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العنوان
Association between the Quantitative Assessment of Schistocytes in Peripheral Blood Smear and Prognosis of Patient Initially Diagnosed as HELLP Syndrome /
المؤلف
Mohammed, Shimaa Bakry.
هيئة الاعداد
باحث / Shimaa Bakry Mohammed
مشرف / Ahmed Hamdy Naguib
مشرف / Ayman Abd El-Kader Mohamed
مشرف / Rasha Abd El-Rahman El-Gamal
تاريخ النشر
2016.
عدد الصفحات
133 p. :
اللغة
الإنجليزية
الدرجة
ماجستير
التخصص
أمراض النساء والتوليد
تاريخ الإجازة
1/1/2016
مكان الإجازة
جامعة عين شمس - كلية الطب - Obstetrics & Gynecology
الفهرس
Only 14 pages are availabe for public view

from 32

from 32

Abstract

HELLP syndrome is a life-threatening obstetric complication usually considered to be a variant or complication of pre-eclampsia (Haram ., et al 2009).
HELLP syndrome may occasionally be confused with other diseases complicating pregnancy: acute fatty liver of pregnancy, gastroenteritis, hepatitis, appendicitis, gallbladder disease, immune thrombocytopenia, lupus flare, antiphospholipid syndrome, hemolytic-uremic syndrome, thrombotic thrombocytopenic purpura, and nonalcoholic fatty liver disease (Page – Girling ., 2011)( Minakami et al., 2014).
The distinction between thrombotic thrombocytopenic purpura-hemolytic uremic syndrome and severe preeclampsia is important for therapeutic and prognostic reasons. However, the clinical and histological features are so similar that establishing the correct diagnosis is often difficult; furthermore, these disorders may occur concurrently ( Burns., etal 2004).
When TTP/HUS does occur during pregnancy, they often are confused initially with obstetric diagnoses such as severe preeclampsia; hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome; acute fatty liver of pregnancy; eclampsia, and antiphospholipid antibody syndrome. This might be related to the fact that the disease entity is rare and often is unexpected. Nevertheless, a delay in diagnosis of TTP/HUS may result in life-threatening maternal and fetal consequences (Stella ., et al 2009).
Aim of study was to Compare the quantitative assessment of schistocytes in peripheral blood smear between women initially diagnosed as HELLP syndrome who show no spontaneous resolution within 48 hrs after delivery and those who show spontaneous resolution within 48 hrs after delivery which may help in decreasing the maternal mortality rate at Ain Shams maternity hospital .
The current study included 100 patients who were initially diagnosed as HELLP. Blood sample taken 12hrs peripartum .The included women followed up for 48hrs postpartum and divided to 2 groups according to deterioration or improvement . 75% improved after 48 hours from delivery 25% were deteriorated so they were differentially diagnosed as Microangiopathic hemolytic anemia .
The 25% of the patients were treated by PEX/FFP after being deteriorated from whom 22% survived and 3% died.
In this study there were no significant differences between women who deteriorated postpartum and women who did not regarding the initial values of systolic blood pressure, diastolic blood pressure, albuminuria, hemoglobin concentration, platelet count or serum creatinine. The initial levels of serum ALT, AST and total bilirubin were, however, significantly, higher in women who deteriorated postpartum .
In the included study we found that schistocytes had been found in peripheral blood smear in HELLP syndrome.
In the result of current study The median of schistocytes percentage was significantly higher in women who showed postpartum deterioration, when compared to women who did not deteriorated and the validity of Schistocytes% percentage at different cutoff values as Predictor of Postpartum Deterioration in Included Women were : (1) Schistocytes percentage of ≥0.95 % with sensitivity of 88% , specificity of 85.5% , (PPV) positive predictive value of 66.7% , (NPV) negative predictive value of 95.5% , (FP) false positive of 14.7% , (FN) false negative of 12% ,( LR+) positive likelihood ratio of 6 .
(2) Schistocytes percentage ≥1.4% with sensitivity of 84% ,specificity of 96% , (PPV) positive predictive value of 87.5% ,( NPV) negative predictive value of 94.7%, (FP) false positive of 4% , (FN) false negative of 16% ,( LR+) positive likelihood ratio of 21 .
(3) Schistocytes percentage ≥1.9% with sensitivity of 80% ,specificity of 98.7% ,(PPV) positive predictive value of 95.2% ,(NPV) negative predictive value of 93.7%,(FP) false positive of 1.3% , (FN) false negative of 20% ,(LR+) positive likelihood ratio of 60 . In the current study only initial ALT, initial AST and initial total bilirubin were significant predictors of postpartum deterioration. Their AUCs, though being significantly large, were smaller than the AUC for schistocytes; indicating that the latter is a more significant and better predictor for postpartum deterioration .
In the result of our study The median of schistocytes percentage was significantly higher in women who died when compared to women who survived . The validity of schistocytes percentage as predictor of maternal mortality : schistocytes percentage ≥ 8.2% of sensitivity 100% , specificity 95.9% , PPV positive predictive value 42.95% ,NPV negative predictive value 100% , FP false positive 4.1% , FN false negative 0%, LR+ positive likelihood ratio 24.3 .
There were significant positive correlations between schistocytes percentage and each of systolic and diastolic blood pressures, serum ALT, serum AST, serum total bilirubin and serum creatinine 48 hours postpartum. There were significant negative correlations between schistocytes and each of hemoglobin concentration and platelet count 48 hours postpartum .
Schistocytes percentage in peripheral blood smear in cases provisional diagnosed as HELLP Syndrome might predict disease progression and might have value in starting PTX/FFP as early as possible .


Recommendations :
• HELLP syndrome associated with serious maternal morbidity and mortality .
• The median of schistocytes percentage was significantly higher in women who showed postpartum deterioration, when compared to women who did not deteriorated .
• The median of schistocytes percentage was significantly higher in women who died when compared to women who survived .
• We recommend using schistocyte percentage in peripheral blood smear routinely in any patient who will be provisionally diagnosed as HELLP Syndrome and to start PTX/FFP early if percentage exceeds 1.9% which has low false positivity .
Pitfalls
We need further studies to assess the value of Schistocyte percentage in prediction of deterioration of patient who will be provisionally diagnosed as HELLP Syndrome . Follow up Schistocyte percentage might need after treatment with PTX/FFP for better assessment of treatment.