Preeclampsia-eclampsia admitted to critical care unit

AUTHOR’S QUERY SHEET
Author(s): J. Rojas-Suarez and P. Vigil-De Gracia
Article title: Pre-eclampsia-eclampsia admitted to critical care unit
Article no: DJMF 678432
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1. José Rojas-Suarez
2. Paulino Vigil-De Gracia

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Journal of Maternal-Fetal and Neonatal Medicine, 2012; Early Online: 1–4
© 2012 Informa UK, Ltd.
ISSN 1476-7058 print/ISSN 1476-4954 online
DOI: 10.3109/14767058.2012.678432
Objective: To evaluate women with hypertensive disorder
admitted to critical care unit. Methods: This study was carried out
in Cartagena, Colombia, between January 2006 and December
2009. Patients were divided into 4 groups; severe pre-eclampsia,
eclampsia, HELLP syndrome and HELLP with eclampsia (HEEH).
Result: A total of 217 cases were admitted. The admitting diag-
noses were severe pre-eclampsia without HELLP syndrome
(39.2%), HELLP syndrome without eclampsia (33.6%), eclampsia
without HELLP syndrome (20.3%) and Eclampsia with HELLP
syndrome or HEEH (6.9%). Groups were similar with respect to
parity (p = 0.25), gestational age (p = 0.11), cesarean section
(p = 0.58), mechanical ventilation (p = 0.54), level of systolic (p
= 0.48) and diastolic blood pressure (p = 0.15) and inotropic
support (p = 0.32). Average total duration of hospitalization
was significantly different among groups, more time in women
with HEEH (p = 0.001). Multiple organ dysfunctions was diag-
nosed > 70% of all women admitted to intensive care, but was
significantly more frequent in patients with HELLP syndrome
and HEEH (p = 0.001). There were 5 maternal deaths (2.3%).
Causes of maternal death were intracranial hemorrhage (3),
intra-abdominal bleeding (1) and pulmonary complications
(1). Conclusion: Women with HELLP syndrome with or without
eclampsia are associated with major morbidity and mortality.
Therefore, the maternal outcome in eclampsia is influenced for
HELLP syndrome.
Keywords: Maternal Mortality, Eclampsia, HELLP syndrome,
critical care unit pre-eclampsia-eclampsia
Introduction
Hypertensive disorders of pregnancy affect about 10% of all preg-
nant women around the world [1].
Hypertension in pregnancy is the first-leading cause of morbidity
and mortality in Latin America and Caribbean [2], and is a major
riskfactorforfetalmorbidityandmortality[3].About63,000women
worldwide die every year because of eclampsia and pre-eclampsia
[4], with 99% of these deaths occurring in low income countries.
The HELLP syndrome represents a severe form of pre-
eclampsia-eclampsia, and is characterized by hemolysis, elevated
liver enzymes and low platelets [5]. Eclampsia is defined as the
occurrence in a woman with pre-eclampsia of seizures that
cannot be attributed to other causes [3] and HELLP/Eclampsia
or Eclampsia/HELLP (HE/EH) is defined as the presence of
eclampsia more HELLP syndrome in the same woman [6]. Like
eclampsia, HELLP syndrome can cause significant morbidity and
mortality for both mother and fetus. Either one by itself consti-
tutes an obstetric emergency. However, both at the same time
could be fatal [6].
Worldwide, it has been considered that eclampsia is the final
expression of pre-eclampsia and that represents the worst prog-
nosis for these women. Thus, for decades magnesium sulphate
have been given to women with pre-eclampsia, in the belief that
they reduce the risk of seizure, and so improve outcome. There is
evidence to support that reduce the fits, and maternal mortality
although the differences were not significant [7]. A recent review
of published cases [6] suggests that in maternal mortality by
eclampsia, the management to avoid seizures in women with pre-
eclampsia syndrome is not the main goal, except in patients with
HELLP syndrome.
The present study was carried out to find the trends of maternal
complications and deaths due to severe pre-eclampsia, eclampsia,
HELLP syndrome and concurrent HELLP with eclampsia in
women admitted to critical care unit.
Material and methods
This is a retrospective study that included 217 consecutive cases.
This study was carried out in the intensive care unit from the
Clínica de Maternidad Rafael Calvo, Cartagena, Colombia,
between January 2006 and December 2009. The local Ethic
Committee approve this study. We included only women admitted
to the critical care unit. Patients were divided into 4 groups:
A-Severe pre-eclampsia without HELLP syndrome.
B-Eclampsia without HELLP syndrome.
C-HELLP syndrome without eclampsia.
D-Eclampsia more HELLP syndrome (HE/EH complication).
Severe pre-eclampsia was defined as elevated blood pressure (at
least 140/90 mm Hg) with proteinuria (a dipstick reading of 2+ or
more) in association with one o more of the following: headache,
visual disturbances, epigastric pain, pulmonary edema, acute
renal insufficiency [3,8]. A blood pressure of 160/110 mmHg or
higher with proteinuria in the absence of any of the other features
was also classified as severe pre-eclampsia [3,8].
Eclampsia was defined as the report of convulsion or seizures
during pregnancy or postpartum in a woman with pre-eclampsia
that cannot be attributed to other causes [3,8].
HELLP syndrome was determined by the presence
pre-eclampsia in association with thrombocytopenia
ORIGINAL ARTICLE
Pre-eclampsia-eclampsia admitted to critical care unit
José Rojas-Suarez1 & Paulino Vigil-De Gracia2
1Critical Care Unit, Clínica de Maternidad Rafael Calvo. Grupo de Investigación en Cuidados Intensivos y Obstetricia, Universidad de
Cartagena, Cartagena, Colombia and 2Critical Care Unit, department of Obstetrics and Gynecology, Caja de Seguro Social, Panama
AQ1
Correspondence: Paulino Vigil-De Gracia, Critical Care Unit, department of Obstetrics and Gynecology, Caja de Seguro Social, Apartado
Postal: 0823-03828, Panama. Phone: 507 66143240. E-mail: pvigild@hotmail.com
(Received 21 October 2011; revised 12 December 2011; accepted 13 March 2012)

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2 J. Rojas-Suarez and P. Vigil-De Gracia
Journal of Maternal-Fetal and Neonatal Medicine
(<150,000 cells/µl), hemolysis, and hepatic dysfunction (elevated
transaminases and lactic dehydrogenase activities).
HELLP/Eclampsia or Eclampsia/HELLP (HE/EH) was defined
as the presence of eclampsia and HELLP syndrome in a woman.
Demographic data included maternal age, parity, gestational
age, and associated medical conditions. Records were reviewed
for presenting symptoms, laboratory findings, maternal compli-
cations and perinatal deaths.
Acute renal insufficiency was diagnosed in the presence of
oliguria-anuria in association with severe reduction in renal func-
tion (serum creatinine ≥ 1.2 mg/dl and reduced creatinine clear-
ance). Pulmonary edema was diagnosed according to the presence of
clinical and radiographic findings; and congestive heart failure was
diagnosed with the previous signs and symptoms and respiratory
difficulty as new onset of difficulty breathing, as evidenced by tachy-
pnea, or dyspnea or low peripheral oxygen saturation. Coagulopathy
was defined as clinically abnormal bleeding or a laboratory diagnosis
of a coagulation abnormality. Multiple organ dysfunctions were
defined as at least two organ systems dysfunction (cardiovascular,
respiratory, neurological, hematological, renal, metabolic, hepatic).
Laboratory evaluation included serial measurement of liver
function tests, complete blood cell count, coagulation profile, and
renal function tests. All women received intensive monitoring of
blood pressure, cardiac and general status.
Management of severe pre-eclampsia, eclampsia, and HELLP
syndrome included bed rest; to prevent or avoid seizure, all
women initially received magnesium sulfate as a 4 g intravenous
loading dose followed by 1 g intravenous per hour before delivery,
intrapartum and for 24 h postpartum. Labetalol and Nifedipine
were used as antihypertensives in these patients, some cases
required sodium nitroprusside or nitroglycerin in low dose.
A plasma volume expansion with saline solution was used in
all women studied to maintain adequate intravascular volume. In
the presence of oliguria one or two fluid boluses of 300–500 ml
are administered.
All statistical analysis was performed with the use of EPI-Info
(version 3.5.1, 2008). The two groups were compared with use of
analysis of variance, the Mann–Whitney/Wilconxon test, Fisher’s
exact test, the χ2-test as appropriate. Each category was compared
among the different groups. All significance tests were two-tailed,
with an α level of 0.05.
Results
During the study period there are 51,084 births and 217 (0.42%)
women with pre-eclampsia-eclampsia were admitted to critical
care unit. The admitting diagnoses were severe pre-eclampsia
without HELLP syndrome (39.2%), HELLP syndrome without
eclampsia (33.6%), eclampsia without HELLP syndrome (20.3%)
and Eclampsia with HELLP syndrome or HEEH (6.9%). Groups
were similar with respect to parity, gestational age, cesarean
section, mechanical ventilation, level of blood pressure and
inotropic support (Tables I and II). One hundred seventy-four
women in total were delivered by caesarean section (80.2%).
Table I. General characteristics.
N Group 1 (85) Group 2 (44) Group 33) Group 4 (15) p
Age year (SD) 26 (7) 22.2 (8.2) 25.1 (6.4) 21.5 (6.8) 0.01
Parity (SD) 1.9 (1.5) 1.4 (1) 1.9 (1.4) 1.6 (0.7) 0.25
Women with pregnancy at ICU* N (%) 21 (24.7) 6 (13.6) 7 (9.6) 0 (0) 0.01
Week’s Gestation (SD) 32.8 (5.4) 35.2 (3.8) 33.4 (6.3) 34.7 (4.1) 0.11
Cesarean (%) 81 84 75 87 0.58
SBP (SD) 159 (22) 153 (22) 154 (20) 158 (28) 0.48
DBP (SD) 109 (15) 105 (16) 109 (14) 114 (20) 0.15
Hemoglobin (SD) 10 (2.3) 10.9 (1.8) 9.3 (2.5) 10.3 (2,4) 0.01
Platelets 215,000 265,000 79,000 86,000 0.001
Perinatal Deaths N (%) 16(18.8) 5(11.4) 14(19.1) 1(6.7) 0.42
Group 1: Severe pre-eclampsia without HELLP syndrome.
Group 2: Eclampsia without HELLP syndrome.
Group 3: HELLP syndrome without eclampsia.
Group 4: HELLP syndrome with eclampsia or HEEH.
*Admitted before delivery to intensive critical unit.
SBP, Systolic blood pressure, mmHg; DBP, diastolic blood pressure.
Table II. Interventions in the intensive care unit.
Group 1 (85) Group 2 (44) Group 3 (73) Group 4 (15) p
Stay ICU days (SD) 4.4 (6.8) 3.3 (2.2) 4.8 (3.2) 6.9 (6) 0.001
Mechanical Ventilation N (%) 10 (11.8) 9 (20.5) 10 (13.7) 3 (20.0) 0.54
Inotropic support N (%) 3 (3.5) 1 (2.3) 4 (5.5) 2 (13.3) 0.32
Total blood transfusion (%) 15 (18) 3 (7) 37 (51) 7 (47) 0.001
Platelets transfusion (%) 3 (3.5) 0 (0) 14 (19) 2 (13.3) 0.001
Red cells transfusion (%) 15 (17.6) 3 (7) 32 (44) 7 (47) 0.001
MOF (%) 60 (71) 31 (70) 71 (97) 14 (93) 0.001
≥3 OF % 30 (35) 18 (41) 42 (57) 12 (80) 0.001
Deaths N (%) 1 (1.1) 1 (2.2) 2 (2.7) 1 (6.7) 0.6
Group 1: Severe pre-eclampsia without HELLP syndrome.
ICU, Intensive care unit; MOF, multiple organic failure (≥2 organic failure); OF, organic failure.

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Eclampsia and HELLP syndrome in critical care 3
©  Informa UK, Ltd.
The average maternal age was 24.6 ± 7 years; significantly the
groups with eclampsia without HELLP syndrome were younger,
Table I. Significantly, women with HELLP syndrome without
eclampsia or eclampsia with HELLP syndrome were admitted
post delivery at the critical care unit.
Average total duration of hospitalization at the critical care unit
was significantly different among groups, less time to eclampsia
without HELLP syndrome and more time to HEEH (eclampsia
with HELLP syndrome), Table II.
The hemoglobin concentration was lower in women with
HELLP syndrome, and the use of transfusion of blood compo-
nents was statistically significant more frequent in the group with
HELLP syndrome and HEEH (Table II). Multiple organ dysfunc-
tions was diagnosed >70% of all women admitted to intensive
care, but was significantly more frequent in patients with HELLP
syndrome without eclampsia and HEEH. Three o more organ
dysfunctions were statistically significant in the group with
eclampsia more HELLP syndrome (HEEH), Table II.
The perinatal deaths were similar among groups, Table I.
There were 5 maternal deaths (2.3%), Table II. Causes of
maternal death were: 3 cases with intracranial hemorrhage
[eclampsia with HELLP syndrome (1), HELLP syndrome (1), and
severe pre-eclampsia (1)], one case with intra-abdominal bleeding
(HELLP syndrome) and one case with pulmonary complications
secondary to bronco aspiration (eclampsia).
Comments
This observational study shows that 0.4% of women (pregnancy/
post partum) attended in our hospital are admitted to intensive
care unit with pre-eclampsia-eclampsia. Furthermore, patients
with HELLP syndrome with or without eclampsia represent the
most important complication because were associated with major
morbidity and mortality in women with pre-eclampsia-eclampsia.
There are statistically significant fewer women with HELLP
syndrome admitted with pregnancy to intensive care unit, they
were admitted mainly post delivery. This may be due to early
referral of high-risk patients, rapid pregnancy termination and
could explain our mortality rate relatively low. There is limited
information available in the literature about maternal outcomes
in pre-eclampsia-eclampsia-HELLP syndrome admitted at inten-
sive care unit.
The term severe maternal morbidity, has been used to refer
to complications occurring during pregnancy, delivery or
puerperium that may be life-threatening if not treated with
adequate medical care, this category include women admitted
to an intensive care unit during pregnancy or puerperium who
needs intensive life-saving treatment [9,10]. Pregnant patients
account for a small but significant number of intensive care unit
admissions. Thus, an indicator of pronounced maternal morbidity
is obstetric transfer to the intensive care unit [11]. pre-eclampsia-
eclampsia who develops pulmonary edema, oliguria or acute
renal failure, hepatic hemorrhage, persistent hypertension,
neurologic dysfunction or cerebral edema may require invasive
hemodynamic monitoring and can benefit from being closely
managed in the intensive care unit setting [11].
Eclampsia it is a common problem in developing countries
because illiteracy, lack of health awareness and education, poverty,
and superstitious beliefs prevent women from seeking medical
advice during pregnancy. We therefore believe that the reduction
in incidence of eclampsia in some countries has occurred because
women with severe pre-eclampsia and HELLP syndrome are
being managed better with quick birth and according to guidelines
including the pregnancy termination and are thus prevented from
having an eclamptic fit. However, to manage women with HELLP
syndrome the first step is the diagnosis and unfortunately in
developing countries this diagnosis is made very late or not made.
Then, it is possible that in developing countries a lot of death by
eclampsia have HELLP syndrome. The present study found major
morbidity and mortality in women with HELLP syndrome and
less complication in women with eclampsia without HELLP
syndrome; however when both complications are present in
the same patient exist a major risk of maternal morbidity and
mortality. Therefore, prevention or control of fits is very impor-
tant in patients with severe pre-eclampsia, especially when exist
the diagnosed of HELLP syndrome.
In the present study, 15% of patients received mechanical
ventilation; this is comparable with some reports [12]. The
median length of stay in the intensive care unit was 4 days; women
with HELLP syndrome more eclampsia (HEEH) significantly
stays more time in the intensive care unit. Patients with HELLP
syndrome with or without eclampsia received significantly more
blood products transfusions. Interestingly, eclampsia group
received less packed red cell, platelets or transfusion of blood
products than the other three groups. Furthermore, there were
five maternal deaths in this study, representing a mortality rate
of 2.3% and three deaths were in patients with HELLP syndrome.
In the evaluation of multiple organ failure with three or more
organ failures, the cases with HELLP syndrome with or without
eclampsia had significantly higher percentages. However, the
major risk is for eclampsia with HELLP syndrome (HEEH).
Then, according to our outcomeshigher multiple organ failure
in women with HELLP syndrome and mainly in patients with
HEEH confirms that the worst prognostic in women with pre-
eclampsia-eclampsia is produced by HELLP syndrome not by
eclampsia.
Studies analyzing MOF in pre-eclampsia-eclampsia patients
are urgently needed in order to adopt more effective strategies for
reducing maternal mortality in developing countries. Findings of
the present study indicate that such strategies should be oriented
particularly toward early treatment of pre-eclampsia-eclampsia by
general doctor and obstetrician-gynecologist providing prenatal
and delivery care.
Eclampsia is a potentially fatal disorder of pregnant women
that has been prevalent since the Hippocrates, but the preva-
lence varies widely [13]. It is a common problem in developing
countries. In those countries most pre-eclampsia with HELLP
syndrome cases remains unrecognized until severe complica-
tions, such as eclampsia, occur.
HELLP syndrome is an enigmatic condition, and its etiopatho-
genesis is not completely understood and can be responsible for a
multiplicity of adverse outcomes including cerebral hemorrhage/
stroke, cardiopulmonary compromise/failure, renal failure, liver
hematoma or rupture, placental abruption, preterm delivery
and death of the mother [14,15]. The risk of serious morbidity
correlates usually with increasingly severe signs, symptoms, and
laboratory abnormalities, especially the platelets count [16,17].
Maternal morbidity is greatest and maternal mortality most likely
when HELLP syndrome deteriorates to a class 1 (50,000 or less
platelets [5,18]),. Delivery is the cornerstone of therapy, however
in some cases the diagnosis of HELLP syndrome is made post
eclampsia or after any complications.
Optimal maternal and fetal outcomes are dependent on prompt
recognition and treatment of HELLP syndrome. In women with
pre-eclampsia is very important diagnose HELLP syndrome and
the pregnancy termination can be the better treatment in this

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4 J. Rojas-Suarez and P. Vigil-De Gracia
Journal of Maternal-Fetal and Neonatal Medicine
group of patients. Patients with suspected HELLP syndrome
should be hospitalized immediately and observed in a labor and
delivery unit. This is a very important step to reduce eclampsia
and maybe deaths by pre-eclampsia-eclampsia.
Of the limitations of this study, the first is that is an obser-
vational study, not a clinical trial study; then the outcomes can
be interpreted with caution. A second limitation is that relevant
cases may have been not admitted to critical care unit. Finally, the
great of this study is that there are few studies about this topic;
the number of cases is large enough to be able to find differences
among the classification groups, furthermore the methodology is
comprehensive and reproducible.
A team of obstetricians and other specialists such as,
nephrologists, intensivists and neurologists, an anesthetist, and
nurses with interest and experience are needed in an intensive
care unit to protect preeclamptic-eclamptic mothers from
death. Eclampsia, HELLP syndrome and special HEEH are very
high-risk patients and require intensive monitoring, thorough
investigation, and prompt and rational treatment whenever
necessary. It is time that doctors took a new look at this major
obstetric problem.
Declaration of interest: The authors report no declaration of
interest.
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- 1 -
ORIGINAL PAPER
Eclampsia and HELLP syndrome in critical care
José J. Rojas-Suarez, and Paulino P. Vigil-De Gracia
Pre-eclampsia-eclampsia admitted to critical care unit
José Rojas-Suarez1
, & Paulino Vigil-De Gracia2
1
Critical Care Unit, Clínica de Maternidad Rafael Calvo. Grupo de Investigación
en Cuidados Intensivos y Obstetricia, Universidad de Cartagena. , Cartagena,
Colombia and 2
Critical Care Unit, department of Obstetrics and Gynecology. ,
Caja de Seguro Social, Panama, Panama
*Corresponding Authorence: Adress: Paulino Vigil-De Gracia, Critical Care Unit,
department of Obstetrics and Gynecology, Caja de Seguro Social, Apartado
Postal: 0823-03828, Panama, Panama. Phone: 507 66143240, . E-mail:
pvigild@hotmail.com
Keywords: Maternal Mortality, Eclampsia, HELLP syndrome, critical care unit
preeclampsia-eclampsia.
Objective: To evaluate women with hypertensive disorder admitted to critical care
unit.
Methods: This study was carried out in Cartagena, Colombia, between January
2006 and December 2009. Patients were divided into 4 groups; severe pre-
eclampsiapreeclampsia, eclampsia, HELLP syndrome and HELLP with eclampsia
(HEEH).
Result: A total of 217 cases were admitted. The admitting diagnoses were severe
eclampsiapreeclampsia without HELLP syndrome (39.2%), HELLP syndrome
eclampsia (33.6%), eclampsia without HELLP syndrome (20.3%) and Eclampsia
HELLP syndrome or HEEH (6.9%). Groups were similar with respect to parity (p
gestational age (pp = 0.11), cesarean section (pp = 0.58), mechanical ventilation
level of systolic (pp = 0.48) and diastolic blood pressure (pp = 0.15) and inotropic

- 2 -
(pp = 0.32). Average total duration of hospitalization was significantly different
groups, more time in women with HEEH (pp = 0.001). Multiple organ
diagnosed > 70% of all women admitted to intensive care, but was significantly
frequent in patients with HELLP syndrome and HEEH (pp = 0.001). There were 5
deaths (2.3%). Causes of maternal death were intracranial hemorrhage (3), intra-
bleeding (1) and pulmonary complications (1).
Conclusion: Women with HELLP syndrome with or without eclampsia are
major morbidity and mortality. Therefore, the maternal outcome in eclampsia is
for HELLP syndrome.
Keywords: Maternal Mortality, Eclampsia, HELLP syndrome, critical care unit
eclampsia-eclampsia
Introduction
Hypertensive disorders of pregnancy affect about 10% of all pregnant women
around the world [1].
Hypertension in pregnancy is the first-leading cause of morbidity and mortality in
Latin America and Caribbean [2], and is a major risk factor for fetal morbidity
and mortality [3]. About 63,000 women worldwide die every year because of
eclampsia and pre-eclampsia [4]preeclampsia, with 99% of these deaths occurring
in low income countries.
The HELLP syndrome represents a severe form of pre-eclampsiapreeclampsia-
eclampsia, and is characterized by hemolysis, elevated liver enzymes and low
Eclampsia is defined as the occurrence in a woman with pre-
seizures that cannot be attributed to other causes [3] and HELLP/Eclampsia or
Eclampsia/HELLP (HE/EH) is defined as the presence of eclampsia more HELLP
in the same woman [6]. Like eclampsia, HELLP syndrome can cause significant
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and mortality for both mother and fetus. Either one by itself constitutes an
emergency. However, both at the same time could be fatal [6].
Worldwide, it has been considered that eclampsia is the final expression of pre-
eclampsiapreeclampsia and that represents the worst prognosis for these women.
Thus, for decades magnesium sulphate have been given to women with pre-
eclampsiapreeclampsia, in the belief that they reduce the risk of seizure, and so
improve outcome. There is evidence to support that reduce the fits, and maternal
mortality although the differences were not significant [7]. A recent review of
published cases [6] suggests that in maternal mortality by eclampsia, the
management to avoid seizures in women with pre-eclampsiapreeclampsia
syndrome is not the main goal, except in patients with HELLP syndrome.
The present study was carried out to find the trends of maternal complications and
deaths due to severe pre-eclampsiapreeclampsia, eclampsia, HELLP syndrome
and concurrent HELLP with eclampsia in women admitted to critical care unit.
Material and methods
This is a retrospective study that included 217 consecutive cases. This study was
carried out in the intensive care unit from the Clínica de Maternidad Rafael Calvo,
Cartagena, Colombia, between January 2006 and December 2009. The local Ethic
Committee approve this study. We included only women admitted to the critical
care unit. Patients were divided into 4 groups:
A- Severe pre-eclampsiapreeclampsia without HELLP syndrome.
B- Eclampsia without HELLP syndrome.
C- HELLP syndrome without eclampsia.
D- Eclampsia more HELLP syndrome (HE/EH complication).
Severe pre-eclampsiapreeclampsia was defined as elevated blood pressure (at
mm Hg) with proteinuria (a dipstick reading of 2+ or more) in association with
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the following: headache, visual disturbances, epigastric pain, pulmonary edema,
insufficiency [3,8]. A blood pressure of 160/110 mmHg or higher with proteinuria
absence of any of the other features was also classified as severe pre-eclampsia
[3,8]preeclampsia.
Eclampsia was defined as the report of convulsion or seizures during pregnancy
or postpartum in a woman with pre-eclampsiapreeclampsia that cannot be
attributed to other causes [3,8].
HELLP syndrome was determined by the presence pre-eclampsiapreeclampsia in
association with thrombocytopenia (< 150 ,000 cells/µl), hemolysis, and hepatic
dysfunction (elevated transaminases and lactic dehydrogenase activities).
HELLP/Eclampsia or Eclampsia/HELLP (HE/EH) was defined as the presence of
eclampsia and HELLP syndrome in a woman.
Demographic data included maternal age, parity, gestational age, and associated
medical conditions. Records were reviewed for presenting symptoms, laboratory
findings, maternal complications and perinatal deaths.
Acute renal insufficiency was diagnosed in the presence of oliguria-anuria in
association with severe reduction in renal function (serum creatinine ≥ 1.2 mg/dl
and reduced creatinine clearance). Pulmonary edema was diagnosed according to
the presence of clinical and radiographic findings; and congestive heart failure
was diagnosed with the previous signs and symptoms and respiratory difficulty as
new onset of difficulty breathing, as evidenced by tachypnea, or dyspnea or low
peripheral oxygen saturation. Coagulopathy was defined as clinically abnormal
bleeding or a laboratory diagnosis of a coagulation abnormality. Multiple organ
dysfunctions were defined as at least two organ systems dysfunction
(cardiovascular, respiratory, neurological, hematological, renal, metabolic,
hepatic).
Laboratory evaluation included serial measurement of liver function tests,
complete blood cell count, coagulation profile, and renal function tests. All

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women received intensive monitoring of blood pressure, cardiac and general
status.
Management of severe pre-eclampsiapreeclampsia, eclampsia, and HELLP
syndrome included bed rest; to prevent or avoid seizure, all women initially
received magnesium sulfate as a 4 gm intravenous loading dose followed by 1 gm
intravenous per hour before delivery, intrapartum and for 24 hours postpartum.
Labetalol and Nifedipine were used as antihypertensives in these patients, some
cases required sodium nitroprusside or nitroglycerin in low dose.
A plasma volume expansion with saline solution was used in all women studied to
maintain adequate intravascular volume. In the presence of oliguria one or two
fluid boluses of 300– – 500 ml are administered.
All statistical analysis was performed with the use of EPI-Info (version 3.5.1,
The two groups were compared with use of analysis of variance, the Mann–-
Whitney/Wilconxon test, Fisher’s exact test, the χchi-square2
-test as appropriate.
was compared among the different groups. All significance tests were two-tailed,
αalpha level of 0.05.
Results
During the study period there are 51 51,084 births and 217 (0.42%) women with
eclampsiapreeclampsia-eclampsia were admitted to critical care unit. The
diagnoses were severe pre-eclampsiapreeclampsia without HELLP syndrome
HELLP syndrome without eclampsia (33.6%), eclampsia without HELLP
and Eclampsia with HELLP syndrome or HEEH (6.9%). Groups were similar
parity, gestational age, cesarean section, mechanical ventilation, level of blood
inotropic support (Tables 1 I and II2). One hundred seventy-four women in total
were delivered by caesarean section (80.2%).
The average maternal age was 24.6 ± 7 years; significantly the groups with
without HELLP syndrome were younger, table Table I1. Significantly, women
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syndrome without eclampsia or eclampsia with HELLP syndrome were admitted
post delivery at the critical care unit.
Average total duration of hospitalization at the critical care unit was significantly
different among groups, less time to eclampsia without HELLP syndrome and
HEEH (eclampsia with HELLP syndrome), table Table II2.
The haemoglobin concentration was lower in women with HELLP syndrome, and
use of transfusion of blood components was statistically significant more frequent
group with HELLP syndrome and HEEH (table Table II2). Multiple organ
diagnosed > 70% of all women admitted to intensive care, but was significantly
frequent in patients with HELLP syndrome without eclampsia and HEEH. Three
organ dysfunctions were statistically significant in the group with eclampsia more
syndrome (HEEH), table Table II2.
The perinatal deaths were similar among groups, table Table I1.
There were 5 maternal deaths (2.3%), table Table II2. Causes of maternal death
3 cases with intracranial hemorrhage [eclampsia with HELLP syndrome (1),
syndrome (1), and severe pre-eclampsiapreeclampsia (1)], one case with intra-
bleeding (HELLP syndrome) and one case with pulmonary complications
bronco aspiration (eclampsia).
Comments
This observational study shows that 0.4% of women (pregnancy/post partum)
attended in our hospital are admitted to intensive care unit with pre-
eclampsiapreeclampsia-eclampsia. Furthermore, patients with HELLP syndrome
with or without eclampsia represent the most important complication because
were associated with major morbidity and mortality in women with pre-
eclampsiapreeclampsia-eclampsia.
There are statistically significant fewer women with HELLP syndrome admitted
pregnancy to intensive care unit, they were admitted mainly post delivery. This
early referral of high-risk patients, rapid pregnancy termination and could explain
mortality rate relatively low. There is limited information available in the

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maternal outcomes in pre-eclampsiapreeclampsia-eclampsia-HELLP syndrome
admitted at intensive care unit.
The term severe maternal morbidity, has been used to refer to complications
occurring during pregnancy, delivery or puerperium that may be life-threatening if
not treated with adequate medical care, this category include women admitted to
an intensive care unit during pregnancy or puerperium who needs intensive life-
saving treatment [9,10]. Pregnant patients account for a small but significant
number of intensive care unit admissions. Thus, an indicator of pronounced
maternal morbidity is obstetric transfer to the intensive care unit [11]. pre-
eclampsiaPreeclampsia-eclampsia who develops pulmonary edema, oliguria or
acute renal failure, hepatic hemorrhage, persistent hypertension, neurologic
dysfunction or cerebral edema may require invasive hemodynamic monitoring
and can benefit from being closely managed in the intensive care unit setting [11].
Eclampsia it is a common problem in developing countries because illiteracy, lack
health awareness and education, poverty, and superstitious beliefs prevent women
seeking medical advice during pregnancy. We therefore believe that the reduction
incidence of eclampsia in some countries has occurred because women with
eclampsiapreeclampsia and HELLP syndrome are being managed better with
quick birth and according to guidelines including the pregnancy termination and
are thus prevented from having an eclamptic fit. However, to manage women with
HELLP syndrome the first step is the diagnosis and unfortunately in developing
countries this diagnosis is made very late or not made. Then, it is possible that in
developing countries a lot of death by eclampsia have HELLP syndrome. The
present study found major morbidity and mortality in women with HELLP
syndrome and less complication in women with eclampsia without HELLP
syndrome; however when both complications are present in the same patient exist
risk of maternal morbidity and mortality. Therefore, prevention or control of fits
important in patients with severe pre-eclampsiapreeclampsia, especially when
diagnosed of HELLP syndrome.
In the present study, fifteen 15%percent of patients received mechanical
this is comparable with some reports [12]. The median length of stay in the

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unit was 4 days; women with HELLP syndrome more eclampsia (HEEH)
significantly stays more time in the intensive care unit. Patients with HELLP
syndrome with or without eclampsia received significantly more blood products
transfusions. Interestingly, eclampsia group received less packed red cell, platelets
or transfusion of blood products than the other three groups. Furthermore, there
were five maternal deaths in this study, representing a mortality rate of 2.3% and
three deaths were in patients with HELLP syndrome.
In the evaluation of multiple organ failure with three or more organ failures, the
cases with HELLP syndrome with or without eclampsia had significantly higher
percentages. However, the major risk is for eclampsia with HELLP syndrome or
(HEEH). Then, according to our outcomeshigher multiple organ failure in women
with HELLP syndrome and mainly in patients with HEEH confirms that the worst
prognostic in women with pre-eclampsiapreeclampsia-eclampsia is produced by
HELLP syndrome not by eclampsia.
Studies analyzing MOF in pre-eclampsiapreeclampsia-eclampsia patients are
urgently needed in order to adopt more effective strategies for reducing maternal
mortality in developing countries. Findings of the present study indicate that such
strategies should be oriented particularly toward early treatment of pre-
eclampsiapreeclampsia-eclampsia by general doctor and obstetrician-gynecologist
providing prenatal and delivery care.
Eclampsia is a potentially fatal disorder of pregnant women that has been
prevalent since the Hippocrates, but the prevalence varies widely [13]. It is a
common problem in developing countries. In those countries most pre-
eclampsiapreeclampsia with HELLP syndrome cases remains unrecognized until
severe complications, such as eclampsia, occur.
HELLP syndrome is an enigmatic condition, and its etiopathogenesis is not
completely understood and can be responsible for a multiplicity of adverse
including cerebral hemorrhage/stroke, cardiopulmonary compromise/failure, renal
liver hematoma or rupture, placental abruption, preterm delivery and death of the
[14,15]. The risk of serious morbidity correlates usually with increasingly severe
symptoms, and laboratory abnormalities, especially the platelets count [16,17].
morbidity is greatest and maternal mortality most likely when HELLP syndrome
to a class 1 (50 50,000 or less platelets [5,18]),. Delivery is the cornerstone of

- 9 -
however in some cases the diagnosis of HELLP syndrome is made post eclampsia
or after any complications.
Optimal maternal and fetal outcomes are dependent on prompt recognition and
treatment of HELLP syndrome. In women with pre-eclampsiapreeclampsia is
diagnose HELLP syndrome and the pregnancy termination can be the better
group of patients. Patients with suspected HELLP syndrome should be
immediately and observed in a labor and delivery unit. This is a very important
eclampsia and maybe deaths by pre-eclampsiapreeclampsia-eclampsia.
Of the limitations of this study, the first is that is an observational study, not a
clinical trial study; then the outcomes can be interpreted with caution. A second
limitation is that relevant cases may have been not admitted to critical care unit.
Finally, the great of this study is that there are few studies about this topic; the
number of cases is large enough to be able to find differences among the
classification groups, furthermore the methodology is comprehensive and
reproducible.
A team of obstetricians and other specialists such as, nephrologists, intensivists
and neurologists, an anesthetist, and nurses with interest and experience are
needed in an intensive care unit to protect preeclamptic-eclamptic mothers from
death. Eclampsia, HELLP syndrome and special HEEH are very high-risk patients
and require intensive monitoring, thorough investigation, and prompt and rational
treatment whenever necessary. It is time that doctors took a new look at this major
obstetric problem.
Declaration of interest:
The authors report no declaration of interest.
References
1-. WHO recommendations for prevention and treatment of pre-eclampsia and
World Health Organization 2011.
2. Khan KS, Wojdyla D, Say L, Gülmezoglu AM, Van Look PF. WHO
analysis of causes of maternal death: a systematic review. Lancet 2006;367:1066–
1074.

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3-. Report of the National High Blood Pressure Education Program Working
Group on High Blood Pressure in Pregnancy. Am J Obstet Gynecol 2000;183:S1-
–S22.
4. Langer A, Villar J, Tell K, Kim T, Kennedy S. Reducing eclampsia-related
deaths–a call to action. Lancet 2008;371:705–706.
5. Isler CM, Rinehart BK, Terrone DA, Martin RW, Magann EF, Martin JN
Jr. Maternal mortality associated with HELLP (hemolysis, elevated liver
enzymes, and low platelets) syndrome. Am J Obstet Gynecol 1999;181:924–928.
6-. Vigil-De Gracia P. Maternal deaths due to eclampsia and HELLP
Gynecol Obstet 2009;104:90-–94.
7-. Magpie Trial Collaboration Group. 2002. Do Women with pre-eclampsia,
babies, benefit from magnesium sulphate? The Magpie Trial: a randomized
controlled trial. Lancet 359:1877-–1890.
8. Brown MA, Lindheimer MD, de Swiet M, Van Assche A, Moutquin JM.
The classification and diagnosis of the hypertensive disorders of pregnancy:
statement from the International Society for the Study of Hypertension in
Pregnancy (ISSHP). Hypertens Pregnancy 2001;20:IX–XIV.
9. Murphy DJ, Charlett P. Cohort study of near-miss maternal mortality and
subsequent reproductive outcome. Eur J Obstet Gynecol Reprod Biol
2002;102:173–178.
10. Karnad DR, Guntupalli KK. Critical illness and pregnancy: review of a
global problem. Crit Care Clin 2004;20:555–76, vii.
11. Collop NA, Sahn SA. Critical illness in pregnancy. An analysis of 20
patients admitted to a medical intensive care unit. Chest 1993;103:1548–1552.
12. Lataifeh I, Amarin Z, Zayed F, Al-Mehaisen L, Alchalabi H, Khader Y.
Indications and outcome for obstetric patients’ admission to intensive care unit: a
7-year review. J Obstet Gynaecol 2010;30:378–382.
13. Leitch CR, Cameron AD, Walker JJ. The changing pattern of eclampsia
over a 60-year period. Br J Obstet Gynaecol 1997;104:917–922.

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14. Martin JN Jr, Rose CH, Briery CM. Understanding and managing HELLP
syndrome: the integral role of aggressive glucocorticoids for mother and child.
Am J Obstet Gynecol 2006;195:914–934.
15-. Keiser SD, Owens MY, Parrish MR et al. In press. HELLP syndrome with
without eclampsia. Am J Perinatol In press.http://dx.doi.org/10.1055/s-0030–
16. Cavkaytar S, Ugurlu EN, Karaer A, Tapisiz OL, Danisman N. Are clinical
symptoms more predictive than laboratory parameters for adverse maternal
outcome in HELLP syndrome? Acta Obstet Gynecol Scand 2007;86:648–651.
17. Osmanagaoglu MA, Osmanagaoglu S, Ulusoy H, Bozkaya H. Maternal
outcome in HELLP syndrome requiring intensive care management in a Turkish
hospital. Sao Paulo Med J 2006;124:85–89.
18-. Vigil-De Gracia P. 2001. Int J Gynaecol Obstet. 2001. Pregnancy
eclampsia-eclampsia with HELLP syndrome. Int J Gynaecol Obstet 72(1):17–23.
Table I1. General characteristics.
(N) Group 1 (85) Group 2 (44) Group 3 (73) Group 4 (15) pP
Age year (SD) 26 (7) 22.2 (8.2) 25.1 (6.4) 21.5 ((6.8) 0.01
Parity (SD) 1.9 (1.5) 1.4 ((1) 1.9 ((1.4) 1.6 ((0.7) 0.25
Women with
pregnancy at
ICU* N ((%)
21 ((24.7) 6 ((13.6) 7 ((9.6) 0 ((0) 0.01
Week´s Gestation
(SD)
32.8 ((5.4) 35.2 ((3.8) 33.4 ((6.3) 34.7 ((4.1) 0.11
Cesarean
(%)
81 84 75 87 0.58
SBP (SD) 159 ((22) 153 ((22) 154 ((20) 158 ((28) 0.48
DBP (SD) 109 ((15) 105 (16) 109 ((14) 114 ((20) 0.15
Hemoglobin (SD) 10 ((2.3) 10.9 ((1.8) 9.3 ((2.5) 10.3 ((2,4) 0.01
Platelets 215000 265000 79000 86000 0.001
Perinatal Deaths
N ((%)
16(18.8) 5(11.4) 14(19.1) 1(6.7) 0.42
Group 1: Severe pre-eclampsiapreeclampsia without HELLP syndrome.
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*Admitted before delivery to intensive critical unit.
SBP, = Systolic blood pressure, mmHg; DBP, = diastolic blood pressure.
Table II2. Interventions in the intensive care unit.
Group 1
(85)
Group 2
(44)
Group 3
(73)
Group 4
(15)
pP
Stay ICU days (SD) 4.4 (6.8) 3.3 (2.2) 4.8 (3.2) 6.9 (6) 0.001
Mechanical
Ventilation N (%)
10 (11.8) 9 (20.5) 10 (13.7) 3 (20.0) 0.54
Inotropic support N
(%)
3 (3.5) 1 (2.3) 4 (5.5) 2 (13.3) 0.32
Total blood
transfusion (%)
15 (18) 3 (7) 37 (51) 7 (47) 0.001
Platelets transfusion
(%)
3 (3.5) 0 (0) 14 (19) 2 (13.3) 0.001
Red cells transfusion
(%)
15 (17.6) 3 (7) 32 (44) 7 (47) 0.001
MOF (%) 60 (71) 31 (70) 71 (97) 14 (93) 0.001
≥ 3 OF % 30 (35) 18 (41) 42 (57) 12 (80) 0.001
Deaths N (%) 1 (1.1) 1 (2.2) 2 (2.7) 1 (6.7) 0.6
Group 1: Severe pre-eclampsiapreeclampsia without HELLP syndrome.
ICU, = intensive care unit; MOF, = multiple organic failure (≥ 2 organic failure); OF, = organic
failure.
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