.a as the only replac8llent fluid was found to be IIOSt efficacious for the lmedlate perlpartal or postpartal patient. Twelve of 14 postpartal HELLP patients responded to the exchange process; 2 died with .ultlple organ failure despite PEX. CONCLUSIONS: The use of PEX (total. not part 1 a 1) 1 n selected situations with severe preeclampslal eclampsia and HEllP syndrot1Hl Is efficacious and can be lifesaving In the rare parturient with advanced or atypical disease unresponsive to conventional therapy.

321 THE PRESENCE OF HELLP SYNDR<I4E IN THE ECLAMPTIC PARTURIENT IS A MAJOR MATERNAL AND PERINATAL RISK INDICATOR. J.N. Martin, Jr., K.G. Perry, Jr .• P.G. BlakaX, E.F. Magann. W.E. Roberts, R.W. Martin. Dept. Ob/Gyn, Unl versl ty of Missl sslppl Medical Center, Jackson. MS. OBJECTIVE: To determine If there are dlscernable differences and Impact on patient and progeny between eclamptic pregnancies with or without concurrent HEllP syndrome. STUDY DESIGN: A maternal-perinatal database of all antepartum/Intrapartum eclamptic pregnancies In a single tertiary care center during 141 IIIOnths since 1980 was constructed retrospectively and prospectively. Patients were grouped accordl ng to the presence or absence of perlpartum HELLP syndrot1Hl with thrombocytopenia (Class 1 • platelet nadir [PH] < 50,OOO/uL, Class 2 • PN > 50,000 - < 100,Ooo/uL, Class "3 • PH > 100,000 - < 150,ooO/ul). hemolysis, and hepatic dysfunction. -RESULTS: 117 eclamptic gravidas were lIIanaged among 49.782 live births (1:425); 55 had uncomplicated disease, and 62 had HELLP syndrome (Class 1 • 14, Class 2 = 20, Class 3 • 28). In addition to significantly shorter gestations. lower birth weights, and higher perinatal mortality (113 vs 18:1000). the HElLP + eclampsia patient

!roup experienced more frequent maternal transfusions 65~ vs 35~), greater overall serious maternal morbidity ARDS, pulmonary edema. acute renal fal1ure. Infection),

a greater need for Invasive central monitoring. and mortality. Both maternal deaths In the series occurred In association with ARDS and multiple organ failure. Eclamptic gravidas without HELlP syndrome experienced relatively benign perinatal courses with Insignificant elevations In liver function tests. CONCLUSION: The presence of HELLP syndrome In an eclamptic gravida Identifies a very high-risk ~ternal-perlnatal situation preferably managed In a tertiary care center; the absence of HELlP syndrome In an eclamptic gravida Is reassuring and usually associated with a healthy maternal-perinatal outcome.

January 1993 Am J Obslel Gynecol

322 ANALYSIS OF 454 PREGNANCIES WITH SEVERE PREECLAMPSIA!

323

ECLAMPSIA HELLP SYNDR<J4E USING THE 3-CLASS SYSTEM OF CLASSIFICATION. J.N. Martin, Jr .• E.F. Magann, P.G. BlakeX, R.W. Martin, K.G. Perry, Jr., W.E. Roberts. Dept. Ob/Gyn. Unlv. Mississippi Med. Ctr .• Jackson, MS. OBJECTIVES: To characterize the clinical features and perinatal outcome of 454 pregnancies with HELLP syndrome which were lIanaged In a single tertiary center between January 1980 and September 1991. STUDY DESIGN: Comprehensive data on every patient with HELLP syndrOlll8 has been recorded prospectively since 1985 and retrospectively to 1980. Patients are grouped Into one of 3 classes based on perlpartal platelet nadir (PH): Class 1 PN < 50.000/uL, Class 2 PH > 50 ,000 -< l00,OOO/uL, Class . ! PH > 100,000 - < lSO,OOO/uL. RESULTS: -Factor Class 1 Class 2 Class 3 Tl'ffients --rrz- ~ ~ ~ Protein 1-4+ 91.2 92.5 77.7 P < 0.001 ~ Dlas BP > 90 89.3 91 . 5 95.5 NS ~ Eclampsia 17.2 16.3 14.0 NS Mean Peak LDH 1354 612 369 P < 0.001 Mean Peak SGOT 608 170 73 P < 0.001 Mean Peak Uric 7.8 7.7 7.4 NS ~ Mat Morbidity 64 54 40 P < 0.001 , Mat Mortality 2 lOP < 0.001 Mean Gest Age 31.0 32.4 33.2 P < 0.001 Mean Gest Wgt 1540 1701 1933 P < 0.001 ,; Perl Morb 78 69 63 P < 0.05 Perl Mort 164:1000 144:1000 117:1000 P < 0.05 CONCLUSIONS: (1) A gradual, progressive rise In lIIaternal and perinatal IIOrbldlty/llOrtallty Is evident as the pregnancy IIOves from class 3 to class 1 HELlP syndrOllle; (2) HELLP syndrOll8 severity and gestational age are Inversely related; (3) eclampsia occurs In a 1:6 patient ratio In all classes of HELLP syndrOfle; and (4) traditional parameters of preeclampsia severity (hypertenSion. proteinuria, uric acid) do not accurately ref1 ect the severl ty of HELLP syndrome as do 1 ab values Including platelets. LDH. Indirect bilirubin and SGOT.

MATERNAL MORTALITY AND MORBIDITY IN 442 PREGNANCIES WITH HELLP SYNDROME. B......S..i!m. M.K. Ramadan'. I. Usta,' M. Salama,' B. Mercerx. Univ. of TN. Mernphis. OBJECTIVES: To report overall maternal outcome and delermine the influence of obstetric complicalions and time of onset of the syndrome on maternal morbidity. STUDY DESIGN: Review of prospectively collected data in 442 pregnancies with HELLP syndrome managed at this center from Aug. 1977 to July 1992. Pregnancies were divided according whether HELLP developed before delivery or postpartwn. RESULTS: 437 women had 442 pregnancies with HELLP; 309 (70%) developed before delivery and 133 (30%) occurred postpartum. 49 (\1%) developed at <27 weeks. 313 (71 %) at 27-36; and 80 (18%) developed at term. 35 had eclampsia and 407 had severe preeclampsia. There were 5 maternal deaths (1 .1 %). 4 subcapsular liver hematomas. and 4 had retinal detachment. Other serious maternal morbidity included DlC (21 %) . abruptio placentae (16%). acute renal failure (7 .7%) and pulmonary edema (6%). CT·scan of abdomen was performed in 26 women; 9 were normal, 3 had subcapsular live .. hematomas, 2 had liver infarcts. 2 had parenchymal liver hemorrhage. and 10 had various hematomas and asciles. 55% required transfusions with blood and/or blood products. and 9 women (2%) required laparolomies for major intrabdominal bleeding. Abruptio placentae was strongly correlaled with the development of DlC (P<O.OOOI). ARF (P<O.OOI). and pulmonary edema (P<O.OI). Also, there was a slrong association between pulmonary edema and ARF (P<O.oool). There were no differences in laboralory findings between HELLP before and after delivery; however. there were other differences (Table).

Before Delivery Postpartwn P Value #(%) #(%)

Delivery at < 27 wk 45 (14.6) 4 (3) < 0.0007 Delivery a137-42 wk 47 (15.2) 33 (25) < 0.023 Pulmonary edema 14 (4.5) 12 (9.0) < 0 .10 Acule renal failure 17 (5.4) 16 (12) < 0 .028 Eclampsia 22 (7.1) 13 (10) NS Abruptio placenlae 49 (16) 20 (15) NS DlC 66 (21) 26 (20) NS CONCLUSIONS: Most cases of HELLP develop before term and this syndrome is associated with increased maternal morbidity. The development of HELLP postpartwn is a risk·factor for pulmonary edema and renal failure.