Re: OB: Fun with preeclampsia--very long!

From: Robert Woolley (wooll005@tc.umn.edu)
Sun Jul 29 21:41:22 2001

>
> Actually, Garry has already posted that her diastolics were "in the 90's"
> subsequent to the office readings. So, if she's 91 diastolic, she's
> hypertensive, but if she's 90 she's not? Spare me.

I see. So 89 is good enough to be preeclampsia, too, right? And 88? And 87? And 86? By your logic, you can't draw a line *anywhere*, which means that every patient has hypertension, right?

Nobody's ears are good > enough to make the distinction (and dynamaps are not always reliable, either).
> I think, however, we've already established that women can have HELLP syndrome
> w/ minimally elevated BP's, in any case. This woman had a 20 mmHg rise in BP,
> which, although the experts say that it doesn't matter, usually raises a bit
> of
> a red flag for those of us who provide care to pregnant women.

Sure. Red flag it plenty. But that doesn't mean diagnose and treat, which is what you're endorsing.

>
>>> Additionally, with respect to your comment that nothing should have been
>>> done until another platelet count was done.
>>
>> I did not say that.
>
> Sorry, then, I misinterpreted. What you said was:
>
> "OK, so again it sounds like you *are* saying that 90K platelets means you
> should at least intervene as if the patient has preeclampsia, even if you
> don't
> actually diagnose it. Is that correct? I see no other conclusion, since you
> way one shouldn't wait to see what the next plt count it."
>
> I read that as meaning you *would* wait until the next platelet count before
> intervening.

No, that's what somebody else was saying. I don't think the next platelet count necessarily will either confirm or rule out preeclampsia. I'm just saying that you don't treat for preeclampsia until you have established the diagnosis, whenever that is. It might be an hour later at the next bp check, might be with the next plt count, might be with the next UA.

>>
>> Right. Of course, that's also true for somebody who goes into labor with
>> platelets of 200K. So, following your logic, we should assume that every
>> patient is about to drop her platelets, so we have to intervene now.
>
> Excuse me? This woman already *has* a thrombocytopenia, albeit not yet
> severe.

I don't dispute that. But as I've said many times, thrombocytopenia does not equal preeclampsia, although that equation seems popular here.

>> Sections
>>> on a woman w/ severe thrombocytopenia are *not* a pretty sight, as I'm
>>> sure many would agree.
>>
>> Right. So again, we'd better just do sections on every patient, since any of
>> them might suddenly become thrombocytopenic.
>
> I guess I should ask what your definition of thrombocytopenia is, too, Bob. I
> was always under the impression (as are our anaethesia people) that 95 K *was*
> thrombocytopenia.

To be more accurate, just add the word "severe" before my "thrombocytopenic."

>>
>> Right. So why are you supporting intervention for preeclampsia when it is
>> "unclear" whether she had it? Would you recommend mastectomy and
>> chemotherapy for a patient if you were "unclear" whether she had breast
>> cancer?
>
> Bob, because, unlike w/ breast cancer, you actually usually have some time to
> deal with making a diagnosis before the woman does something bad, like seize,
> abrupt or just plain die. Pre-eclampsia and its sequelae are, in a developed
> nation like Canada, still the 4th leading cause of maternal death in Ontario.
> People are understandable extremely respectful of the damage it can do.

It seems that you're saying that the slightest hint of preeclampsia warrants a full-court press to deliver, no matter what it takes, and whether or not the patient worsens clinically. Correct?

>
> I suppose you won't believe me about another woman I looked after who had
> pressures of 130/80 (from baseline 110/60 early preg) in labour, and 90K
> platelets. LFT's were fine. Had a PIH style labour -- blew the kid out. The
> next day, postpartum, her pressures went to 170/110. But, really, there
> wasn't
> a thing wrong with her, eh?

I wouldn't say that. But I wouldn't have diagnosed her with preeclampsia at the point you're describing. Besides, if she were in rapid labor, no other intervention would have been required.

> I feel like I'm pissing in the wind here, anyway, but the point to me is that
> those of us who actually *do* provide care to pregnant and labouring women
> have
> all had scary experiences w/ women who have presented like the woman Garry
> had...even me, and I'm supposed to be looking after low-risk women.

How many times are you willing to induce/section women for *suspicion* of preeclampsia for every one that does, in fact, have it? 10? 100? 1000? I trust you're not claiming 100% specificity if you act on platelets of 90K and dbp of 90. What do you think the positive predictive value of that combination to be?



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