Ethnic, geographical, altitude considerations and maternal mortality on HELLP syndrome in Ecuador: a population-based cohort study.

Abstract Objectives : We evaluated the incidence of elevated liver enzymes and low platelets (HELLP) syndrome, risk factors and maternal mortality in Ecuador. Design : A retrospective population-based cohort study Setting : Ecuador from 2015-2017. Population : All deliveries in hospital from 2015-2017 in Ecuador. Data from Ecuadorian National Institute of Statistics and Census (INEC) and the Ecuadorian Ministry of Health. Methods : HELLP syndrome cases were identified by ICD-10 code in all hospitalized individuals. Logistic regression analysis was used to study the relationship between HELLP syndrome and the variable of interest. Geospatial statistical analysis by cantons was done to identify statistical significant spatial clusters. Main outcome measures : HELLP syndrome incidence and maternal mortality. Results : The incidence of HELLP syndrome is 0.76 (0.69-0.84)/ 1000 deliveries. Afro-Ecuadorian communities shown a higher risk OR=2.18 (1.03-4.63) compared to Native Ecuadorian communities. Middle and high altitude have a significant risk factor OR=2.79 (2.19-3.55) and OR=3.61 (2.58-5.03). Older maternal age was also identified as risk factors. Women living more than 20km from the obstetric unit have an OR=2.55 (2.05-3.18). Moreover, we found that cantons with higher crude HELLP syndrome incidence also have lower number of physicians (R=0.503, p-value <0.001). The mortality incidence of women with HELLP syndrome is 21.22 (12.05-20.59)/1000 deliveries with HELLP syndrome diagnoses. Conclusions : High altitude, advanced maternal age as well as geographical distance between residence and attention units are risk factors for HELLP syndrome. Maternal mortality in women with HELLP syndrome is higher than preeclampsia and eclampsia but comparable with previous reports in other countries. Funding : The study was funded by Universidad de Las Américas, Quito. Ecuador. Fund reference: VET.MCA.21.01.