Volume 16~ Number 1. Part 2

97 PLASMA IMMUNOREACTIVE ENDOTHELIN CONCENTRATIONS IN SEVERE PREECLAMPTIC AND NORMOTENSIVE GRAVIDAS. KG Perry, Jrx, IN Martin, Jr, RW Martin, PG BlakeX, 0 Aublefn~, JC Burnett, Jrx. University of Mississippi Medical Center, Jackson, MS and Mayo Medical School, Rochester, MN.

Endothelin, a potent vasoconstrictive peptide isolated from cultured porcine aortic endothelial cells, exhibits in vitro vasoconstrictive effects on various arteries. Increased plasma ET concentrations [ET] have been noted in patients with congestive heart failure, uremia, and hypertension. We hypothesized that increased production or release of ET might playa role in the pathophysiology of severe preeclampsia. Plasma immunoreactive [ET] were studied prospectively in 36 gravidas: 9 normotensives in active labor, 14 normotensives not in labor, and 13 severe preecl ampt i cs. Pati ents were matched for gestational age. Samples were collected from preeclamptic and normotensive patients in labor and 24 hours postpartum; a single sample was collected from nonlaboring controls. No differences in age, race, gravidity, parity, gestational age, or maternal weight were detected among patient groups. There was a significant difference (P < 0.001) in mean arterial pressure between preeclamptics (X ~ 130.5 + 10.1) and control gravidas (X E 85.9 + 7.2). There were significant differences in [ET] between preeclamptics (X • 7.19 + 0.97) and normotensives: laboring controls, X ~ 6.12 +" 0.67 (P = 0.025) and nonlaboring controls, X = 5.30 +-1.26 (P < 0.001). Antepartum and postpartum [ET] did -not change significantly in the preeclamptic

~roup (P • 0.67) or in the control group (P ~ 0.82). ET] were slightly increased in the laboring controls X = 6.12 + 0.67) compared to nonlaboring controls (X =

5.30 + lots), but not significantly (P = 0.073). We conclu-de that (1) labor and delive~ does not appear to exert a Significant impact on [ET] in preecl amptic or normotensive patients, (2) [ET] are significantly higher in severe preeclamptics than normotensive gravidas, and (3) ET may playa role in the clinical manifestations of severe preeclampsia.

98 ECLAMPSIA AND THE HELLP CONNECTION. IN Martin, Jr MD, JF Miles, MDx, PG Blake, RN, MSNx, KG Perry, MOK, JF McCaul, MDx, RW Martin, MD. University of Mississippi Medical Center, Jackson, MS.

HELLP syndrome is reported to complicate 3-12% of all preeclamptic gestations. Eclampsia or HELLP syndrome as a form of severe preeclampsia is associated with significantly increased maternal and perinatal morbidity and mortality. When HELLP syndrome and eclampsia occur concurrently, the cumulative negative impact of these two serious pregnancy complications is potentially severe. In order to investigate this issue, a retrospective review was undertaken of all eclamptic gestations managed during a 9-year span between January 1, 1980 and December 31, 1988. Among the 113 patients were 48 with simple antepartum eclampsia, 44 with antepartum eclampsia/HELLP syndrome (Cl ass 1~6, Cl ass 2=17, Cl ass 3=21), 10 wi th simple postpartum eclampsia and 11 with postpartum eclampsia/HELLP syndrome (Class 1=6, Class 2=4, Class 3=1). Both antepartum groups were comparable regarding maternal age, race, peak blood pressure, range of proteinuria, delivery mode and cervical dilatation at time of convulsion. In contrast to simple antepartum eclampsia, the group of 44 eclamptic gravidas with evidence of concurrent HELLP syndrome had significantly earlier gestations (33 vs 37 wks), lower blrthweights (1888 vs 2669 gm), more frequent maternal transfusions (69 vs 31%), greater overall maternal morbidity and higher perinatal mortality (167 vs 24:1000). Antepartum and postpartum ecl ampsi a with concurrent HELlP syndrome were associated with Significantly elevated peak mean serum LDH, SGOT/AST, SGPT/ALT and uric acid determinations in comparison to uncomplicated eclampsia. We conclude that (1) the appearance of HELLP syndrome appears to distinguish a particularly high risk group of eclamptic patients; (2) between 29% (Classes 1 & 2) and 49% (Classes 1-3) of eclamptic patients will have HELLP syndrome; and (3) there appear to be at least two forms of antepartum eclampsia with significantly different maternal/fetal implications.

SPO Abstracts 275

99 RATE OF WORSENING THROMBOCYTOPENIA IN THE TERMINAL STAGES OF HELLP SYNDROME. IN Martin, Jr, MD, KG Perry, MDx, PG Blake, RN, MSNx, RW Martln, MO, JC Files, MDx. University of Mississippi Medical Center, Jackson, MS.

100

Thrombocytopeni a is an easily measured i ndi cator of the severity of microangiopathic hemolytic anemia in patients with HELLP syndrome. Late in the course of disease when medical/obstetric decisions are preSSing, the obstetrician wonders: How rapidly will the platelet count (PC) decrease? What time course for disease deterioration can be anticipated? The hospital course of 158 patients with Class 1 (platelet nadir < 50,OOO/uL) or Class 2 (platelet nadir> 50,000 - < 100",OOO/uL) HELLP syndrome managed between 1980-1989 were analyzed retrospectively to seek answers to these questions. The rate of PC decrease per day until delivery was determined for each patient. Admission PC was> 150,OOO/uL in 30 patients and decreased an average of 41% per day. Admission PC was> 100,000 < 150,OOO/uL in 55 patients and decreased an average of ~6% per day in 52 cases but double that rate in 3 patients whose PC decreased rapidly < 50,OOO/uL. The remaining 73 patients were admitted with PC < 100,OOO/uL: 14 patients were transfused platelets at admission thus excluding them from analysis; the PC of 7 (4.4%) increased between admission and delivery; and the rate of PC decrease in the other 52 nontransfused HELLP gravidas averaged 32% per day until delivery. Thus it appears that (1) not all PC's in patients with HELLP syndrome will decrease following hospitalization--rare patients «5%) will demonstrate unassisted modest increases in PC; (2) most HELLP patients will exhibit PC decreases in the range of 25-50% during a 24 hour period; (3) determination of the PC more often than q 24 h does not appear necessary if > 100,OOO/uL--if PC is < 100,OOO/uL, assessments q 12 h appear prudent; and (4) a prospective investigation with timed sampling of PC at 12 hour intervals will be necessary to further elucidate terminal platelet patterns in HELLP syndrome.

HELLP SYNDROME: GUIDELINES FOR HEMOTHERAPY. IN Martin, ~~ JB Woods, MDx, PG Blake, RN, MSNx, KG Perry, MUA, KW Martin, MD, JC Files, MDx. University of Mississippi Medical Center, Jackson, MS.

There are no commonly accepted guidelines for the hemotherapy of patients with HELLP syndrome although 38-93% of these critically ill mothers receive some form of blood product transfusion. The clinical courses of 70 patients with Class 1 (platelet nadir < 50,OOO/uL) and 88 with Cl ass 2 HELLP syndrome \pl atel et nadi r > 50,OOO/uL - < 100,OOO/uL) were reviewed retrospectively in order to Cevelop guidelines for the hemotherapy of this variant form of severe preeclampsia/eclampsia. Some form of transfusion was utilized in 42 (60%) Class 1 patients and 38 (43%) Class 2 HELLP patients. Peripartal transfusions of platelets, plasma or red cells within 24 hours of delivery were given to 30%, 50% and 51% respectively of Class 1 HELLP patients versus 1.1%, 3.4% and 31% respectively in Class 2. Some form of delayed transfusion (> 24 hours postpartum) was given to 31 (44%) Class 1 HELLP mothers; only 11.4% of Class 2 HELLP mothers recei ved del ayed red cell transfusions. A 11 forms of hemotherapy were associated with a significantly increased rate of postpartum infection regardless of delivery mode or receipt of prophylactic antibiotics. Patients with platelets < 30,OOO/uL immediately prior to abdominal or vaginal delivery who were not transfused a 10-unit platelet pack experienced a Significantly increased incidence of hemorrhage (63%) versus none in the transfused group. Platelet transfusion to patients with platelets between 30,000 - 50,OOO/uL around delivery was associated with a 25% incidence of bleeding without regard to whether or not the patient received transfused platelets. It appears that (1) a platelet count < 30,OOO/uL prior to delivery should lead to platelet transfusion in order to avert unnecessary blood loss; and (2) a conservatIve transfusion policy possibly in association wIth prophylactic antibiotic therapy appears reasonab 1 e in patients wi th HELLP syndrome in order to minImize the risk of infection.