Association Between the Quantitative Assessment of Schistocytes in Peripheral Blood Smear and Prognosis of Patient Initially Diagnosed as HELLP Syndrome.
Conditions: Pre-Eclampsia, Severe, HELLP Syndrome, Microangiopathy
Sponsor: AYMAN ABDELKADER MOHAMED ABDELKADER

Association between the Quantitative Assessment of Schistocytes in Peripheral Blood Smear and 
Prognosis of Patient Initially Diagnosed as HELLP Syndrome (protocol) 
 
1 
Association between the Quantitative Assessment of 
Schistocytes in Peripheral Blood Smear and Prognosis 
of Patient Initially Diagnosed as HELLP Syndrome 
Thesis Protocol 
Submitted for partial fulfillment of Master Degree in 
Obstetrics & Gynecology 
Presented by 
       Shimaa Bakry Mohammed 
 
M. B., B. Ch.2009 
Faculty of Medicine, Ain Shams University 
Work at Abu Sewair medical administration 
Under the supervision of 
Ass. Prof. Ahmed Hamdy Naguib 
Assistant Professor of Obstetrics and Gynecology 
Faculty of Medicine, Ain Shams University 
Lecturer. Ayman Abd El-Kader Mohamed 
Lecturer of Obstetrics and Gynecology 
Faculty of Medicine, Ain  Shams University 
Lecturer. Rasha Abd El-Rahman El-Gamal 
Lecturer of Clinical and Chemical Pathology                                      
Faculty of Medicine, Ain  Shams University 
 
Faculty of Medicine 
Ain Shams University 
2014 
 

Association between the Quantitative Assessment of Schistocytes in Peripheral Blood Smear and 
Prognosis of Patient Initially Diagnosed as HELLP Syndrome (protocol) 
 
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Introduction 

Association between the Quantitative Assessment of Schistocytes in Peripheral Blood Smear and 
Prognosis of Patient Initially Diagnosed as HELLP Syndrome (protocol) 
 
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HELLP syndrome probably represents a severe form of 
preeclampsia, but the relationships between the two 
disorders remain controversial. As many as 15 to 20 percent 
of patients with HELLP syndrome do not have antecedent 
hypertension or proteinuria, leading some authorities to 
believe that HELLP syndrome is a separate disorder from 
preeclampsia (Reubinoff –Schenker ., 1991). 
The most common symptom is abdominal pain and 
tenderness in the midepigastrium, right upper quadrant, or 
below the sternum (Sibai – Ramadan .,  1993). 
Many patients also have nausea, vomiting, and malaise, 
which may be mistaken for a nonspecific viral illness or viral 
hepatitis, 
particularly 
if 
the 
serum 
aspartate 
aminotransferase and lactate dehydrogenase are markedly 
elevated (Catanzarite ., et al 1995). 
Less common signs and symptoms include headache, 
visual changes, jaundice, and ascites. Mistaking abdominal 
pain, nausea, vomiting, and malaise for viral illness is a 
common pitfall that has resulted in maternal death or severe 
morbidity (Isler ., et al 1999). 
 
 
Hypertension (blood pressure ≥140/90 mmHg) and 
proteinuria are present in approximately 85 percent of cases, 

Association between the Quantitative Assessment of Schistocytes in Peripheral Blood Smear and 
Prognosis of Patient Initially Diagnosed as HELLP Syndrome (protocol) 
 
4 
but it is important to remember that either or both may be 
absent in women with otherwise severe HELLP syndrome 
(Sibai, 2004). 
Signs and symptoms typically develop between 28 and 
36 weeks of gestation, but second trimester or postpartum 
onset is also common. In an illustrative series of 437 women 
who had 442 pregnancies complicated by the HELLP 
syndrome, 70 percent occurred prior to delivery. Of these 
patients, approximately 80 percent were diagnosed prior to 
37 weeks of gestation and fewer than 3 percent developed 
the disease between 17 and 20 weeks of gestation (Sibai ., et 
al 1993). 
Serious maternal morbidity may be present at initial 
presentation or develop shortly thereafter. This includes 
disseminated intravascular coagulation, abruptio placentae, 
acute renal failure, pulmonary edema, subcapsular or 
intraparenchymal liver hematoma, and retinal detachment, 
bleeding related to thrombocytopenia is an unusual 
presentation (Sibai ., et al 1993). 
 
Outcome and prognosis of HELLP syndrome is 
associated with a variety of maternal morbidities, which can 
rarely result in a fatal outcome. The risk of serious morbidity 

Association between the Quantitative Assessment of Schistocytes in Peripheral Blood Smear and 
Prognosis of Patient Initially Diagnosed as HELLP Syndrome (protocol) 
 
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correlates with increasing severity of maternal symptoms 
and laboratory abnormalities (Martin ., et al 2006).  
The majority of patients will show evidence of 
resolution of the disease process within 48 hours after 
delivery(ACOG 2004) 
Differential 
diagnosis HELLP 
syndrome 
may 
occasionally be confused with other diseases complicating 
pregnancy: acute fatty liver of pregnancy, gastroenteritis, 
hepatitis, 
appendicitis, 
gallbladder 
disease, 
immune 
thrombocytopenia, lupus flare, antiphospholipid syndrome, 
hemolytic-uremic syndrome, thrombotic thrombocytopenic 
purpura, and nonalcoholic fatty liver disease (Page- Girling 
., 2011). 
Thrombotic thrombocytopenic purpura and hemolytic 
uremic syndrome are systemic disorders characterized by 
endothelial injury and the formation of small vessel platelet-
rich thrombi. The resulting thrombotic microangiopathy 
produces 
microangiopathic 
hemolytic 
anemia 
and 
thrombocytopenia; presenting features may also include 
neurologic and/or renal abnormalities (Scully ., et al 2012). 
If untreated, thrombotic thrombocytopenic purpura-
hemolytic uremic syndrome in adults typically follows a 
progressive course in which irreversible renal failure, 
progressive neurologic deterioration, cardiac ischemia, and 
death are common outcomes (Remuzzi ., 1987).  

Association between the Quantitative Assessment of Schistocytes in Peripheral Blood Smear and 
Prognosis of Patient Initially Diagnosed as HELLP Syndrome (protocol) 
 
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The mortality rate prior to the use of plasma exchange 
was approximately 90 percent (von ., 2002). 
The mainstay of treatment for most patients with 
thrombotic thrombocytopenic purpura-hemolytic uremic 
syndrome is plasma exchange, which in the context of this 
syndrome refers to the removal of the patient’s plasma by 
pheresis and the replacement with donor plasma rather than 
another replacement fluid such as albumin (Scully., et al 
2012). 
Compared with the mortality rate of 90 percent prior to 
the use of plasma exchange, the mortality rate for patients 
treated with plasma exchange is 25 percent or less (Kremer., 
et al 2010). 
Thrombotic 
thrombocytopenic 
purpura-hemolytic 
uremic syndrome should be considered in all pregnant 
women with severe thrombocytopenia, severe anemia, and 
elevated lactate dehydrogenase enzyme (Stella .,et al 2009). 
The distinction between thrombotic thrombocytopenic 
purpura-hemolytic 
uremic 
syndrome 
and 
severe 
preeclampsia is important for therapeutic and prognostic 
reasons. However, the clinical and histological features are 
so similar that establishing the correct diagnosis is often 
difficult; 
furthermore, 
these 
disorders 
may 
occur 
concurrently ( Burns ., etal 2004). 

Association between the Quantitative Assessment of Schistocytes in Peripheral Blood Smear and 
Prognosis of Patient Initially Diagnosed as HELLP Syndrome (protocol) 
 
7 
The diagnosis of thrombotic thrombocytopenic purpura 
rests on evidence of microangiopathic hemolytic anemia and 
thrombocytopenia 
in 
the 
absence 
of 
disseminated 
intravascular coagulation and other known causes of 
thrombotic microangiopathy. Highly specific diagnostic 
tools such as serum levels of ADAMTS13 are not routinely 
available for immediate clinical diagnosis. The presence of 
schistocytes on a blood smear is the morphologic hallmark 
of the disease . During the early 1970s plasma exchange was 
introduced as an effective treatment for TTP, making early 
and rapid diagnosis urgent . ( Burns ., etal 2004) 
 
 
So we are searching for the association between the 
quantitative assessment ofschistocytes in peripheral blood 
smear and prognosis of patient initially diagnosed as 
HELLPsyndrome.

Association between the Quantitative Assessment of Schistocytes in Peripheral Blood Smear and Prognosis of Patient Initially Diagnosed as 
HELLP Syndrome (protocol) 
 
8 
Aim of the work 
Research question: 
        In  patients who are initially diagnosed as HELLP syndrome does  the 
quantitative assessment of schistocytes will predict deterioration of HELLP 
syndrome after delivery ? 
 Research hypothesis: 
We supposed that there might be a difference in the quantitative assessment 
of schistocytes in peripheral blood smear between women initially diagnosed as 
HELLP syndrome who showed no spontaneous resolution within 48 hrs after 
delivery and those who showed spontaneous resolution within 48 hrs after 
delivery. 
Aim of study: 
The aim  of the current study is to search for a diagnostic test which might predict 
microangiopathic hemolytic anemia and persistent HELLP syndrome from cases 
who inially diagnosed as HELLP syndrome in order to start PEX ∕  FFP which 
might decrease the maternal mortality rate at Ain Shams maternity hospital 
Patients and Methods 
Study Design: 
o diagnostic test accuracy.  (pilot study ) 
Study Setting: 
o Ain Shams University Maternity Hospital from January 2015 to December 
2015.  
o Intensive Care Unit , Wards, Labour ward at Ain Shams University Maternity 
Hospital and Hematology Unit and Clinical Pathology Unit at Ain Shams 
University. 
Study Population:  
A total of 100 women with an initial diagnosis of HELLP syndrome will be 
recruited in the study. 

Association between the Quantitative Assessment of Schistocytes in Peripheral Blood Smear and Prognosis of Patient Initially Diagnosed as 
HELLP Syndrome (protocol) 
 
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Blood sample taken within 12hrs peripartum and patients will be followed up 
48hrs after delivery and subdivided in to  2 groups according to improvement or 
deterioration after 48hrs after delivery . 
Inclusion ctiteria : 
o Gestational age more than 20 weeks. 
o Age from18 to 40 years old. 
o Fulfilled criteria for the diagnosis of severe preeclampsia. 
o Fulfilled criteria for the diagnosis of HELLP syndrome. 
Diagnostic criteria for severe preeclampsia(one of the following): 
• Blood pressure of 160 mm Hg systolic or higher or 110 mm Hg diastolic 
or higher on two occasions at least 6 hours apart while the patient is on 
bed rest (unless antihypertensive therapy is intiated befor this time). 
• New onest Cerebral or visual disturbances. 
• Pulmonary edema or cyanosis. 
• Sever persistant epigastric or right upper-quadrant pain unresponsive to 
medication and not accounted for by alternative diagnosis, or both. 
• Impaired liver function as indicated by abnormally elevated blood 
concentration of liver enzymes (to twic normal concentration). 
• Thrombocytopenia (platlet count less than 100, 000 per microliter. 
(ACOG ., 2013) 
Diagnostic criteria for HELLP syndrome: 
●Hemolysis documented by an increased LDH level and progressive anemia . 
●Hepatic dysfunction documented by an LDH level >600 IU/L, elevated liver 
enzymes documented by AST >40 IU/L, ALT>40 IU/L, or both . 
●Thrombocytopenia documented by a platelet nadir less than 150, 000 cells/mm³. 
Thrombocytopenia is subclassified as class one HELLP syndrome: platelet nadir 
≤50, 000 cells/mm³, class two HELLP syndrome: platelet nadir ≤100, 000 
cells/mm³, or class three HELLP syndrome: platelet nadir ≤150, 000 
cells/mm³.(Martin .,  et al 1999) . 
 
 
 
 
 
Anticepation of Microangiopathic Hemolytic Anemia:  

Association between the Quantitative Assessment of Schistocytes in Peripheral Blood Smear and Prognosis of Patient Initially Diagnosed as 
HELLP Syndrome (protocol) 
 
10 
Thrombotic thrombocytopenic purpura-hemolytic uremic syndrome should 
be considered in all pregnant women with severe thrombocytopenia, severe 
anemia, and elevated lactate dehydrogenase enzyme (Stella ., et al 2009). 
Methodology: 
All included women will be subjected to the following: 
o History taking and consent 
o Consent form:  
o Patient name:  
o Hospital number:  
o Information to the participant:  
o The procedure  
1. The results of your blood results and hospital data will be used in 
this clinical trial. 
2. An extra blood sample will be withdrawn at the time of diagnosis 
which is a simple procedure with no known complications. 
3. All your data and blood results, will saved confidentially and it 
will appear as a number in the results. 
4. The results of these investigation will not affect your 
management plan. 
o General, abdominal and local examination. 
Laboratory test: 
 complete blood count, using EDTA-anticoagulated peripheral blood sample, for 
concentration and platelet counts. 
Peripheral blood smears will be taken within 12hrs peripartum and prepared 
within two hours of blood collection using the EDTA-anticoagulated peripheral 
blood sample. The blood smear then spread, air-dried, and fixed and stained 
according to standard procedures with panoptical stains Romanwsky stain as 
reported by (International Council for Standardization in Hematology; 1984). 
Schistocytes are fragments of red blood cells (RBCs) produced by extrinsic 
mechanical damage within the circulation. The detection of schistocytes is an 
important morphological clue to the diagnosis of thrombotic microangiopathic 
anemia (TMA). Reporting criteria between different laboratories, however, are 
not uniform, owing to variability of shape and nature of fragments, as well as 
subjectivity and heterogeneity in their morphological assessment. Lack of 
standardization may lead to inconsistency or misdiagnosis, thereby affecting 
treatment and clinical outcome. The Schistocyte Working Group of the 

Association between the Quantitative Assessment of Schistocytes in Peripheral Blood Smear and Prognosis of Patient Initially Diagnosed as 
HELLP Syndrome (protocol) 
 
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International Council for Standardization in Hematology 2012 (ICSH) has 
prepared specific recommendations to standardize schistocyte identification, 
enumeration, and reporting. They deal with the type of smear, method of 
counting, morphological description based on positive criteria (helmet cells, 
small, irregular triangular, or crescent-shaped cells, pointed projections, and lack 
of central pallor). A schistocyte count has a definite clinical value for the 
diagnosis of TMA in the absence of additional severe red cell shape 
abnormalities, with a confident threshold value of 1%. Automated counting of 
RBC fragments is also recommended by the ICSH Working Group as a useful 
complement to the microscope, according to the high predictive value of negative 
results, but worthy of further research and with limits in quantitation. 
International 
Council 
for 
Standardization 
in 
Haematology 
recommendations for schistocyte counting 2012: 
1. Schistocytes should be evaluated on peripheral blood smears using an optical 
microscope at medium magnification and estimated as a percentage after 
counting at least 1000 red blood cells. 
2. A schistocyte count should be requested and carried out when a diagnosis of 
thrombotic microangiopathies caused by red cell mechanical damage is 
suspected, usually in patients with thrombocytopenia. 
3. Schistocytes should be identified by specific positive morphological criteria. 
Schistocytes are always smaller than intact red cells and can have the shape 
of fragments with sharp angles and straight borders, small crescents, helmet 
cells, keratocytes, or microspherocytes*. 
4. A schistocyte count should be considered clinically meaningful if schistocytes 
represent the main morphological red blood cells abnormality in the smear 
(other than signs of erythropoietic regeneration). 
5. A robust morphological indication for the diagnosis of thrombotic 
microangiopathic anemia in adults should be recognized when the percentage 
of schistocytes is above 1%. 
6. Fragmented red cell enumeration by automated blood cell counters should be 
considered a useful complement to microscopic evaluation, as it provides 
rapid results with a high predictive value of negative samples. A microscope 
check is needed for positive and macrocytic samples†. 
*Microspherocytes only in the presence of other mentioned RBC shapes. 

Association between the Quantitative Assessment of Schistocytes in Peripheral Blood Smear and Prognosis of Patient Initially Diagnosed as 
HELLP Syndrome (protocol) 
 
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†Macrocytic samples are at risk of underestimation or absence of flag (‘false 
negative’ test) (International Council for Standardization in Hematology 
2012). 
 
 Schistocytes counting: Schistocytes will be identified and counted on the 
peripheral blood smear using optical microscopy. The results of microscopic 
examination then will be expressed as a percentage, after counting at least 1000 
RBCs in optimal areas of the film. Interpretation of the examination results had 
been done following the (International Council for Standardization in 
Hematology, 2012) recommendations for identification, diagnostic value, and 
quantitation of schistocytes.