When we're pregnant, we worry. Luckily most complications are very rare, says Dr Howard Lee

HELLP Syndrome

HELLP syndrome is a rare but serious illness of pregnancy. The name is made up from initials that are the condition's symptoms: H = haemolysis, or rupture of red blood cells, EL = elevated liver enzymes, which indicates liver damage; and LP = low blood levels of platelets, which are specialised white cells vital for normal blood clotting.

The cause of HELLP syndrome is not really known, although it is often linked to pre-eclampsia or previous pregnancies - especially if there was a problem with any of them. It is not possible to know who will get it, as it can affect any pregnant woman.

There have been some suggested links between the development of the syndrome and a reaction with the genetic material that was supplied by the baby's father - a type of allergy to the father's genes in other words. There is a 27 per cent chance that it can occur again during a subsequent pregnancy, but if it does it is usually less severe.

The treatment for HELLP syndrome is ending the pregnancy by delivering the baby. But as the condition - which most often occurs in the last three months of pregnancy ? can also start long before a pregnancy reaches term, the baby may not be ready to be born. It will not be able to survive if very premature.

A woman diagnosed with HELLP syndrome is very ill, but after delivery there is usually a fairly rapid improvement within a couple of days, and it is only in the very worst cases that the life of the woman is threatened.

There is no way to prevent this serious illness, but attending regular antenatal reviews and reporting any undue symptoms to your doctor is important so that an early and proper diagnosis of the condition can be made. It is not infrequent for the syndrome to be easily misdiagnosed as hepatitis or gall bladder disease, as upper abdominal pain is an occasional symptom.

Dystocia

This literally means difficult or abnormally slow labour, and it is the result of a combination of one or more factors that can involve either mother or baby. Signs and symptoms include:

• Abnormalities of the uterine contractions, which may be too weak or uncoordinated to open the cervix during the first stage of labour or too weak to continue the expulsive processes during the second stage.
• Abnormalities of the baby's presentation or position in the birth canal - anything other than head first increases the probability of dystocia - or alternatively there may be other problems with the baby with regard to abnormal growth of parts or overall size - a weight of 4.5 Kg or more, particularly, may lead to a shoulder dystocia, where the shoulders get stuck.
• Abnormalities of the mother's bony pelvis or the birth canal itself can lead to a retarded progress of the baby through the birth canal.

Dystocia can be associated with increased problems in the mother and/or baby during the stage of labour, delivery and afterwards. Some of these problems are a direct result of the treatments, which may be:

• Medical - using drugs to encourage uterine contractions during various stages in labour.
• Surgical - using forceps or vacuum extraction techniques to either adjust the baby's position or assist with delivery, or Caesarean section for delivery.
• Complications can also occur in the form of infection - to the mother or baby - as a result of both the delay in labour itself as well as infection associated with the manipulative treatments needed.

  Intrahepatic cholestasis of pregnancy (ICP)

  Intense, generalised itching (pruritis) is the main (and sometimes only) feature, which is caused by the increased level of bile salts in the blood. It usually begins in the third trimester, but may occur any time after 20 weeks. The itching, which can be very severe, is usually noticed first at night and can be most intense on the palms and the soles. It is vital to seek immediate medical help if you experience this symptom.

  Jaundice, caused by increased levels of bile chemicals in the blood, can also appear in ICP. Confirmation of the diagnosis is usually made from laboratory test results.

  This condition, also known as obstetric cholestasis, icterus gravidarum and cholestatic jaundice of pregnancy, is caused by a temporary dysfunction of the mother's liver during pregnancy, which resolves shortly after delivery.

  The exact cause is not known, but it is widely accepted that in those affected, the high oestrogen level in the blood has in someway altered the functioning of the liver cells, causing various bile chemicals that would normally pass into the gut to build up in the blood instead.

  It is generally not regarded as harmful to the mother - and there are no long-term problems - but it can be associated with an increased risk of stillbirth or premature death of the baby if the ICP is not recognised and treated.

  ICP is a relatively rare condition, apparently with some hereditary links (grandmother, mother and sisters, but it sometimes skips generations), occurring in less than one in 1,000 pregnancies.

  However, it is up to four times as common in multiple rather than single pregnancies. If it does appear in a pregnancy, there is a 60-70 per cent chance that it will recur in a future pregnancy, often with increased intensity.

  The treatment has two primary objectives:

  • To try and alleviate the itching, which can be very intense. This is not easy to achieve as medication is not very effective.
  • To induce labour when the baby is thought to be mature enough to be safely delivered, certainly in cases where any foetal distress is noted.

  Pyogenic Granuloma

  A pyogenic granuloma can arise in up to five per cent of pregnancies - usually in the second or third trimester - and then the term 'pregnancy tumour','granuloma of pregnancy' or 'granuloma gravidarum' is used. It is this variant with which we are particularly concerned.

  This is a relatively common, rapidly growing - and non-malignant - lesion (basically formed by an overgrowth of blood vessels) that can also occur in children and young adults as a typically solitary, glistening red nodule, prone to bleed easily. The first appearance is as a small, pin-head sized lesion, which can grow anywhere from 2-20 mm (about the diameter of a one penny piece).

  The exact cause for the appearance of a pyogenic granuloma is unknown. Many factors have been suggested, including hormonal influences, but there is little conclusive evidence for any of them. As many of the lesions that do occur in pregnancy resolve soon after delivery, any treatment for removal is often postponed until then.

  There is typically rapid growth of the lesion over a period of a few weeks, and although frequently appearing on the head and neck, it can appear elsewhere on the body. In pregnancy, for instance, the most common site for its appearance is within the lining of the mouth - particularly on the gums or lips.

  If treatment is needed (because of irritation or bleeding) it is usually in the form of a destructive technique using a laser, electro-cautery or chemical method. Surgical treatment for removal is only very occasionally used. Recurrence can be quite common.