Edema associated with low plasma protein level and any gestational hypertension as warning signs of HELLP syndrome.

Because preeclampsia is a multisystem disorder, its definition has recently been revised, including cases with evidence of renal, liver, neurological, or hematological dysfunction. However, the role of edema remains unclear. While the presence of mild edema is common in normal pregnancy, in severe preeclampsia protein transfer from the vascular into the interstitial compartment could lead to low serum protein level and favor the transport of fluid to the interstitial compartment. Over a 4-year period, 9749 women have given birth in our university maternity ward. In this period of time, 86 women developed severe preeclampsia. Among them, we retrospectively identified nine patients who first presented with mild de novo hypertension or preeclampsia, extensive edema or excessive gestational weight gain (GWG), and documented low serum protein levels; five patients also reported headache. Serum protein levels ranged from 51 to 56 g/l. We analyzed the progression of the disease in these women, and found that these patients developed criteria for complete or partial hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome in four and five cases, respectively. All patients were delivered quickly of healthy babies, and no other maternal adverse outcomes occurred. As plasma proteins are the primary determinants of plasmatic colloid osmotic pressure (COP), headache in association with edema, low serum protein levels, and even mild hypertension, could reflect cerebral vasogenic edema with the same mechanism as for cerebral edema reported in posterior reversible encephalopathy syndrome and eclampsia. Thus, the sequential association of edema or excessive GWG with markedly low serum protein levels and mild gestational hypertension could signal the imminent development of severe preeclampsia and possibly HELLP syndrome. This sequence should be assessed in additional large-scale prospective studies.