Corticosteroids for HELLP syndrome in pregnancy

Pre-eclampsia is a serious complication of pregnancy characterized by high blood pressure with protein in the urine and sometimes progression to seizures (fits). HELLP syndrome is a more severe form of pre-eclampsia which can cause problems with liver function, blood clotting, and low platelets. HELLP may be diagnosed during pregnancy or after giving birth and is associated with ill health for the mother including liver hematoma, rupture, or failure; pulmonary edema; renal failure and death. Infant health may also be poor, primarily due to premature birth and growth restriction.This review examined the effect of treating women with HELLP syndrome using corticosteroids (which can reduce inflammation). The results of this review did not indicate that there was a clear effect on the health of pregnant women when treated with corticosteroids, or their babies. Corticosteroids did appear to improve some components of the women's blood tests, but it is not clear that this had an effect on their overall health. The review identified 11 randomized controlled trials involving 550 women that compared corticosteroid (dexamethasone, betamethasone, or prednisolone) given during pregnancy, just after delivery or in the postnatal period, or both before and after birth, with placebo or no treatment. Two further trials showed that there was no clear difference between dexamethasone and betamethasone on the substantive clinical outcomes for women or their infants. Dexamethasone did improve maternal platelet count and some biochemical measures to a greater extent than betamethasone.

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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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).

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