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Meta-Analysis
. 2010 Sep 8:(9):CD008148.
doi: 10.1002/14651858.CD008148.pub2.

Corticosteroids for HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome in pregnancy

Douglas M Woudstra  1 , Sue Chandra, G Justus Hofmeyr, Therese Dowswell
Affiliations
Meta-Analysis

Corticosteroids for HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome in pregnancy

Douglas M Woudstra et al. Cochrane Database Syst Rev. .

Abstract

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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References

References to studies included in this review

    1. Bouchnak M, Souissi K, Ouragini H, Abbes Z, Douiri H, Maghrebi H. Maternal benefit of postpartum corticosteroid therapy in patients with HELLP (hemolysis elevated liver enzymes low platelets count) syndrome [Interet de la corticotherapie en post partum dans le HELLP (hemolysis elevated liver enzymes low platelets count) syndrome] Tunisie Medicale. 2005;83(8):473–6. - PubMed
    1. Fonseca JE, Mendez F, Catano C, Arias F. Dexamethasone treatment does not improve the outcome of women with HELLP syndrome: a double-blind, placebo-controlled, randomized clinical trial. American Journal of Obstetrics & Gynecology. 2005;193(5):1591–8. - PubMed
    1. Isler CM, Barrilleaux PS, Magann EF, Bass JD, Martin JN. A prospective, randomized trial comparing the efficacy of dexamethasone and betamethasone for the treatment of antepartum hellp (hemolysis, elevated liver enzymes, and low platelet count) syndrome [Un estudio prospectivo, randomizado que compara la eficacia de la dexametasona y betametasona para el tratamiento anteparto del sindron de hellp (hemolisis, elevacion de enzimas hepaticas y plaquetopenia)] Revista Chilena de Obstetricia y Ginecologia. 2001;66(3):248–50.

    2. *

    3. Isler CM, Barrilleaux PS, Magann EF, Bass JD, Martin JN., Jr A prospective, randomized trial comparing the efficacy of dexamethasone and betamethasone for the treatment of antepartum hellp (hemolysis, elevated liver enzymes, and low platelet count) syndrome. American Journal of Obstetrics and Gynecology. 2001;184(7):1332–7. discussion 1337-9. - PubMed

    1. *

    2. Isler CM, Magann EF, Rinehart BK, Terrone DA, Bass JD, Martin JN., Jr Dexamethasone compared with betamethasone for glucocorticoid treatment of postpartum hellp syndrome. International Journal of Gynecology & Obstetrics. 2003;80(3):291–7. - PubMed
    3. Isler CM, Magann EF, Rinehart BK, Terrone DA, Bass JD, Martin JN., Jr Dexamethasone versus betamethasone for postpartum hellp syndrome: a randomized prospective clinical trial of comparative efficacy. American Journal of Obstetrics and Gynecology. 2000;182(1 Pt 2):S87.
    1. Kadanali S, Kucukozkan T, Bukam B. Helpful effect of high-dose corticosteroid use on Hellp syndrome [Yuksek doz kortikosteroid kullaniminin HELLP sendromu seyrine olumlu etkileri] Jinekoloji Ve Obstetrik Dergisi. 1997;11:55–8.

References to studies excluded from this review

    1. Barrilleaux PS, Martin JN, Jr, Klauser CK, Bufkin L, May WL. Postpartum intravenous dexamethasone for severely preeclamptic patients without hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome: a randomized trial. Obstetrics & Gynecology. 2005;105(4):843–8. - PubMed

References to studies awaiting assessment

    1. Borekci B, Bebek Z, Ingec M, Kadanali S. Effects of postpartum corticosteroids in patients with HELLP syndrome [HELLP sendromlu hastalarin tedavisinde postpartum kortikosteroid kullaniminin etkileri] Journal of the Turkish German Gynecology Association Artemis. 2008;9(2):79–83.
    1. Morrison JC. Effect on maternal thrombocytopenia in patients with HELLP syndrome of maternal steroid administration. Personal communication. 1992.

References to ongoing studies

    1. Fonseca J. [accessed 12 July 2010];Dexamethasone efficacy in HELLP syndrome, a multicentric, double-blind, placebo-controlled, randomized clinical trial. http://clinicaltrials.gov/ct2/show/record/NCT01138839

Additional references

    1. Abramovici D, Friedman SA, Mercer BM, Audibert F, Kao L, Sibai BM. Neonatal outcome in severe preeclampsia at 24 to 36 weeks’ gestation: does the HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome matter? American Journal of Obstetrics and Gynecology. 1999;180(1 Pt 1):221–5. - PubMed
    1. Clark SL, Phelan JR, Allen SH, Golde SR. Antepartum reversal of hematologic abnormalities associated with the HELLP syndrome. A report of three cases. Journal of Reproductive Medicine. 1986;31:70–2. - PubMed
    1. Deeks JJ, Altman DG, Bradburn MJ. Statistical methods for examining heterogeneity and combining results from several studies in meta-analysis. In: Egger M, Davey Smith G, Altman DG, editors. Systematic reviews in health care: meta-analysis in context. BMJ Books; London: 2001.
    1. Duley L, Henderson-Smart DJ, Walker GJA. Interventions for treating pre-eclampsia and its consequences: generic protocol. Cochrane Database of Systematic Reviews. 2009;(Issue 2) [DOI: 10.1002/14651858.CD007756]
    1. Haram K, Svendsen E, Abildgaard U. The HELLP syndrome: clinical issues and management. A Review. BMC Pregnancy and Childbirth. 2009;9:8. [PUBMED: 19245695] - PMC - PubMed

References to other published versions of this review

    1. Matchaba P, Moodley J. Corticosteroids for HELLP syndrome in pregnancy. Cochrane Database of Systematic Reviews. 2004;(Issue 1) [Art. No.: CD002076. DOI: 10.1002/14651858.CD002076.pub2] - PubMed
    1. Matchaba PT, Moodley J. Corticosteroids for HELLP syndrome in pregnancy. Cochrane Database of Systematic Reviews. 2009;(Issue 3) [Art. No.: CD002076. DOI: 10.1002/14651858.CD002076.pub3] - PMC - PubMed

    1. * Indicates the major publication for the study