Corticosteroids for HELLP syndrome in pregnancy (Review)
                                               Matchaba P, Moodley J
               ThisisareprintofaCochranereview,preparedandmaintained byTheCochraneCollaborationandpublishedinTheCochraneLibrary
               2007, Issue 2
                                              http://www.thecochranelibrary.com
               Corticosteroidsfor HELLP syndromein pregnancy(Review)                               1
               Copyright©2007 The CochraneCollaboration.Published byJohn Wiley & Sons, Ltd
                                                                                                        TABLE OF CONTENTS
                                  ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                                                                                     1
                                  PLAINLANGUAGESUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                                                                                         2
                                  BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                                                                                       2
                                  OBJECTIVES                  .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .             3
                                  CRITERIAFORCONSIDERINGSTUDIESFORTHISREVIEW . . . . . . . . . . . . . . . . . .                                                                                                                           3
                                  SEARCHMETHODSFORIDENTIFICATIONOFSTUDIES                                                                    .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .             3
                                  METHODSOFTHEREVIEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                                                                                         3
                                  DESCRIPTIONOFSTUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                                                                                       4
                                  METHODOLOGICALQUALITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                                                                                        4
                                  RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                                                                                    4
                                  DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                                                                                     5
                                  AUTHORS’CONCLUSIONS                                    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .             6
                                  POTENTIALCONFLICTOFINTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                                                                                        6
                                  ACKNOWLEDGEMENTS                                  .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .             6
                                  SOURCESOFSUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                                                                                       6
                                  REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                                                                                     7
                                  TABLES             .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .             8
                                          Characteristics of included studies                    .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .             8
                                  ANALYSES                .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .            12
                                          Comparison 01. Dexamethasone plus standard treatment versus standard treatment alone .                                                         .    .   .    .   .   .    .   .    .            12
                                          Comparison 02. Dexamethasone versus betamethasone .                                        .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .            13
                                  INDEXTERMS                       .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .            14
                                  COVERSHEET                       .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .            14
                                  GRAPHSANDOTHERTABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                                                                                        15
                                          Analysis 01.01. Comparison 01 Dexamethasone plus standard treatment versus standard treatment alone, Outcome 01                                                                                 15
                                                  Maternal deaths             .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .
                                          Analysis 01.02. Comparison 01 Dexamethasone plus standard treatment versus standard treatment alone, Outcome 02                                                                                 15
                                                  Postpartum sepsis               .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .
                                          Analysis 01.03. Comparison 01 Dexamethasone plus standard treatment versus standard treatment alone, Outcome 03                                                                                 16
                                                  Meanplatelet counts over 48 hours                          .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .
                                          Analysis 01.04. Comparison 01 Dexamethasone plus standard treatment versus standard treatment alone, Outcome 04                                                                                 16
                                                  Meanhospital stay post randomisation (days) .                               .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .
                                          Analysis 01.05. Comparison 01 Dexamethasone plus standard treatment versus standard treatment alone, Outcome 05                                                                                 17
                                                  Neonatal deaths             .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .    .   .
                                          Analysis 01.06. Comparison 01 Dexamethasone plus standard treatment versus standard treatment alone, Outcome 06                                                                                 17
                                                  Neonates with intraventricular hemorrhage .                             .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .
                                          Analysis 01.07. Comparison 01 Dexamethasone plus standard treatment versus standard treatment alone, Outcome 07                                                                                 18
                                                  Neonates with respiratory distress syndrome                             .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .
                                          Analysis 01.08. Comparison 01 Dexamethasone plus standard treatment versus standard treatment alone, Outcome 08                                                                                 18
                                                  Neonates with 5 minute Apgars less than 7 .                             .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .
                                          Analysis 01.09. Comparison 01 Dexamethasone plus standard treatment versus standard treatment alone, Outcome 09                                                                                 19
                                                  Weight at birth in grams                 .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .
                                          Analysis 01.10. Comparison 01 Dexamethasone plus standard treatment versus standard treatment alone, Outcome 10                                                                                 19
                                                  Neonates with retrolental fibroplasia                       .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .
                                          Analysis 01.11. Comparison 01 Dexamethasone plus standard treatment versus standard treatment alone, Outcome 11                                                                                 20
                                                  Numberofcesarean section deliveries                            .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .
                                          Analysis 01.12. Comparison 01 Dexamethasone plus standard treatment versus standard treatment alone, Outcome 12                                                                                 20
                                                  Timeinterval (hours) from randomisation to delivery                                  .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .
                                          Analysis 02.01. Comparison 02 Dexamethasone versus betamethasone, Outcome 01 Mean arterial pressure: adjusted                                                                                   20
                                                  time-averaged change from baseline                         .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .   .    .   .   .    .
                                  Corticosteroidsfor HELLP syndromein pregnancy(Review)                                                                                                                                                      i
                                  Copyright©2007 The CochraneCollaboration.Published byJohn Wiley & Sons, Ltd
                           Analysis 02.02. Comparison 02 Dexamethasone versus betamethasone, Outcome 02 Urinary output (mL/h): adjusted             21
                                time-averaged change from baseline   .  .  .  . .  .  .  . .  .  .  .  . .  .  .  .  . .  .  .  . .  .  .  .
                           Analysis 02.03. Comparison 02 Dexamethasone versus betamethasone, Outcome 03 Platelet count (10-9 cells/L):              21
                                adjusted time-averaged change from baseline   . .  .  .  . .  .  .  .  . .  .  .  .  . .  .  .  . .  .  .  .
                           Analysis 02.04. Comparison 02 Dexamethasone versus betamethasone, Outcome 04 LDH activity (U/L mean): adjusted           21
                                time-averaged change from baseline   .  .  .  . .  .  .  . .  .  .  .  . .  .  .  .  . .  .  .  . .  .  .  .
                           Analysis 02.05. Comparison 02 Dexamethasone versus betamethasone, Outcome 05 AST activity (U/L): adjusted time-          22
                                averaged change from baseline   . .  .  .  .  . .  .  .  . .  .  .  .  . .  .  .  .  . .  .  .  .  . .  .  .
                           Analysis 02.06. Comparison 02 Dexamethasone versus betamethasone, Outcome 06 Number of mothers with oliguria             22
                                (less than 30 ml/hour for 2 hours) . .  .  .  . .  .  .  . .  .  .  .  . .  .  .  .  . .  .  .  . .  .  .  .
                           Analysis 02.07. Comparison 02 Dexamethasone versus betamethasone, Outcome 07 Maternal pulmonary edema            .       23
                           Analysis 02.08. Comparison 02 Dexamethasone versus betamethasone, Outcome 08 Number of participants needing              23
                                acute antihypertensive therapy  . .  .  .  .  . .  .  .  . .  .  .  .  . .  .  .  .  . .  .  .  . .  .  .  .
                           Analysis 02.09. Comparison 02 Dexamethasone versus betamethasone, Outcome 09 Neonates with a 5 minute Apgar              24
                                less than 7 .  .  . .  .  .  .  . .  .  .  .  . .  .  .  . .  .  .  .  . .  .  .  .  . .  .  .  .  . .  .  .
                           Analysis 02.10. Comparison 02 Dexamethasone versus betamethasone, Outcome 10 Neonates needing ventilatory                24
                                support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
                           Analysis 02.11. Comparison 02 Dexamethasone versus betamethasone, Outcome 11 Neonates with respiratory distress          25
                                syndrome    .  .  . .  .  .  .  . .  .  .  .  . .  .  .  . .  .  .  .  . .  .  .  .  . .  .  .  .  . .  .  .
                           Analysis 02.12. Comparison 02 Dexamethasone versus betamethasone, Outcome 12 Neonatal sepsis .        .  . .  .  .       25
                           Analysis 02.13. Comparison 02 Dexamethasone versus betamethasone, Outcome 13 Neonatal hyperbilirubinemia         .       26
                           Analysis 02.14. Comparison 02 Dexamethasone versus betamethasone, Outcome 14 Fetal or neonatal death       .  .  .       26
                           Analysis 02.15. Comparison 02 Dexamethasone versus betamethasone, Outcome 15 Neonate time to discharge (days:            27
                                mean)    .  .  .  . .  .  .  .  . .  .  .  .  . .  .  .  . .  .  .  .  . .  .  .  .  . .  .  .  .  . .  .  .
                      Corticosteroidsfor HELLP syndromein pregnancy(Review)                                                                           ii
                      Copyright©2007 The CochraneCollaboration.Published byJohn Wiley & Sons, Ltd
               Corticosteroids for HELLP syndrome in pregnancy (Review)
               Matchaba P, Moodley J
               This record should be cited as:
               Matchaba P, Moodley J. Corticosteroids for HELLP syndrome in pregnancy. Cochrane Database of Systematic Reviews 2004, Issue 1.
               Art. No.: CD002076. DOI: 10.1002/14651858.CD002076.pub2.
               This version first published online: 26 January 2004 in Issue 1, 2004.
               Date of most recent substantive amendment: 31 October 2003
                                                   ABSTRACT
               Background
               Hemolysis,elevatedliverenzymesandlowplatelets(HELLP)syndromeisasevereformofpre-eclampsia.Pre-eclampsiaisamulti-system
               disease of pregnancy associated with an increase in blood pressure and increased perinatal and maternal morbidity and mortality.Eighty
               percentofwomenwithHELLPsyndromepresentbeforeterm.Therearesuggestions fromobservational studiesthatsteroidtreatment
               in HELLP syndrome may improve disordered maternal hematological and biochemical features and perhaps perinatal mortality and
               morbidity.
               Objectives
               Tosummarisetheevidenceontheeffectsofcorticosteroids on maternal and neonatal mortality and morbidity in women with HELLP
               syndrome.
               Search strategy
               WesearchedtheCochrane Pregnancy and Childbirth Group trials register (October 2003). We scanned lists of references from review
               articles and primary studies.
               Selection criteria
               Randomisedandquasi-randomisedtrialsevaluatingtheeffectsofadjunctivecorticosteroidsinpatientsdiagnosedwithHELLPsyndrome
               were sought.
               Data collection and analysis
               Thetwoauthors independently applied inclusion criteria, assessed trial quality and extracted relevant data.
               Main results
               Of the five studies reviewed (n = 170), three were conducted antepartum and two postpartum. Four of the studies randomised
               participants to standard therapy or dexamethasone. One study compared dexamethasone with betamethasone.
               Dexamethasone versus control
               There were no significant differences in the primary outcomes of maternal mortality and morbidity due to placental abruption,
               pulmonary oedema and liver hematoma or rupture. Of the secondary maternal outcomes, there was a tendency to a greater platelet
               countincreaseover48hours,statisticallysignificantly lessmeannumberofhospitalstaydays(weightedmeandifference(WMD)-4.50,
               95%confidence interval (CI) -7.13 to -1.87), mean interval (hours) to delivery (41 ± 15) versus (15 ± 4.5) (p = 0.0068) in favour of
               womenallocated to dexamethasone.
               There were no significant differences in perinatal mortality or morbidity due to respiratory distress syndrome, need for ventilatory
               support, intracerebral hemorrhage, necrotizing enterocolitis and a five minute Apgar less than seven. The mean birthweight was
               significantly greater in the group allocated to dexamethasone (WMD 247.00, 95% CI 65.41 to 428.59).
               Dexamethasone versus betamethasone
               There were no significant differences in all the maternal and perinatal mortality and in primary morbidity outcomes.
               Corticosteroidsfor HELLP syndromein pregnancy(Review)                               1
               Copyright©2007 The CochraneCollaboration.Published byJohn Wiley & Sons, Ltd