Master the board step 3

Master the Boards: USMLE Step 3
HELLP Syndrome
HELLP syndrome occurs in 5–10 percent of preeclamptic patients. It typically
presents in the third trimester but may occur in the postpartum period, commonly
presenting 2 days after delivery. Risk factors differ from preeclampsia,
since HELLP syndrome is more common in whites, multigravids, and women
of older maternal age.
Treatment
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Schedule immediate delivery at any gestational age.
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Give IV corticosteroids (dexamethasone) when platelets < 100,000/mm 3 both
antepartum and postpartum; continue until platelet count is > 100,000/mm 3
and liver function normalizes.
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Give platelet transfusion if platelet count < 20,000/mm 3 or platelet count
< 50,000/mm 3 if cesarean section will be performed.
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IV MgSO 4 for seizure prophylaxis, even if BP is normal.
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Steroids may also need to be considered for assistance with fetal lung maturation
if prior to 36 weeks.
Complications of HELLP syndrome are as follows:
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DIC
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Abruptio placenta
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Fetal demise
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Ascites
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Hepatic rupture
Medical Complications in Pregnancy
Cardiac Abnormalities
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Heart disorders account for about 10 percent of maternal obstetric deaths.
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Women with high-risk disorders (e.g., pulmonary hypertension, Eisenmenger
syndrome, severe valvular disorders, prior postpartum cardiomyopathy)
should be advised not to become pregnant due to risk of sudden death.
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Cardiovascular changes in pregnancy (30–50 percent ↑ cardiac output [CO])
may unmask or worsen underlying cardiac conditions. These changes are
maximal at 28 and 34 weeks’ gestation.
No seizure medication is
proven safe in pregnancy.
Valproate is the most
dangerous.
Peripartum Cardiomyopathy
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Heart failure with no identifiable cause can develop between the last month
of pregnancy to 5 months postpartum.
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Risk factors include multiparity, age ≥ 30, multiple gestations (i.e., twins or
triplets, etc.), and preeclampsia.
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The 5-year mortality rate is 50 percent.
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