Bases Moleculares Hellp
4
Case Report Microcirculation Approach in HELLP Syndrome Complicated by Posterior Reversible Encephalopathy Syndrome and Massive Hepatic Infarction Stephanno Gomes Pereira Sarmento, 1 Eduardo Feliz Martins Santana, 1 Felipe Favorette Campanharo, 1 Edward Araujo Júnior, 1 Flavia Ribeiro Machado, 2 Nelson Sass, 1 and Antonio Fernandes Moron 1 1 Department of Obstetrics, Paulista School of Medicine, Federal University of S˜ ao Paulo (EPM-UNIFESP), Rua Carlos Weber 956, Apartamento 113 Visage, 05303-000 S˜ ao Paulo, SP, Brazil 2 Department of Medicine, Paulista School of Medicine, Federal University of S˜ ao Paulo (EPM-UNIFESP), 05303-000 S˜ ao Paulo, SP, Brazil Correspondence should be addressed to Edward Araujo J´ unior; [email protected] Received 16 July 2014; Accepted 2 November 2014; Published 18 November 2014 Academic Editor: Aristomenis K. Exadaktylos Copyright © 2014 Stephanno Gomes Pereira Sarmento et al. is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. HELLP syndrome is a complication of severe forms of preeclampsia and occurs mainly in the third trimester of pregnancy. In extreme cases, it may evolve unfavorably and substantially increase maternal mortality. We present the case of an 18-year-old pregnant woman who was admitted to our emergency service in her 31st week, presenting with headache, visual disturbances, and epigastralgia, with progression to a severe condition of HELLP syndrome followed by posterior reversible encephalopathy syndrome (PRES) and hepatic infarction. We highlight the approach taken towards this patient and the case management, in which, in addition to the imaging examinations routinely available, we also used the sidestream dark field (SDF) technique to evaluate the systemic microcirculation. 1. Introduction Preeclampsia generally affects pregnant women in their third trimester and is classically characterized by elevation of pres- sure and proteinuria levels. HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets) is a complication of severe forms of preeclampsia that compromises the blood system, with hemolysis, hepatic lesions, and low platelet counts [1, 2]. Its incidence is approximately one to two cases per 1000 pregnancies and reaches 5% among women with preeclampsia [3]. In extreme cases, it may result in hepatic infarction and posterior reversible encephalopathy syndrome (PRES), which is defined as a predominantly vasogenic form of cerebral edema of parietooccipital location that is typically reversible, with variable clinical presentation. It is not exclusively found in preeclampsia cases [4]. Techniques that directly evaluate the perfusion of the microcirculation at the bedside have been developed to complement the traditional macrohemodynamic parameters. ese techniques have been tested in different clinical situa- tions such as shock and sepsis. Here, we describe a case of HELLP syndrome that severely affected multiple systems, in which we emphasize the use of imaging diagnostic techniques in association with the sidestream dark field (SDF) technique on the microcircula- tion [5]. 2. Case Presentation e patient was a single black 18-year-old woman who was a student born and living in S˜ ao Paulo, Brazil. She was primi- parous and in her second pregnancy, without complications Hindawi Publishing Corporation Case Reports in Emergency Medicine Volume 2014, Article ID 389680, 4 pages http://dx.doi.org/10.1155/2014/389680
description
estudio de las bases fisiopatologicas de hellp
Transcript of Bases Moleculares Hellp
-
Case ReportMicrocirculation Approach in HELLP SyndromeComplicated by Posterior Reversible EncephalopathySyndrome and Massive Hepatic Infarction
Stephanno Gomes Pereira Sarmento,1 Eduardo Feliz Martins Santana,1
Felipe Favorette Campanharo,1 Edward Araujo Jnior,1 Flavia Ribeiro Machado,2
Nelson Sass,1 and Antonio Fernandes Moron1
1 Department of Obstetrics, Paulista School of Medicine, Federal University of Sao Paulo (EPM-UNIFESP), Rua Carlos Weber 956,Apartamento 113 Visage, 05303-000 Sao Paulo, SP, Brazil
2 Department of Medicine, Paulista School of Medicine, Federal University of Sao Paulo (EPM-UNIFESP), 05303-000 Sao Paulo,SP, Brazil
Correspondence should be addressed to Edward Araujo Junior; [email protected]
Received 16 July 2014; Accepted 2 November 2014; Published 18 November 2014
Academic Editor: Aristomenis K. Exadaktylos
Copyright 2014 Stephanno Gomes Pereira Sarmento et al.This is an open access article distributed under the Creative CommonsAttribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work isproperly cited.
HELLP syndrome is a complication of severe forms of preeclampsia and occurs mainly in the third trimester of pregnancy. Inextreme cases, it may evolve unfavorably and substantially increase maternal mortality. We present the case of an 18-year-oldpregnant woman who was admitted to our emergency service in her 31st week, presenting with headache, visual disturbances,and epigastralgia, with progression to a severe condition of HELLP syndrome followed by posterior reversible encephalopathysyndrome (PRES) and hepatic infarction.We highlight the approach taken towards this patient and the casemanagement, in which,in addition to the imaging examinations routinely available, we also used the sidestream dark field (SDF) technique to evaluate thesystemic microcirculation.
1. Introduction
Preeclampsia generally affects pregnant women in their thirdtrimester and is classically characterized by elevation of pres-sure and proteinuria levels. HELLP syndrome (hemolysis,elevated liver enzymes, and low platelets) is a complicationof severe forms of preeclampsia that compromises the bloodsystem, with hemolysis, hepatic lesions, and low plateletcounts [1, 2]. Its incidence is approximately one to two casesper 1000 pregnancies and reaches 5% among women withpreeclampsia [3]. In extreme cases, it may result in hepaticinfarction and posterior reversible encephalopathy syndrome(PRES), which is defined as a predominantly vasogenicform of cerebral edema of parietooccipital location that istypically reversible, with variable clinical presentation. It isnot exclusively found in preeclampsia cases [4].
Techniques that directly evaluate the perfusion of themicrocirculation at the bedside have been developed tocomplement the traditionalmacrohemodynamic parameters.These techniques have been tested in different clinical situa-tions such as shock and sepsis.
Here, we describe a case ofHELLP syndrome that severelyaffected multiple systems, in which we emphasize the useof imaging diagnostic techniques in association with thesidestream dark field (SDF) technique on the microcircula-tion [5].
2. Case Presentation
The patient was a single black 18-year-old woman who was astudent born and living in Sao Paulo, Brazil. She was primi-parous and in her second pregnancy, without complications
Hindawi Publishing CorporationCase Reports in Emergency MedicineVolume 2014, Article ID 389680, 4 pageshttp://dx.doi.org/10.1155/2014/389680
-
2 Case Reports in Emergency Medicine
Figure 1: Cranial tomography showing cerebral parenchyma withbilateral occipital subcortical hypoattenuating areas associated witha slight expansive effect that extends anteriorly towards the parietalregions, which do not change after injection of contrast medium,with diffusely diminished cerebral sulci. Alterations compatible withbilateral occipital areas of subcortical vascular disorder, observed inpatients with hypertensive encephalopathy, as observed in cases ofpreeclampsia known as posterior reversible leukoencephalopathy.
in her previous pregnancy. She had not attended prenatalcare consultations. Her personal history included traces ofsickle cell disease. Shewas admitted to the Emergency Serviceof Hospital Sao Paulo, Paulista School of Medicine, FederalUniversity of Sao Paulo (EPM-UNIFESP) with a complaintof high-intensity holocranial headache in association withblurring of vision and pain in the epigastric region, focusedon a narrow band, which had started on the preceding day.There was a report that the patient had had an episode ofconvulsion during the previous night and another episodewhile being brought to the hospital.
During the initial attendance, the patient was consciousand presented with arterial pressure of 140/90, heart rate of80 bpm, equally photoreactive pupils, agitation, spatial orien-tation, temporal disorientation, muscle disorders, markedlydiminished visual acuity, edema of ++/4+, uterine height of25 cm, normal uterine tonus, normal heartbeats, and absenceof uterine dynamics.
In the admission room, the ocular fundus was examined,showing papilledema. An ultrasound examination showeda pregnancy of 31 weeks, fetal growth restriction with nor-mal Doppler velocimetry, and oligohydramnios. Ophthalmicartery Doppler showed a peak ratio of 0.88. Cranial tomogra-phy was performed with contract medium (Figure 1) and wassubsequently complemented with cranial angioresonanceimaging (Figure 2), showing a bilateral occipital hypoatten-uating area that also reached the parietal region, withoutrespecting anatomical divisions and without correspondingto cerebral sulci or presenting any mass effect. This findingwas suggestive of PRES, with cortical blindness. The lab-oratory tests produced the following results: Hb 13.4 g/dL;Ht 41.7%; platelets: 174,000/uL; creatinine: 1.23mg/dL; urea:31mg/dL; total bilirubin: 0.89mg/dL; TGO 188U/L; TGP
Figure 2: Cranial angioresonance showing cerebral parenchymawith bilateral occipital subcortical areas that present hypersignal inFLAIR and T2, which are associated with a slight expansive effectand do not change after injection of contrast medium, with diffuselycompressed cerebral sulci. Alterations compatible with bilateraloccipital areas of subcortical vascular disease, which may be presentin patients with hypertensive encephalopathy, as observed in casesof preeclampsia known as posterior reversible leukoencephalopathy.
131 U/L; DHL 503U/L; proteinuria in a single sample
