Re: OB: Fun with preeclampsia--very long!
From: Steve & Eryl Raymond (eryl@intekom.co.za)
Sat Jul 28 08:28:48 2001
Just to add something to explain my perspective which seems to have given the
impression that I don't think this patient had PIH/gestational hypertension/HELLP.
This is not the case, as I agree with Kathi, that there is a strong suspicion and it
needs "sniffing". All I'm saying is that a little more time and investigation might
have been sensible.
At present in our ICU we have a 16 year old primipara on a ventilator whose platelets
have fallen steadily from ~200 to yesterday's level of 21. She delivered by C/S after
a short attempt at induction ten days ago, an IUD due to eclampsia. She had pulmonary
oedema on admission and was ventilated from the start, Her BP is under control, her
urine output has been normal after initially low, her urea is steady. She does have a
chest infection which seems to have resulted from a too early attempt to extubate
before the pulmonary oedema was fully resolved, and it may be that the sepsis, is at
least in part, responsible for her thrombocytopenia. But the point I am making is that
the presence of eclampsia in this case is not the whole story in respect of the low
platelets which ought to have been low at first and rising, not falling consistently.
I am wondering if she took some sort of herbal medication which has proved
haematotoxic?
stray
John Robertson MD wrote:
> Kathi brings a very good point to the discussion, and a strong reason
> why I am not on the side of Bob and Steve. I too have seen atypical
> presentations of Pre eclampsia/PIH/HELLP. Part of the reason why I
> think we have so many names for it is that it has so many variations in
> the presentation. The point that Kathi mentions is (part a) how quickly
> it can change and (part b) that they can be sick (and even get sicker)
> for a good time after they have delivered. If the platelets are
> dropping as you deliver, they will not necessarily recover immediately
> after you deliver, and you can be in worse trouble a day or two later.
> John.
>
> At Fri, 27 Jul 2001, Kathi Wilson wrote:
> snip
> >
> >The sickest client with HELLP that I, personally, have been involved with was a
> >woman who presented at 37 weeks w/ "heartburn" that persisted throughout the day
> >despite using remedies. She resisted being assessed at the hospital because she
> >thought we were overreacting. Her BP was 130/90 on assessment, a mild but not
> >significant elevation for her. No proteinuria.
> >
> >Interestingly, the consultant on call (a newbie, actually) only ordered a CBC
> >(which I bet she *never* does again), which demonstrated a *very* mild
> >thrombocytopenia of 121 K. She wanted to send the woman home. My midwife partner
> >stood her ground and said "uh, uh, she's not going home until we do some liver
> >functions". Ta, da. Mildly elevated AST and ALT.
> >
> >Over the next ten hours, her platelets went from 121 to 40, her LFT's soared, and
> >her BP really didn't go up any more than it had been at presentation. Unlike the
> >usual PIH presentation, she didn't respond to induction at all, and was sectioned
> >before she got any sicker. She was transfused w/ 9 units of platelets (4
> >initially, and then another five, and they continued to drop after transfusion).
> >(I shudder to think what would have happened if she'd been sent home....) She
> >ended up w/ all the "letters" in HELLP. Hgb postpartum fell to about 70, bili
> >quite elevated. Got quite a bit sicker pp before she started to get well.
> >
> >This is a disease w/ many end organ manifestations. Proteinuria is only one of
> >them, and may not ever appear. I have a *very* healthy respect for anything that
> >even faintly sniffs funny w/ PIH, and epigastric pain in pregnant women makes me
> >twitch something awful.
> >
> >BTW, w/ a severe pre-eclamptic, our guys put in a foley *and* start oxytocin
> >simultaneously. This was the first time I had not seen it work.
> >
> >--
> >Kathi Wilson, RM
> >Ilderton, Ontario, Canada
> >mailto:wilsonk@gtn.on.ca
> >**********************
> >Thames Valley Midwives
> >**********************
> >346 Platts Lane,
> >London, Ontario, Canada
> >
> >http://tvm.on.ca
> >mailto:info@tvm.on.ca
> >
>
> --
> J.G.M.Robertson MD, 109-9181 Main St. Chilliwack, B.C. V2P 4M9
> (604) 793-9988 e-mail john.robertson@obgyn.net
> Who is wise and understanding among you? Let him show it by his good life,
> by deeds done in the humility that comes from wisdom. James 3 vs 13, NIV
--
Dr.S.H. Raymond
Head of Department of O & G
Empangeni Hospital
South Africa 3880
Phone: (+27) 35-7721111
Fax: (+27) 35-7922596
