B0532 - HELLP Syndrome and COVID-19: A Case Report and Literature Review

Monday, October 24, 2022

10:00 AM – 12:00 PM ET

Location: Crown Ballroom

Presenting Author(s)

Prithi Choday, MD

Hemet Global Medical Center
San Jacinto, CA

Prithi Choday, MD¹, Carlos Buitrago, MD², Keon Hessamian, BS³, George Saffouri, MD⁴
¹Hemet Global Medical Center, San Jacinto, CA; ²University of California Riverside, San Bernardino, CA; ³University of California School of Medicine, Riverside, CA; ⁴University of California Riverside School of Medicine, Riverside, CA

Introduction: Liver disease affects approximately 3% of pregnant women and is associated with increased morbidity and mortality. This is worsened by the increased incidence of liver disease in pregnancy with COVID-19 infection. As incidence for these diseases rises, the importance of studying these conditions must also. We present a case of a patient with acute COVID-19 infection and HELLP syndrome as well as a summary of the associated literature.

A 26-year-old G1P0 female at 32 weeks gestation with medical history of asthma, obesity, gestational DM, and HTN, presented to the ED for evaluation of general malaise. She had COVID-19 infection 2 weeks prior to presentation with symptoms of fever, chills, and dyspnea. Three days after admission, there was an acute drop in platelets and hemoglobin, elevated LDH, hypertension, and elevated LFTs, highly suggestive of HELLP syndrome. She underwent emergency cesarean delivery with rapid resolution of jaundice and LFT elevation.

Methods: We gathered relevant published articles through a PubMed search from March 2020 to May 2022 using the keywords: HELLP, COVID-19, SARS-CoV-2, liver injury in pregnancy. No case-control or cohort studies on the relationship between COVID-19 and HELLP syndrome identified. A total of 5 similar case reports/ series were identified, compiling a total of 8 peripartum women who developed HELLP syndrome and tested positive for COVID-19. We then performed a literature review of these cases alongside our case.

Results: The age of the patients ranged from 23-41 years (mean 29.2). 5 primigravida patients. The mean gestational age was 30.4 weeks. 6 patients diagnosed with COVID-19 on admission, 3 tested positive prior to admission. 6 patients presented to the hospital within 7 days of symptom onset, 3 within 10 days of symptom onset. Ground-glass opacities seen in 7 patients. 7 patients had undergone emergency cesarean section due to complications of HELLP syndrome. Outcomes included 6 living fetuses, 2 stillborn, 1 IUFD, and 1 maternal fatality. 6 of the patients had postoperative complications, including preeclampsia/eclampsia, hypertensive emergency, AHRF, ARF, acute blood loss anemia, sepsis, and CVA.

Discussion: There is a paucity of literature detailing a possible correlation between COVID-19 infection and the development and progression of HELLP syndrome. This case report and review should remain hypothesis-generating and prompt larger, multi-center studies to better describe and elucidate the interplay between these two conditions.

Cases	Case 1 (our case)	Case 2	Case 3	Case 4	Case 5	Case 6	Case 7	Case 8	Case 9
Source		Futterman et al.	Futterman et al.	Madaan et al.	Madaan et al.	Madaan et al.	Norooznezhad et al.	Braga et al.	Mahajan et al.
Patient History
Age (in years)	26	41	31	32	29	26	24	31	23
Gestation History	G1P0	G9P8L8	G2P1L1	G1P0	G3P2L1D1	G1P0	G1P0	G1P0	G2P1A2
Gestational age at presentation (in weeks)	32	22	29	34	37	39	29	31	21
Chief complaint	malaise	–	–	Myalgia, Jaundice, RUQ discomfort	Fever, pedal edema	RUQ pain, headache	Low platelet count	Myalgia, Jaundice, dark urine, diffuse abdominal discomfort	SOB, palpitations
Days since symptom onset	10	7	7	4	–	2	–	1	3
Past Medical History	Asthma, obesity	None	None	None	None	None	ITP	None	DM1
Pregnancy complications	Gestational DM, Gestational HTN	None	None	None	None	Gestational HTN	None	Twin gestation	Grade 2 placenta previa, oligohydramnios
COVID-19 Status
Prior COVID diagnosis	Yes, 2 weeks before admission	No	No	No	No	Yes, 2 days back	No	No	Yes, 5 months back
SARS-CoV-2 Test during this admission	Not done	Positive	Positive	Positive	Positive	Not done	Positive	Positive	Not done
Imaging findings on hospital admission	Not done	GGO	Peripheral opacities	GGO	GGO	GGO	GGO	GGO, bilateral pleural effusions	Consolidation
Admission vitals
Blood pressure (mmHg)	–	99/57	124/83	116/82	144/98	160/100	–	110/60	110/70
Heart Rate (beats per minute)	–	–	–	82	88	98	86	–	110
Temperature (degrees Fahrenheit)	Afebrile	–	–	Afebrile	101	–	Afebrile	Afebrile	Afebrile
Respiratory rate (breaths per minute)	–	–	–	24	20	–	14	16	–
0xygen saturation (%)	–	90% on 15 liters NRB	–	–	–	95% on RA	95% on RA	98% on RA	–
Admission labs
Total white Blood cell count (x109/L)	11.6	25.3	5.6	4.9	5.8	6	9.3	17.2	30.7
Hemoglobin (g/dL)	9.2	12.7	14.8	9.3	8.6	10.1	10.4	–	9.2
Hematocrit	27.8	87.4	44.2	–	–	–	31.3	–	–
Platelets	237	48	24	86	81	90	6	218	90
Sodium	139	–	–	134	137	139	–	–	141
Potassium	4.6	–	–	3.6	3.89	4.49	–	–	3.9
BUN	30	42	6	30	39	33	14	–	47
Creatinine	1.3	1.49	0.5	1.4	1	0.9	0.64	2.3	1.1
AST	292	192	43	626	524	589	346	–	546
ALT	425	88	17	228	230	300	477	558	287
Alkaline phosphatase	106	–	–	122	128	134	–	–	119
Total bilirubin	6.3	–	–	8.8	9.9	9.4	–	9.28	5.4
LDH	–	1366	–	2500	2700	3100	971	1000	2051
CRP	–	8.4	–	60	91.7	78.5	30	2.4	–
D-Dimer	–	>35.2	–	5.53	6.62	6.23	–	–	7.94
Ferritin	–	–	–	650	890	734	–	–	–
Prothrombin time (seconds)	15	14.4	12	–	–	–	–	–	–
Partial thromboplastin time (seconds)	31.5	31.5	32.4	–	–	–	–	–	–
International normalized ratio (INR)	1.1	1.35	< 1	–	–	–	–	–	–
Fibrinogen	696	185	97	–	–	–	–	–	–
Urine protein	–	1+	1+	–	–	–	–	0	–
Outcomes
Fetus status on hospital admission	Fetal heart sounds present, regular	Fetal heart sounds present, regular	Decreased fetal tone	Absent fetal heart sound	Fetal heart sounds present, regular	Fetal heart sounds present, regular	–	Abnormal heart sounds, recurrent late decelerations	Fetal heart sounds present, regular
Days between hospital admission and delivery	3	5	0	0	0	0	9	1	5
Delivery method	Emergency cesarean section	Spontaneous vaginal delivery	Emergency cesarean section	Emergency cesarean section	Normal vaginal delivery	Emergency cesarean section	Emergency cesarean section	Emergency cesarean section	Emergency cesarean section
Fetal outcome	Living	IUFD	Living	Stillborn	Living	Living	Living	Living	Stillborn
Maternal outcome	Living	Living	Living	Living	Living	Living	Living	Living	Deceased
Post-operative complications	Preeclampsia	AHRF, ARF, Sepsis, CVA	Acute blood loss anemia	AHRF on postoperative day 3	Eclampsia, AHRF, Hematuria	None	None	Hypertensive emergency, abdominal wall hematoma, AHRF	Not applicable

Table: Table 1: Comparison of 9 Cases of COVID-19 and HELLP Syndrome.
SOB= shortness of breath, RUQ= right upper quadrant, ITP= immune thrombocytopenic purpura, DM1= diabetes mellitus type 1, DM= diabetes mellitus, HTN= hypertension, GGO= ground-glass opacities, NRB= nonrebreather mask, RA= room air, BUN= blood urea nitrogen, AST= aspartate aminotransferase, ALT= alanine aminotransferase, LDH= lactate dehydrogenase, CRP= C-reactive peptide, IUFD= intrauterine fetal death, AHRF= acute hypoxic respiratory failure, ARF= acute renal failure, CVA= cerebrovascular accident

Disclosures:

Prithi Choday indicated no relevant financial relationships.

Carlos Buitrago indicated no relevant financial relationships.

Keon Hessamian indicated no relevant financial relationships.

George Saffouri indicated no relevant financial relationships.

Prithi Choday, MD¹, Carlos Buitrago, MD², Keon Hessamian, BS³, George Saffouri, MD⁴. B0532 - HELLP Syndrome and COVID-19: A Case Report and Literature Review, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.