Corticosteroids for improving patient relevant outcomes in HELLP syndrome: a systematic review and meta-analysis

Objectives We conducted an update of systematic review to assess the effects of corticosteroids vs placebo or no treatment for improving patient relevant outcomes in hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome. Design A systematic review and meta-analysis of randomized controlled trials. Data sources CENTRAL, MEDLINE/PubMed, Web of Science, and Scopus from the date of inception of the databases to September 20, 2023. The reference lists of included studies and other systematic reviews were thoroughly searched. Eligibility criteria We included randomized controlled trials that enrolled women with HELLP syndrome, whether antepartum or postpartum, to receive any corticosteroid versus placebo or no treatment. No restrictions on language or date of publication were made. Data extraction and synthesis We used a dual independent approach for screening titles and abstracts, full text screening, data extraction and risk of bias assessment. Pairwise meta-analyses were conducted, where two or more studies met methodological criteria for inclusion. The Grading of Recommendations, Assessment, Development and Evaluation approach was used to assess certainty for the pre-specified important outcomes. Results Fifteen trials (821 women) compared corticosteroids with placebo or no treatment. The effect of corticosteroids is uncertain for the primary outcome i.e., maternal death (risk ratio 0.77, 95% confidence interval 0.25 to 2.38, very low certainty evidence). The effect of corticosteroids is also uncertain for other important outcomes including pulmonary edema, dialysis, liver morbidity (hematoma, rupture, and failure), or perinatal death because of very low certainty evidence. Low certainty evidence suggests that corticosteroids have little or no effect on the need for platelet transfusion (risk ratio 0.9821; 95% confidence interval 0.6031 to 1.5994) and may result in a slight reduction in acute renal failure (risk ratio 0.6658; 95% confidence interval 0.3965 to 1.1179) Conclusion In women with HELLP syndrome, the effect of corticosteroids vs placebo or no treatment is uncertain for patient relevant outcomes including maternal death, maternal morbidity, and perinatal death. Article summary Strengths and limitations of this study We used robust systematic review and meta-analysis methods. We synthesized results on patient relevant outcomes that are critical for decision making. The available evidence was associated with limitations related to the small sample size of included trials, different timing to initiate corticosteroids administration, and reporting bias. Outcomes assessed using the Grading of Recommendations, Assessment, Development and Evaluation framework were judged to have very low certainty of evidence due to extremely serious imprecision.