HELLP syndrome is a disorder associated with serious maternal morbidity and mortality. Distinguishing HELLP from other pregnancy related disorders is often challenging and may result in delay of treatment. Differential diagnoses include acute fatty liver of pregnancy, thrombotic thrombocytopenic purpura, antiphospholipid syndrome, and hemolytic uremic syndrome, and are reviewed in this chapter. While there is not any current treatment for HELLP, the mainstay of treatment involves maternal stabilization and timely delivery. Various treatment strategies have been attempted to help decrease the morbidity and mortality of HELLP, including the maternal use of corticosteroids. The authors review the studies and controversies surrounding the maternal use of corticosteroids, plasma exchange, and low molecular weight heparin for the treatment of HELLP, as well as the role of the complement system in HELLP. Further large, well-designed, randomized controlled trials are needed to address the role corticosteroids may play in the treatment of women with HELLP and to help improve maternal and fetal outcomes.

Problem Angiogenic imbalance during pregnancy is associated with immune activation, hypertension, increased T cell infiltration, and neurological insults. Method of Study On gestational day (GD) 12 timed-pregnant rats were infused with anti-angiogenic factors sFlt-1 and sEndoglin (4.7 and 7μg/kg) to create HELLP syndrome via mini-osmotic pumps for 8 days, with a subset of these rats having Orencia (2mg/kg) infused on GD13. On GD19, blood brain barrier (BBB) permeability was evaluated via Evan’s Blue infusion, blood was collected for T cell measurements, inflammatory cytokine secretion. Brain tissues were also collected to examine inflammatory cytokine infiltration. Results T cell attenuation with Orencia decreased circulating CD4+ and CD8+ T cells, circulating TNFα and IL-17, BBB permeability and significantly decreased biochemical evidence of HELLP compared to untreated HELLP rats. Conclusions These data support the hypothesis that T cells have a critical role in contributing to the pathophysiology that is seen in angiogenic imbalance during pregnancy.

Objective Higher-dose oxytocin is more effective than lower-dose regimens to prevent postpartum hemorrhage following cesarean delivery. We compared two higher-dose regimens (80U and 40U) to our routine regimen (10U) among women who delivered vaginally. Methods In a double-masked randomized trial, oxytocin (80U, 40U or 10U) in 500ml was given over 1 hour after placental delivery. The primary outcome was a composite: any treatment of uterine atony or hemorrhage. Prespecified secondary outcomes included outcomes in the primary composite and a decline of 6% or greater in hematocrit. A sample size of 600 per group (N=1800) was required to compare each of the 80U and 40U to the 10U group. At planned interim review (n=1201), enrollment in the 40U group was stopped for futility and enrollment continued in the other groups. Results Of 2,869 women, 1,798 were randomized: 658 to 80U, 481 to 40U and 659 to 10U. Most characteristics were similar across groups. The risk of the primary outcome in the 80U group (6%; RR 0.93, 95% CI: 0.62–1.40) or the 40U group (6%; 0.94, 0.61–1.47) was not different compared with the 10U group (7%). Treatment with additional oxytocin after the first hour was less frequent with 80U compared with 10U (RR 0.41; 0.19–0.88) as was a 6% or greater decline in hematocrit (0.83; 0.69–0.99); both outcomes declined with increasing oxytocin dose. Outcomes were similar between the 40U and 10U groups. Conclusion Compared with 10 units, 80 or 40 units of prophylactic oxytocin did not reduce overall postpartum hemorrhage treatment when given in 500ml over 1 hour for vaginal delivery. Eighty units decreased the need for additional oxytocin and the risk of a 6% or greater decline in hematocrit.

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Hypertension and inflammation during pregnancy are suggested to contribute to the development of post-partum depression and anxiety. Using a rat model of severe preeclampsia and Hemolysis Elevated Liver enzymes Low Platelet syndrome which displays both hypertension and inflammation during pregnancy we evaluated whether rats were prone to develop depression or anxiety in the post-partum period. On gestational day 12, mini-osmotic pumps infusing sFlt-1 and sEng were placed into rats, a subset of these rats were infused with 2mg/kg of Orencia (Abatacept) the following day to determine if immune suppression via T cell depletion prevented any changes in maternal depression and/or anxiety-like behavior. All rats including normal pregnant controls delivered between gestational days 21–22. Post-partum severe preeclamptic rats buried significantly more marbles compared to normal pregnant rats (p=0.002) and Orencia treated rats (p=0.05). Severe preeclamptic rats spent significantly more time in closed arms of the elevated plus maze compared to normal pregnant rats (p=0.009) and Orencia treated rats (p=0.05). Severe preeclamptic rats were hypertensive compared to normal pregnant (p=0.03) and Orencia treated rats (p=0.01). Finally, severe preeclamptic rats had increased blood brain barrier permeability compared to normal pregnant rats (p=0.03), which was reversed in Orencia treated rats (p=0.008). These results suggest that severe preeclampsia/Hemolysis Elevated Liver enzymes Low Platelet syndrome during pregnancy contributes to an increase in anxiety-like behavior, blood brain barrier permeability and hypertension in the post-partum. The current results suggest that T cell suppression during pregnancy can also help prevent chronic hypertension and increased anxiety in the post-partum period.

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Although Wilms tumor (WT) is the most common pediatric renal tumor, adolescent and adult WT is rare. Nevertheless, adolescent renal tumors as a group are sufficiently uncommon that WT must be included in the differential diagnosis for such patients, and in doing so affects the oncologic considerations of the surgery. Herein, we describe a 14-year-old female presenting with a 1-month history of right flank pain. Subsequent work-up revealed a localized, centrally located, enhancing right renal mass. The patient underwent robotic-assisted laparoscopic radical nephrectomy and pathology demonstrated stage II, favorable histology WT. Herein, we will discuss the pertinent details regarding adolescents with renal tumors and the risks and benefits of using a minimally invasive surgical approach.