Journal Reading

Seeking The Mechanism(s) Of Action For Corticosteroids

In HELLP Syndrome: SMASH Study

Presented By:
Desmawati
Hafizhah Abizar
Lisa Dwipurnamasari Tobing
Mellisa Valenthari
Nasrani Widyanata Sibarani

0908120346
0908113677
0908113626
0808113108
0908113622

Advisor:
dr. Muhammad Yusuf , Sp.OG (K)

OBSTETRIC AND GYNECOLOGY DEPARTMENT

MEDICAL FACULTY OF RIAU UNIVERSITY
RSUD ARIFIN ACHMAD
PEKANBARU
2014

Introduction

Materials and Methods

Results

Dexamethasone has no effect

on AT1-AA production

Newborn outcomes

Comment

 Under the Mississippi Protocol, the

patient who presents with HELLP
syndrome is treated with the
following:
Antihypertensives
Magnesium sulfate
IV dexamethasone

 Some studies IV dexamethasone

administration does not appear to have a
beneficial effect in halting the progression
of HELLP syndrome and or maternal
morbidity.
This study refutes that, indicating that
administration of dexamethasone in
addition to antihypertensives and
magnesium sulfate improves clinical
outcomes in patient population.

 Hypertension associated with HELLP

syndrome decreased significantly upon
IV dexamethasone administration.
IV dexamethasone significant
improvement in platelet levels,
hematocrit, and LDH and AST levels
within 12 hours of administration and
continued to do so after a second
administration of dexamethasone.

 Hypertension is well reported to be

associated with the excessive
production of inflammatory
cytokines, agonistic autoantibodies
to the angiotensin II receptor, and
imbalances in antiangiogenic factors
such as sFlt-1 and soluble endoglin.

 In this study, IV dexamethasone

decreased both sFlt-1 and soluble
endoglin, IL-6, and TNF- after 24
hours. However, there was no effect
on PlGF or the ratio of sFlt-1/PlGF.

 The significant effects on other

soluble factors known to stimulate
AT1-AA production suggest that over
time administration of
dexamethasone could have a
profound effect to suppress AT1-AA
and other immune factors known to
play a pathophysiological role in
forms of hypertension during
pregnancy

 Relationship between increased sFlt-1 and

soluble endoglin and endothelin-1 (ET-1):
The increase in these antiangiogenic factors is
in part responsible for the increase in ET-1,
which is associated with preeclampsia.
sFlt-1-induced hypertension is mediated by
activation of the ET-1 pathway. ET-1 activation
is a result of increased inflammatory cytokines
and AT1-AA, which are present in both HELLP
syndrome and preeclampsia

The limitations in this

study
All patients received an
antihypertensive in addition to
magnesium sulfate.
Not all of the women enrolled in this
study were able to complete the 24
hour dexamethasone window before
delivery.

 Additional studies are also needed to

determine whether platelet levels
increase and sFlt and soluble
endoglin levels decrease at 24 and
48 hours after delivery in women
with antepartum HELLP who have
and have not received
dexamethasone.

Conclusion

 Dexamethasone improves soluble

factors shown to cause hypertension
and intrauterine growth restriction such
as TNF-, IL-6, sFlt-1, and soluble
endoglin. Importantly, administration of
dexamethasone within the treatment
regimen improves blood pressure,
platelets, and liver enzyme values of
women suffering with HELLP syndrome.

 This study demonstrate that

implementing the Mississippi Protocol
for treating HELLP patients proves
beneficial to maternal outcome and
will continue to be routine in UMMC
medical practice for improving health
care for women and subsequently
children affected by HELLP
syndrome.