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American Journal of Obstetrics and Gynecology (2005) 193, 1591–8

www.ajog.org

EDITORS’ CHOICE

Dexamethasone treatment does not improve the outcome


of women with HELLP syndrome: A double-blind,
placebo-controlled, randomized clinical trial
Javier E. Fonseca, MD, MSc,a,b,c Fabián Méndez, MD, PhD,a Claudia Cataño, MD,b,c
Fernando Arias, MD, PhDd

School of Public Healtha and School of Medicine,b Universidad del Valle; Department of Gynecology and Obstetrics,
Hospital Universitario del Valle,c Cali, Colombia; Department of Obstetrics and Gynecology, The Toledo Hospital,
Medical College of Ohio, Toledo, OHd

Received for publication March 15, 2005; revised April 4, 2005; accepted July 5, 2005

KEY WORDS Objective: The purpose of this study was to determine the efficacy of dexamethasone for
Dexamethasone treatment of HELLP (hemolysis, elevated liver enzymes and low platelet count) syndrome.
HELLP (hemolysis, Study design: A prospective, double-blind clinical trial was conducted among 132 women with
elevated liver HELLP syndrome who were assigned randomly to treatment or placebo groups. Pregnant women
enzymes and low in the experimental group received 10-mg doses of dexamethasone intravenously every 12 hours
platelet count) until delivery and 3 additional doses after delivery. Puerperal women received 3 10-mg doses of
syndrome dexamethasone after delivery. The same schedule was used in the placebo group. The main
Clinical trial outcome variable was the duration of hospitalization. In addition, we evaluated treatment effects
on the time to recovery of laboratory and clinical parameters and on frequency of complications.
Results: The mean duration of hospitalization of patients who received dexamethasone therapy
was shorter than in the placebo group (6.5 vs 8.2 days), but this difference was not statistically
significant (P = .37). No significant differences were found in the time to recovery of platelet
counts (hazard ratio, 1.2; 95% CI, 0.8-1.8), lactate dehydrogenase (hazard ratio, 0.9; 95% CI, 0.5-
1.5), aspartate aminotransferase (hazard ratio, 0.6; 95% CI, 0.4-1.1) and to the development of
complications. The results were found in both pregnant and puerperal women.
Conclusion: The results of this investigation do not support the use of dexamethasone for
treatment of HELLP syndrome.
Ó 2005 Mosby, Inc. All rights reserved.

Multisystemic abnormalities that are associated with


Supported in part by the Valle State Secretariat of Health; the adverse maternal and fetal outcomes have been recog-
dexamethasone and placebo were provided by Organon Laboratories, nized for many years in women with preeclampsia1-3;
The Netherlands. HELLP (hemolysis, elevated liver enzymes and low
Reprints not available from the authors. Address correspondence to
Javier E. Fonseca, Universidad del Valle, Obstetrics and Gynecology,
platelet count) syndrome4 is one of its most dangerous
Hospital Universitario del Valle, Cali, Valle 57, Colombia. presentations.5 Women with HELLP syndrome may be
E-mail: jfonseca@univalle.edu.co classified by the degree of thrombocytopenia into

0002-9378/$ - see front matter Ó 2005 Mosby, Inc. All rights reserved.
doi:10.1016/j.ajog.2005.07.037
1592 Fonseca et al

HELLP 1 (%50,000 platelets/mm3), HELLP 2 (between All patients received 1 to 1.5 g/hr of magnesium
50,000 and 100,000 platelets/mm3), and HELLP 3 (be- sulfate intravenously. Nifedipine, 10 mg orally every
tween 100,000 and 150,000 platelets/mm3).6 6 hours, was administered to women with diastolic
Treatment of HELLP syndrome usually is restricted arterial pressure O100 mm Hg. Another antihyperten-
to measures of support and treatment of complications. sive medication (clonidine and amlodipine) was admin-
However, since a first report in 1993,7 several clinical istered if the diastolic pressure remained elevated. In
trials have suggested that corticosteroids, mainly dexa- addition, patients received 1000 mL of normal saline
methasone therapy, can ameliorate and stabilize the solution during the first 2 hours and 1000 mL of normal
disease in the antepartum period and accelerate recovery saline solution every 6 hours afterwards. If the urinary
after delivery.8-11 However, these studies were not dou- output remained !30 mL/hr, an additional 500 mL of
ble-blind or placebo-controlled trials and had small normal saline solution was given during 1 hour; if
sample size, and there is a definite need for additional oliguria persisted, 20 mg of furosemide was adminis-
randomized clinical trials.5 For this reason, we con- tered intravenously. Renal failure was diagnosed if the
ducted a study that was aimed to determine the efficacy serum creatinine level was O1.5 mg/dL and if pulmo-
of dexamethasone for the treatment of HELLP nary edema was diagnosed by physical examination and
syndrome classes 1 and 2. chest radiography. When surgery was indicated, 8 units
of platelets were transfused to women with platelet
counts !50,000/mm3. Because the standard of care of
Material and methods the community is interruption of pregnancy after diag-
nosis of HELLP, induction of labor or cesarean delivery
This was a double-blind, placebo-controlled randomized were performed, depending on the maternal and fetal
clinical trial that involved pregnant and puerperal condition. If the gestational age was between 26 to 34
women who were admitted to the Hospital Universitario weeks, betamethasone (12 mg intramuscularly) was
del Valle in Cali, Colombia, between October 2001 and given every 24 hours for up to 2 doses before delivery.
September 2003. Women who were at O20 weeks of Withholding steroids was considered unacceptable by
gestation or during the first 3 days of puerperium were the investigators and the Institutional Review Board.
asked to participate in the study if hypertension devel- Duration of hospitalization was measured from ran-
oped during the pregnancy or the puerperium and met domization to discharge. The duration of hospitaliza-
the criteria for complete HELLP syndrome as defined tion of the 4 maternal deaths was excluded for the
by Sibai12: platelet count, %100,000/mm3; aspartate calculation of mean and median but was included and
aminotransferase (AST), O70 U/L; lactate dehydrogen- treated as censored data in survival analysis. Criteria for
ase (LDH), O600 U/L. Exclusion criteria were oral discharge included a platelet count O100,000/mm3,
temperature O37.5(C and diabetic ketoacidosis. Be- regardless of AST or LDH levels. However, if evidence
cause of the potential for spontaneous recovery, puer- of organ damage or other clinical complications was
peral women were excluded if randomization was not present, the patients remained in the hospital until
accomplished in the first 24 hours after diagnosis. The recovery.
study was approved by the Institutional Review Boards Measurements of blood pressure and urine output
of the Hospital and the Medical School. were carried out every 2 hours. Baseline and follow-up
Pregnant and puerperal women were assigned ran- laboratory studies included platelet count, AST, LDH,
domly to treatment or placebo groups, with the use of and serum creatinine measurements every 12 hours.
stratified and random permuted blocks of 4. The Platelet counts were performed by automated counting;
assignment was kept inside consecutively numbered LDH and AST were processed at 25(C, with a reference
opaque envelopes that were labeled as pregnant or pattern of 120 to 240 U/L and 0 to 18 U/L, respectively.
puerperal and that were opened after informed consent Medical personnel were trained on protocol proce-
had been obtained. Pregnant women in the experimental dures for enrollment and follow-up of patients. Quality
group received 10-mg doses of dexamethasone sodium checks of clinical and laboratory forms were carried out
phosphate (Oradexon) intravenously every 12 hours before data entry. After entry, programs were run to
until delivery and 3 additional doses after delivery. verify the consistency of responses within each ques-
Puerperal women received 3 10-mg doses after delivery. tionnaire. Any detected inconsistencies were resolved by
The same schedule was used in the control group to correction against original data sheets.
administer sterile water as placebo. Dexamethasone and Sample size was calculated by the duration of hospi-
placebo were packed in identical vials in sealed boxes talization, as defined earlier.13 We assumed an average
that were labeled with the corresponding treatment hospital stay of 6 days in the control group and
codes. Codes were not broken until the end of the considered as significant a 33% decrease in stay for
univariate analysis. Treatment was to be discontinued if the experimental group, with a significance level of .01
oral temperature rose above 37.5(C. and a power of 90%. The required sample size was
Fonseca et al 1593

Figure 1 Trial profile.

67 subjects per group. Analysis was carried out on the was performed with linear, logistic, or Cox regression,
basis of intention to treat. A planned subgroup analysis correspondingly. In addition to treatment (ie, the expo-
was performed according to pregnant and puerperal sure of interest), other variables were considered in the
strata. An additional, unplanned subgroup analysis was final model if their probability values were !.2 in the
conducted by severity of clinical presentation at diag- univariate analysis.14-16 Antepartum use of betametha-
nosis. We carried out an interim analysis, at a sample sone up to 2 weeks before randomization was also
size of 50 individuals, with no differences with final considered during modeling. Where appropriate, results
results. Continuous variables were analyzed with un- are presented as relative risk with 95% CI, odds ratio,
paired t-test or Mann-Whitney test, according to their and hazard ratio.
distribution. If needed, transformations were carried out
to allow for normal based statistics. Time to recovery of Results
laboratory parameters (platelets, LDH, and AST) and
duration of hospitalization was analyzed by Kaplan- A total of 144 patients were considered eligible and were
Meier. Categoric variables were compared by chi- invited to participate in the study. Two patients (1.4%)
squared test or Fisher’ s exact test. Multivariate analysis were excluded because of fever, and 2 patients (1.4%)
1594 Fonseca et al

Table I Baseline characteristics Table II Duration of hospitalization according to treatment


Therapy Duration of
Placebo Dexamethasone hospitalization (days) Placebo (66) Dexamethasone (66)
Characteristic (n = 66) (n = 66) Mean (D.S.) 8.2 (12.55) 6.5 (9.66)
Age (y)* 26.2 G 7.20 24.5 G 7.00 Median 4 4
Gestational age (wk)* 33.5 G 4.20 33.8 G 4.50 Range 2-89 2-64
Parity (n)* 2.0 G 2.06 1.2 G 1.25 Interquartile range 3-8 3-6
Platelets (n/mm3)* 58,446 G 21,053 61,171 G 18,912 Difference of mean: 1.7 (2.28-5.61), P = .37
AST (U/L)* 492 G 579 573 G 621
Alanine 229 G 251 281 G 300
aminotransferase
median values of 57,798/mm3 and 59,200/mm3, respec-
(U/L)*
LDH (U/L)* 2,242 G 1,671 2,124 G 1,849 tively. The mean LDH was 2183 U/L, with a median of
Total bilirubin 3.7 G 4.67 3.3 G 3.20 1701 (range, 623-12,600); the mean AST was 532 U/L,
(mg/mL)* with a median of 280 (range, 71-2870). Baseline charac-
Creatinine (mg;/mL)* 0.9 G 0.53 0.9 G 0.49 teristics according to study groups were similar (Table I).
Urinary 85 G 65.50 92 G 59.70
output (mL/min)*
Systolic pressure 141 G 21.01 145 G 21.00 Duration of hospitalization
(mm Hg)*
Diastolic pressure 93 G 13.40 93 G 12.61 The distribution of duration of hospitalization was
(mm Hg)* transformed (1/duration of hospitalization) to allow
the use of statistical methods that are based on the
Qualitative protein in urine (n)
Gaussian distribution. The mean duration of hospital-
Positive 57 (87.36%) 55 (83.33%)
Negative 4 (6.06%) 4 (6.6%) ization was shorter among patients who received dexa-
Unknown/ 5 (7.58%) 7 (10.61%) methasone therapy; however, this difference was not
unavailable statistically significant. Median and interquartile ranges
Acute renal 4 (6.06%) 6 (9.09%) also were found to be no different (Table II). The
failure at univariate and multivariate analysis showed that a
enrollment longer duration of hospitalization was associated with
Pulmonary edema 1 (1.52%) 1 (1.52%) a lower urinary output (!30 mL/h) and higher LDH
HELLP class at enrollment (n) levels. Survival analysis of time to discharge showed
HELLP 1 28 (42.42%) 21 (32.31%) no differences (Figure 2,A; hazard ratio, 1.3; 95% CI,
HELLP 2 38 (57.58%) 44 (67.69%) 0.9-1.9).
Steroid use up to 2 weeks before delivery (n)
No 44 (66.67%) 48 (72.73%)
Time to recovery of laboratory tests
Yes 21 (31.82%) 16 (24.24%)
Unknown 1 (1.52%) 2 (3.03%) There was no statistically significant difference between
* Data are given as mean G SD. dexamethasone-treated and placebo-treated patients
with respect to the time that was required to achieve a
platelet count of O100,000/mm3 (Figure 2,B; Table III).
declined to participate. Eight puerperal women (5.5%) Recovery of the platelet count was more likely to occur
were not allocated to treatment during the first 24 hours among patients with urinary output at enrollment of
after diagnosis and were also excluded. After these ex- O30 mL/h and less likely among those with renal
clusions, 132 women were eligible for randomization: 60 failure, although these findings were not significant at
women were still pregnant, and 72 women were in the the multivariate analysis. Platelet counts did not reach
puerperal state. Two patients received only 2 doses of levels of O100,000/mm3 in all 4 maternal deaths.
steroid after delivery because of death. Two women (in LDH levels of !600 U/L were not reached before
the experimental and control groups) received 1 dose of discharge by 72 patients (38 experimental patients and
dexamethasone that was not provided by the study 34 control patients), which included the 4 deaths and 68
(Figure 1). patients who were discharged when their platelet counts
The mean age of enrolled women was 25.3 years were O100,000/mm3. There was no statistically signif-
(range, 14-44 years); the mean gestational age was 33.6 icant difference between treated and control patients
weeks (range, 20-41 weeks), and the mean parity was 2.4 who reached an LDH of !600 U/L before discharge
pregnancies (range, 0-12 pregnancies). Platelet counts regarding their time to recovery (Figure 2,C; Table III)
ranged from 13,000 to 100,000/mm3, with mean and or other patient characteristics at enrollment.
Fonseca et al 1595

Figure 2 Cumulative risk of (A) discharge, (B) platelet recovery (count O100,000), (C) LDH recovery (!600 U/L), (D) AST
recovery (!70 U/L) according to treatment received.

AST levels of !70 U/L were not reached by 53 (P = .32). A third antihypertensive drug was required in
patients (32 experimental patients and 21 control pa- 8 patients, 4 per treatment group.
tients), which included 2 of the maternal deaths and 51
patients who were discharged once their platelet counts
reached O100,000/mm3. Among patients with an AST Complications and blood transfusion
level of !70 U/L before discharge, there was a trend to
faster recovery among those patients who received There were 4 maternal deaths, 3 deaths in the dexa-
placebo (log rank test probability value, .07) that was methasone group and 1 death in the placebo group.
not significant after adjustment for renal failure, ethnic- Three of the maternal deaths occurred in women with
ity, and parity (hazard ratio, 0.7; 95% CI,0.4-1.1; Figure liver failure and severe hemolysis, with AST and LDH
2,D; Table III). levels of O2600 U/L and O6450 U/L, respectively. The
other death was due to a cerebrovascular accident. The
treatment groups were not different regarding develop-
Recovery of clinical parameters ment of complications or transfusion need (Table IV).
Interestingly, there were a higher number of infections
No significant differences in urinary output were found among those patients who received placebo, and mater-
between the 2 treatment groups. Furosemide was nal death and pulmonary edema were more frequent
required in 23 patients: 13 patients received placebo, among those women who received dexamethasone ther-
and 10 patients received dexamethasone therapy (rela- apy, even after adjustment. Infections were found to be
tive risk, 0.8; 95% CI, 0.4-1.6). All patients were associated independently with admission to the intensive
hypertensive, and 124 patients (93.9%) required nifed- care unit (odds ratio, 10.4; 95% CI, 2.2-48.2), renal
ipine therapy; therefore, we were not able to evaluate failure (odds ratio, 8.8; 95% CI, 1.9-38.8), and vaginal
changes in blood pressure, because they could have delivery (odds ratio, 6.7; 95% CI, 1.3-33.3). The higher
been associated with antihypertensive use. The addition odds of infection with vaginal delivery remained after
of a second antihypertensive drug was necessary in 30 adjustment for the occurrence of premature rupture of
patients, 13 of whom received dexamethasone therapy membranes and the use of antibiotics and steroids
1596 Fonseca et al

Table III Determinants of duration of hospitalization, platelet count, LDH and AST recovery by univariate Cox regression
Duration of hospitalization Platelets* LDHy ASTz
x x x
Hazard ratio 95% CI Hazard ratio 95% CI Hazard ratio 95% CI Hazard ratiox 95% CI
Treatment
Placebok 1 1 1 1
Dexamethasone 1.3 0.87-1.94 1.2 0.80-1.77 0.9 0.53-1.52 0.6 0.39-1.05
Steroid use up to 2 weeks before delivery
Nok 1 1 1 1
Yes 0.9 0.60-1.46 0.9 0.59-1.43 1.0 0.58-1.88 1.2 0.73-2.12
Delivery
Vaginalk 1 1 1 1
Cesarean 0.8 0.51-1.27 0.7 0.47-1.09 1.2 0.68-2.17 1.4 0.8-2.33
Class HELLP at admisión
HELLP 1k 1 1 1 1
HELLP 2 0.8 0.54-1.28 1.2 0.79-1.81 1.3 0.76-2.32 0.9 0.56-1.5
Acute renal failure at admission
Nok 1 1 1 1
Yes 0.3 0.15-0.44 0.5 0.22-0.99 0.3 0.07-1.17 0.5 0.17-1.36
Urinary output at admisión
!30 cc/hourk 1 1 1 1
31-100 cc/hour 4.7 1.94-11.52 2.4 1.07-5.17 1.2 0.47-3.26 1.3 0.50-3.46
O100 cc/hour 5.8 2.13-15.80 2.6 1.07-6.22 0.8 0.23-2.45 1.9 0.64-5.46
* Platelets above 100,000/mm3.
y
LDH below 600 U/L.
z
AST below 70 U/L.
x
Non-adjusted Hazard ratio.
k
Reference category.

Table IV Complications associated with HELLP syndrome


according to steroids use
Placebo Dexamethasone R.R. crude
Complication n (%) n (%) (95% CI)
Acute renal 8 (12.9) 6 (10.0) 0.8 (0.29-2.10)
failure*
Oliguria 4 (6.06) 5 (7.58) 1.3 (0.35-4.45)
Pulmonary 1 (1.54) 3 (4.62) 3.1 (0.32-28.09)
edema*
Eclampsia 10 (15.15) 8 (13.79) 0.8 (0.34-1.90)
Infections 10 (15.15) 5 (7.58) 0.5 (0.18-1.38)
Dead 1 (1.52) 3 (4.62) 3.0 (0.32-28.1)
Platelets 10 (15.15) 12 (18.18) 1.2 (0.56-2.58) Figure 3 Interval between randomization and recovery of the
transfusión platelet count to O100,000/mm3 by study group among
Plasma 6 (9.09) 5 (7.58) 0.8 (0.27-2.60) patients with HELLP 1.
transfusión
* Only included patients without the event before randomization. tions, recovery of laboratory parameters, transfusion
need, or duration of hospitalization. Among puerperal
before randomization. Platelet transfusion was found to women, the mean duration of hospitalization tended to
be associated with the development of renal failure be lower in those women who received placebo than in
(odds ratio, 4.0; 95% CI, 1.1-14.3) and AST levels at those women who received dexamethasone therapy (6.8
enrollment. vs 8.2 days), but this difference was not significant.
Median duration was 4 days in both groups; the
Subgroup analysis by pregnant interquartile ranges were 3 to 9 days and 3 to 6 days,
and puerperal patients respectively. Among pregnant women, the duration of
hospitalization was lower in the women who received
Stratified analysis of pregnant and puerperal groups dexamethasone therapy (4.5 vs 9.9 days), but this
showed no differences in the occurrence of complica- difference did not reach statistical significance. The
Fonseca et al 1597

Table V Randomized clinical trials of corticosteroids in HELLP syndrome


Author Year Number of subjects Antepartum Postpartum Placebo controlled Double blind Benefical effect Ref
Magann 1994 25 Yes No No No Yes 8
Magann 1994 25 No Yes No No Yes 9
Vigil-De Gracia 1997 34 No Yes No No Yes 10
Yalcin 1998 30 No Yes No No Yes 11
Isler 2003 32 No Yes No No Yes 19
Present work 2005 132 Yes Yes Yes Yes No

median duration was 4 days in both groups, and the study among patients with HELLP syndrome that
interquartile ranges were 3 to 4.5 days and 3 to 7 days report sample size estimation. The estimate was based
for dexamethasone therapy and placebo, respectively. on the duration of hospitalization because it has been
widely accepted that this outcome variable reflects the
development of complications and the rate of recovery
Subgroup analysis by severity of clinical and laboratory variables and because it is a
useful indicator for patients and clinicians. Other valu-
The time to recovery of the platelet count was found to
able features in this study that support its internal
be heterogeneous when the cases were stratified by
validity are the study design (stratified randomization
HELLP class at the time of enrollment (Mantel-Cox
in blocks and double blind) and the small number of
test: chi-squared test, 4.76; P = .03). Therefore, we
protocol violations that result in compliance with the
performed a subgroup analysis according to severity at
assigned treatment of O95%. The external validity of
enrollment. No differences were found among patients
this study is also high probably because of the large
who were classified as HELLP class 2 and control
number of eligible patients who accepted randomiza-
subjects; however, among 49 patients with HELLP
tion, the adoption of a widely accepted dose of dexa-
1 (28 patients with placebo and 21 patients with dexa-
methasone for the treatment group, the use of
methasone therapy), the conditional probability of
betamethasone in preterm deliveries, and the clinical
platelet recovery was higher in those patients who
relevance of the outcome measures.
received dexamethasone therapy (Figure 3), even after
A weakness of this study is that 28.03% of our
adjustment for potential confounders (hazard ratio, 3.4;
patients received betamethasone during the 2 weeks
95% CI, 1.3-8.5). Also, the duration of hospitalization
before delivery for the purpose of accelerating fetal lung
was shorter among women who received dexamethasone
maturity and preventing neonatal intracranial bleeding.
therapy when means (4.6 and 10.4 days), medians (3.5
However, analyses were carried out to adjust by previ-
and 5.0 days), and interquartile ranges were compared.
ous steroid administration (Table III). Furthermore,
This trend persisted after adjustment (P = .03).
analyses were carried out that included only women who
did not received other steroids before delivery (45
Comment women in the placebo group and 50 women in the
dexamethasone group; power, O90%; a, .05) with
Several randomized clinical trials have been published to similar results; therefore, previous administration of
evaluate the effect of dexamethasone therapy in women betamethasone did not affect final results.
with HELLP syndrome.9-11 Although they indicate that The results of this study indicate that the adminis-
dexamethasone therapy is beneficial, the strength of this tration of dexamethasone in patients with complete class
conclusion is limited because of small number of patients 1 and 2 HELLP syndrome, when compared with similar
in each trial, the lack of blinding and placebo controls, patients who received placebo, does not reduce the
the inclusion of women with mild forms of the disease, number of complications or the need for blood products
and the lack of an strict definition of the syndrome (Table administration or shorten platelets and LDH recovery.
V). Observational studies have also found better out- These results were consistent in global and planned
comes in patients with HELLP syndrome who received subgroup analysis. Contrasted with previous studies,
dexamethasone therapy. However, 2 of the studies were AST recovery was slower in patients who were assigned
retrospective, with historic control groups,17,18 and the to dexamethasone therapy than to placebo, and this
other 2 studies compared different steroids.19,20 finding remained in the subgroup analysis. Unfortu-
To the best of our knowledge, this is the largest nately, we cannot speculate about the clinical implica-
reported clinical trial to evaluate the use of dexameth- tions of the last finding, given that patient follow-up
asone therapy in HELLP syndrome and the first that is evaluations finished at the time of platelets recovery,
double blind and placebo controlled. This is also the first regardless of AST levels.
1598 Fonseca et al

Although no statistically significant differences were history of thrombocytopenia in pregnancy-induced hypertension.


found in the planned analysis of the duration of hospi- Am J Perinatol 1989;6:32-8.
4. Weinstein L. Syndrome of hemolysis, elevated liver enzymes, and
talization, those pregnant women who received placebo low platelet count: a severe consequence of hypertension in
stayed, on average, twice as long as those women who pregnancy. Am J Obstet Gynecol 1982;142:159-67.
received dexamethasone therapy (9.9 vs 4.5 days). This 5. Sibai BM. Diagnosis, controversies, and management of the
difference was due to 2 patients of the control group syndrome of hemolysis, elevated liver enzymes, and low platelet
who stayed long periods (49 and 89 days), one of whom count. Obstet Gynecol 2004;103:981-91.
6. Martin JN, Blake PG, Perry KG, McCaul JF, Hess LW, Martin
had rupture of the uterus and subsequent complications, RW. The natural history of HELLP syndrome: patterns of disease
and the other who refused blood transfusion, regardless progression and regression. Am J Obstet Gynecol 1991;164:1500-13.
of clinical indication (hemoglobin levels of 6.2 and 2.8 g/ 7. Magann EF, Martin RW, Isaacs JD, Blake PG, Morrison JC,
dL before and after cesarean delivery), and experienced Martin JN. Corticosteroids for the enhancement of fetal lung
respiratory distress syndrome and renal failure that maturity: impact on the gravida with preeclampsia and the HELLP
syndrome. Aust N Z J Obstet Gynaecol 1993;2:127-31.
prolonged the hospitalization. These 2 outliers affected 8. Magann EF, Bass D, Chauhan SP, Sullivan DL, Martin RW,
the mean duration of hospitalization, but comparisons Martin JN. Antepartum corticosteroids: disease stabilization in
of median and interquartile range did not show differ- patients with the syndrome of hemolysis, elevated liver enzymes,
ences between groups. and low platelets (HELLP). Am J Obstet Gynecol 1994;171:
Subgroup analysis according to the severity of disease 1148-53.
9. Magann EF, Perry KG, Meydrech EF, Harris RL, Chauchan SP,
showed that, among patients with HELLP 1, there were Martin JN. Postpartum corticosteroids: accelerated recovery from
a shorter average time to platelet recovery and less the syndrome of hemolysis, elevated liver enzymes and low
duration of hospitalization in women who received platelets (HELLP). Am J Obstet Gynecol 1994;171:1154-8.
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is diminished because this was an unplanned analysis post-partum treatment of HELLP syndrome. Int J Gynecol Obstet
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and the severity of the disease was not taken into 11. Yalcin OT, Sener T, Hassa H, Ozalp S, Okur A. Effects of
account at randomization. It is accepted that the results postpartum corticosteroids in patients with HELLP syndrome. Int
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exploratory.21 12. Sibai BM. The HELLP syndrome (hemolysis, elevated liver
In summary, the results of this investigation do not enzymes and low platelets): Much ado about nothing? Am J
Obstet Gynecol 1990;162:311-6.
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We thank the residents in Obstetrics and Gynecology at
17. Martin JN, Perry KG, Blake PG, May WA, Moore A, Robinette
the University Hospital, Universidad del Valle, Cali, L. Better maternal outcomes are achieved with dexamethasone
Colombia, for their help in this project. therapy for postpartum HELLP (hemolysis, elevated liver en-
zymes, and thrombocytopenia) syndrome. Am J Obstet Gynecol
1997;177:1011-7.
18. Varol F, Aydin T, Gucer F. HELLP syndrome and postpartum
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