The patient is 38 weeks pregnant with HELLP syndrome, low platelets (10,000), impaired RFT, and cervix closed.
Caesarean section in such scenarios is performed for Obstetric indication such as breech presentation, fetal distress or failed induction. The risk of bleeding in HELLP is significantly higher with C/S in addition to the risk of GA as this patient can not have regional anaesthesia. induction of labour should be with prostaglandins with continuous fetal monitoring. On the other hand failed induction of labour leads to an emergency section which carries higher risk but most women are expected to have a successful vaginal delivery at full term.
If there are no formal indication to cesarian section I think the cytotec induction of labour is preferrable due to mother and newborn advantages. Once cesarean section is a surgical procedure that has risk and possible complications for both mother and newborn. More, I think we should always incentive to vaginal delivery as way to minimize the high rates of cesarean section
Those patients with HELLP usually induce with Pitocin and have short easy labors. Cesarean is far too risky with those unstable women. And why cytotec? Cytotec is famous for unpredictable behavior.
I understand your question to focus on termination of pregnancy. In this case I would advocate for induction of labor. The use of Cytotec is best before 28-30 weeks as it carries higher risk for uterine hyper stimulation and necessitates closer monitoring. Other prostaglandin E could also be used.
I think that induction of labour with increasing dose of oxytocin is safer option for this case especially if she is multiparous, as cytotec is unlicensed for induction of labour at term with a viable fetus. If vagiprost (misopristol 25 mcg vaginal suppository) is available in your setting, you can use it to ripen the cervix then continue induction with oxytocin with good monitoring. Correction of platelet count is required by platelet transfusion before starting induction of labour. Cesarean section is still an option if you think that there is very high possibility of failure of induction (although the likelihood of success of induction of labour in case of unfavorable cervix (Bishop's score less than 4) is about 30%). In this case is best done during the day time in presence of efficient anesthetic staff and informing the intensive care unit for postoperative follow up.
It is better to deliver vaginally to decrease risk of bleeding as long as the materal and fetal condition could stand without deterioration ,any complication occurs or failure proceed to cs.
There is increasing evidence about increased morbidity in subsequent pregnancies associated with caesarean section in a current pregnancy. To give a woman the best chance of a subsequent healthy pregnancy, induction where possible is advisable.
I would suggest induction with a Foley catheter if time allows a period of one days ripening. Is associated with less caesareans for fetal distress and less hemorrage after delivery!
Dear colleague, I would try to stabiize the patient with Magnesiumsulphate and antihypertensives, prime the cervix with Foley catheter and opt for vaginal delivery. Vaginal delivery gives the least chance on bleeding problems and subsequent pregnancies and deliveries. Most women with HELLP at term do react well on induction (due to the fetal stress response perhaps). However, if the patient becomes too ill, you need to perform a CS if she doesn't respond quickly enough to your induction methods.
I am agree with Dr K.M.Paarlberg. The patient must be stabilized first because she has 10,000 platalets with administration of platelets to increase the number. We can't wait to long because HELLP syndrome is an emergency. Induction of labor with Cytotec is forbidden; it establish hipertony of the uterus and fetal distress. In this case cesarean section is the best option with general anesthesia (rahianestesia is contraindicated). Of course we have the risk for haemorrage, but during the surgery must have supply of blood and platalets and mabe Pabal (carbetocine) for good uterine retraction.
- Badges
- Science topic
- Similar topics
- Biological Science
- Molecular Biology
- Biomolecules
- Nucleic Acids
- DNA