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Corticosteroids for HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome in pregnancy
Douglas M Woudstra1, Sue Chandra, G Justus Hofmeyr
1Department of Obstetrics and Gynaecology, University of Alberta, 13619 - 108 Avenue, Edmonton, Alberta, Canada, T5M 2C7.
Insights
Corticosteroids do not clearly improve major outcomes for HELLP syndrome. While steroids increase platelet counts, especially dexamethasone over betamethasone, evidence for routine use in HELLP management is insufficient.
Area of Science:
- Obstetrics and Gynecology
- Maternal-Fetal Medicine
- Pharmacology
Background:
- HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome is a severe manifestation of pre-eclampsia.
- It poses significant risks to both mother and child.
- Corticosteroids are often used with the aim of improving outcomes.
Purpose of the Study:
- To evaluate the effectiveness of corticosteroids in treating HELLP syndrome.
- To assess their impact on maternal and infant outcomes.
Main Methods:
- Systematic review of randomized controlled trials (RCTs) from the Cochrane Pregnancy and Childbirth Group's Trials Register.
- Included trials compared corticosteroids with placebo, no treatment, or other corticosteroids.
- Data on maternal/infant mortality, morbidity, and platelet counts were extracted.
Main Results:
- Eleven trials (550 women) showed no significant difference in maternal or infant mortality/morbidity with corticosteroid use compared to placebo.
- Corticosteroids significantly improved platelet counts, particularly when initiated antenatally.
- Dexamethasone showed superiority over betamethasone in increasing platelet counts.
Conclusions:
- Current evidence does not support the routine use of corticosteroids for HELLP syndrome based on major clinical outcomes.
- While corticosteroids improve platelet counts, this effect alone may not justify general use.
- Use may be considered when rapid platelet recovery is clinically desired.
Background:
Pre-eclampsia is a relatively common complication of pregnancy. HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome is a severe manifestation of pre-eclampsia with significant morbidity and mortality for pregnant women and their children. Corticosteroids are commonly used in the treatment of HELLP syndrome in the belief that they improve outcomes.
Objectives:
To determine the effects of corticosteroids on women with HELLP syndrome and their children.
Search Strategy:
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2010).
Selection Criteria:
Randomized controlled trials comparing any corticosteroid with placebo, no treatment, or other drug; or comparing one corticosteroid with another corticosteroid or dosage in women with HELLP syndrome.
Data Collection And Analysis:
Two review authors assessed trial quality and extracted data independently.
Main Results:
Eleven trials (550 women) compared corticosteroids with placebo or no treatment. There was no difference in the risk of maternal death (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.28 to 3.21), maternal death or severe maternal morbidity (RR 0.27, 95% CI 0.03 to 2.12), or perinatal/infant death (RR 0.64, 95% CI 0.21 to 1.97). The only clear effect of treatment on individual outcomes was improved platelet count (standardized mean difference (SMD) 0.67, 95% CI 0.24 to 1.10). The effect on platelet count was strongest for women who commenced treatment antenatally (SMD 0.80, 95% CI 0.25 to 1.35).Two trials (76 women) compared dexamethasone with betamethasone. There was no clear evidence of a difference between groups in respect to perinatal/infant death (RR 0.95, 95% CI 0.15 to 6.17) or severe perinatal/infant morbidity or death (RR 0.64, 95% CI 0.27 to 1.48). Maternal death and severe maternal morbidity were not reported. In respect to platelet count, dexamethasone was superior to betamethasone (MD 6.02, 95% CI 1.71 to 10.33), both when treatment was commenced antenatally (MD 8.10, 95% CI 6.23 to 9.97) and postnatally (MD 3.70, 95% CI 0.96 to 6.44).
Authors' Conclusions:
There was no clear evidence of any effect of corticosteroids on substantive clinical outcomes. Those receiving steroids showed significantly greater improvement in platelet counts which was greater for those receiving dexamethasone than those receiving betamethasone. There is to date insufficient evidence of benefits in terms of substantive clinical outcomes to support the routine use of steroids for the management of HELLP. The use of corticosteroids may be justified in clinical situations in which increased rate of recovery in platelet count is considered clinically worthwhile.
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