This month Saskia Middeldorp, MD, discusses treatment of HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome.
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I have a 31-year-old female patient with HELLP syndrome who is 12 weeks pregnant with her second child. APL: DRVVT (+) not corrected with 1:1 mix and DRVVT confirmed (+); anticardiolipin antibodies and beta-2 glycoprotein antibodies are normal. She is taking low-dose aspirin daily. Should she be on enoxaparin sodium as well?
The presence of HELLP syndrome (“late pregnancy morbidity”) combined with two positive lupus anticoagulant tests at least 12 weeks apart would mean that your patients fulfills the criteria for antiphospholipid syndrome (APS). If you have not had the time to repeat testing, she may not officially meet the definition yet. Regardless, there is consensus that she should be treated with low-dose aspirin to prevent recurrent preeclampsia or other potential deleterious outcomes to herself or the neonate based on her history.
Regarding low-molecular-weight heparin (LMWH), the jury is out. Although narrative reviews by renowned experts often suggest the use of heparin (in the absence of a history of thrombosis), there are no high-quality data to support this approach. To my knowledge, there are no reliable data that LMWH improves pregnancy outcomes in women with late pregnancy morbidity such as HELLP or preeclampsia. This is a rather evidence-free zone, as well-sized trials have not been conducted in this population. One randomized control trial with LMWH plus aspirin in this population was stopped prematurely because of low accrual rates (n=32) and observed a very low rate of recurrent hypertensive pregnancy disorders in both groups. In AFFIRM (An Individual Patient Data Meta-analysis of low-molecular-weight heparin for prevention of Placenta-Mediated Pregnancy Complications), about 4 percent of women (n=31) had antiphospholipid antibodies, and LMWH did not show a clear beneficial effect, but obviously the sample size was small. Hence, in my practice, I stick to aspirin and do not prescribe LMWH for this indication.
van Hoorn M, Hague W, van Pampus M, et al. Low-molecular-weight heparin and aspirin in the prevention of recurrent early-onset pre-eclampsia in women with antiphospholipid antibodies: the FRUIT-RCT. Eur J Obstet Gynecol Reprod Biol. 2016;197:168-73.
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NEXT MONTH'S CLINICAL DILEMMA
I have a 22-year-old female patient with stage 2a lymphocyte-predominant Hodgkin lymphoma involving lymph nodes in the pelvis who presented while pregnant (she has since delivered a healthy child.). Her disease is progressing slowly, but a recent CT scan showed slightly increasing nodes, so she needs to begin therapy. The radiation oncologist does not want to treat her because of her fertility. I sent her to a fertility clinic that recommended harvesting eggs, but the patient refused and “will let God decide” if she has children. I have presented her case at our lymphoma rounds and the recommendation was for six cycles of R-CHOP rather than an ABVD regimen. What would you do? If R-CHOP is the right approach, would you add an LHRH agonist?
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