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Meta-Analysis
. 2010 Sep 8;2010(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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Conflict of interest statement

None known.

Figures

1.1
1.1. Analysis
Comparison 1 Any corticosteroid versus placebo or control, Outcome 1 Maternal death.
1.2
1.2. Analysis
Comparison 1 Any corticosteroid versus placebo or control, Outcome 2 Maternal death or severe morbidity.
1.3
1.3. Analysis
Comparison 1 Any corticosteroid versus placebo or control, Outcome 3 Perinatal/infant death.
1.4
1.4. Analysis
Comparison 1 Any corticosteroid versus placebo or control, Outcome 4 Maternal liver hematoma, rupture or failure.
1.5
1.5. Analysis
Comparison 1 Any corticosteroid versus placebo or control, Outcome 5 Maternal pulmonary edema.
1.6
1.6. Analysis
Comparison 1 Any corticosteroid versus placebo or control, Outcome 6 Maternal renal failure.
1.7
1.7. Analysis
Comparison 1 Any corticosteroid versus placebo or control, Outcome 7 Eclampsia.
1.8
1.8. Analysis
Comparison 1 Any corticosteroid versus placebo or control, Outcome 8 Caesarean section or elective delivery including induction of labor.
1.9
1.9. Analysis
Comparison 1 Any corticosteroid versus placebo or control, Outcome 9 Length of stay in hospital or obstetrical delivery room for the mother.
1.10
1.10. Analysis
Comparison 1 Any corticosteroid versus placebo or control, Outcome 10 Need for dialysis.
1.11
1.11. Analysis
Comparison 1 Any corticosteroid versus placebo or control, Outcome 11 Abruptio placenta.
1.12
1.12. Analysis
Comparison 1 Any corticosteroid versus placebo or control, Outcome 12 Respiratory distress syndrome with/without ventilatory support.
1.13
1.13. Analysis
Comparison 1 Any corticosteroid versus placebo or control, Outcome 13 Intracerebral hemorrhage.
1.14
1.14. Analysis
Comparison 1 Any corticosteroid versus placebo or control, Outcome 14 Necrotizing enterocolitis.
1.15
1.15. Analysis
Comparison 1 Any corticosteroid versus placebo or control, Outcome 15 Gestational age at delivery.
1.16
1.16. Analysis
Comparison 1 Any corticosteroid versus placebo or control, Outcome 16 Retinopathy of prematurity/retrolental fibroplasia.
1.17
1.17. Analysis
Comparison 1 Any corticosteroid versus placebo or control, Outcome 17 Apgar score at 5 minutes < 7.
1.18
1.18. Analysis
Comparison 1 Any corticosteroid versus placebo or control, Outcome 18 Length of stay in hospital or special care nursery/NICU (days).
1.19
1.19. Analysis
Comparison 1 Any corticosteroid versus placebo or control, Outcome 19 Long‐term growth and development ‐ head circumference < 2 SD at 24 months.
1.20
1.20. Analysis
Comparison 1 Any corticosteroid versus placebo or control, Outcome 20 Long‐term growth and development ‐ Abnormal Griffiths or BSID scales at 24 months.
1.21
1.21. Analysis
Comparison 1 Any corticosteroid versus placebo or control, Outcome 21 Days of mechanical ventilation required (days).
1.22
1.22. Analysis
Comparison 1 Any corticosteroid versus placebo or control, Outcome 22 Platelet count or rate of change of platelet count.
1.23
1.23. Analysis
Comparison 1 Any corticosteroid versus placebo or control, Outcome 23 AST level or rate of change of AST level (*non pre‐specified outcome).
1.24
1.24. Analysis
Comparison 1 Any corticosteroid versus placebo or control, Outcome 24 ALT level or rate of change of ALT level (*non pre‐specified outcome).
1.25
1.25. Analysis
Comparison 1 Any corticosteroid versus placebo or control, Outcome 25 LDH level or rate of change of LDH level (*non pre‐specified outcome).
1.26
1.26. Analysis
Comparison 1 Any corticosteroid versus placebo or control, Outcome 26 Diastolic blood pressure or rate of change of mean arterial blood pressure (*non pre‐specified outcome).
1.27
1.27. Analysis
Comparison 1 Any corticosteroid versus placebo or control, Outcome 27 Rate of change of urinary output (*non pre‐specified outcome).
2.1
2.1. Analysis
Comparison 2 Dexamethasone versus betamethasone, Outcome 1 Maternal death.
2.2
2.2. Analysis
Comparison 2 Dexamethasone versus betamethasone, Outcome 2 Maternal death or severe morbidity.
2.3
2.3. Analysis
Comparison 2 Dexamethasone versus betamethasone, Outcome 3 Perinatal/infant death.
2.4
2.4. Analysis
Comparison 2 Dexamethasone versus betamethasone, Outcome 4 Severe perinatal/infant morbidity or death.
2.5
2.5. Analysis
Comparison 2 Dexamethasone versus betamethasone, Outcome 5 Maternal pulmonary edema.
2.6
2.6. Analysis
Comparison 2 Dexamethasone versus betamethasone, Outcome 6 Caesarean section.
2.7
2.7. Analysis
Comparison 2 Dexamethasone versus betamethasone, Outcome 7 Length of stay in hospital or obstetrical delivery room for the mother.
2.8
2.8. Analysis
Comparison 2 Dexamethasone versus betamethasone, Outcome 8 Respiratory distress syndrome with/without ventilatory support.
2.9
2.9. Analysis
Comparison 2 Dexamethasone versus betamethasone, Outcome 9 Intracerebral hemorrhage.
2.10
2.10. Analysis
Comparison 2 Dexamethasone versus betamethasone, Outcome 10 Necrotizing enterocolitis.
2.11
2.11. Analysis
Comparison 2 Dexamethasone versus betamethasone, Outcome 11 Gestational age at delivery.
2.12
2.12. Analysis
Comparison 2 Dexamethasone versus betamethasone, Outcome 12 Fetal sepsis or infection.
2.13
2.13. Analysis
Comparison 2 Dexamethasone versus betamethasone, Outcome 13 Apgar score at 5 minutes < 7.
2.14
2.14. Analysis
Comparison 2 Dexamethasone versus betamethasone, Outcome 14 Length of stay in hospital or special care nursery/NICU.
2.15
2.15. Analysis
Comparison 2 Dexamethasone versus betamethasone, Outcome 15 Use of mechanical ventilation.
2.16
2.16. Analysis
Comparison 2 Dexamethasone versus betamethasone, Outcome 16 Adjusted time averaged change in platelet count.
2.17
2.17. Analysis
Comparison 2 Dexamethasone versus betamethasone, Outcome 17 Adjusted time averaged change in AST level (*non pre‐specified outcome).
2.18
2.18. Analysis
Comparison 2 Dexamethasone versus betamethasone, Outcome 18 Adjusted time averaged change in LDH level (*non pre‐specified outcome).
2.19
2.19. Analysis
Comparison 2 Dexamethasone versus betamethasone, Outcome 19 Adjusted time averaged change in mean arterial pressure (mmHg) (*non pre‐specified outcome).
2.20
2.20. Analysis
Comparison 2 Dexamethasone versus betamethasone, Outcome 20 Adjusted time averaged change in urinary output (*non pre‐specified outcome).
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Update of

References

References to studies included in this review

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    1. Runnard Heimel PJ, Huisjes AJM, Franx A, Koopman C, Bots ML, Bruinse HW. A randomized placebo‐controlled trial of prolonged prednisolone administration to patients with HELLP syndrome remote from term: maternal and neonatal complications [abstract]. American Journal of Obstetrics and Gynecology 2004;191(6 Suppl 1):S41. - PubMed
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Vigil‐De 1997 {published data only}
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Barrilleaux 2005 {published data only}
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Borekci 2008 {published data only}
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