Long-term follow-up in patients with a history of (H)ELLP syndrome

Objective. To provide long-term follow-up data on women with a history of h emolysis, elevated liver enzymes, and low platelets [(H)ELLP] syndrome rega rding the risk of recurrence in subsequent pregnancies and disease in later life. Methods. All women admitted to the Academic Medical Centre between January 1984 and January 1996 with (H)ELLP syndrome and a living singleton fetus in utero were included. Women with known preexisting diseases were excluded. The (H)ELLP syndrome was defined as elevated liver enzymes (serum aspartate aminotransferase or serum alanine aminotransferase greater than or equal t o 50 Un) and low platelet count (< 100 X 10(9)/L). Those patients with hemo lysis (LDH greater than or equal to 600 U/L) were classified as HELLP, the remaining ones were classified as ELLP. The participants were asked to fill out a questionnaire regarding their general health and their own obstetric and medical history and that of their first- and second-degree relatives. Results. One hundred sixteen (94%) of 123 women responded: 4 women had died . The median age of the group was 36.0 years at completion of the questionn aire; the median interval after the index pregnancy was 5.7 years (3-12.9). The incidence of hypertension requiring medical treatment was three times higher than in a reference population of Dutch women between 20 and 40 year s old. The need for psychological support was frequent. Thirty-nine patient s (34%) refrained from further pregnancies. Twenty-nine percent of the firs t subsequent pregnancies were complicated by gestational hypertension (GH), but only 2% had (H)ELLP syndrome. Birth weight was, on average, described psychosocial factors as possibly involved in the etiology of preeclampsia. The obvious impact of the experience of severe preeclampsia and/or (H)ELLP syndrome on patients has not been described previously. The second aim of the study was to assess the personal and family medical h istory of women with a history of (H)ELLP syndrome. Women with a history of GH are at risk of chronic hypertension, ischemic heart disease, and diabet es mellitus (6). A prospective cohort study comparing women with or without a history of GH demonstrated an increased risk of several distinct cardiov ascular conditions later in life (13). Nisell et al. (14) found that 7 year s after pregnancy complicated by preeclampsia or pregnancy-induced hyperten sion, there was an increased risk of chronic hypertension as compared with a control group. In women with a history of hypertension in pregnancy, incr eased death rates of ischemic heart disease are described (15). In our stud y, 8% of the patients reported medically treated hypertension, which is thr ee times more frequent as compared with a female Dutch reference population 20-40 years old. However, genetic factors such as insulin resistance, hype rtension, and obesity are risk factors for atherosclerotic disease as well as for preeclampsia. Venous thrombosis is more frequent during pregnancy and the puerperium, rep orted with an incidence of respectively 0.45 per 1000 deliveries and 1.9 pe r 1000 deliveries (16). The annual incidence of venous thrombosis in the ge neral population is about 2.0 per 1000 (17). Two patients (1.6%) in our stu dy developed deep venous thrombosis: afterward, we detected factor V Leiden mutation in both patients. The high prevalence of hemostatic abnormalities in women with a history of preeclampsia puts them at risk of venous thromb oembolism in later life (18). Sibai et al. (10) suggest that pregnancy may be regarded as a screening tes t for the occurrence of chronic hypertension and diabetes mellitus later in life. The same may possibly be true of cardiovascular disease and venous t hromboembolism. Later in life, patients with a history of preeclampsia and/ or (H)ELLP syndrome have more health problems when compared with other wome n of the same age. It appears that having suffered from the (H)ELLP syndrom e makes a deep impression on the afflicted women. This experience may have a lasting negative effect on the psychosocial function in the years that fo llow.