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Cigdem Arkuran's ReferenceFrom: Luis Sanchez-Ramos, MD (luis.sanchez@jax.ufl.edu)Tue Jul 31 10:27:14 2001
As promised, I reviewed the paper cited by Dr. Arkuran (Rath et al J Perinat Med 2000;28:249-260). The author, Werner Rath, dedicated this *Review* article to Professor Erich Saling (scalp pH sampling)on the occasion of his 75th birthday! Indeed, on the 2nd page of the review, Dr. Rath states that "up to 20% of HELLP syndrome patients present no hypertension" and that "15% of the pregnant women show neither hypertension nor significant proteinuria". To support these statements, he gives us two references:(1) Reubinoff & Schencker Int J Gynecol Obstet 1991;36:95-102 and Sibai et al Am J Obstet Gynecol 1986;155:501-509. Reubinoff's review article makes the same statement (almost word for word) on page 96 "it should be emphasized that 15% of HELLP syndrome patients present with neither hypertension nor significant proteinuria". He cites the same Sibai article as Rath did to support his statement. Sibai et al reviewed the medical records of 112 patients with HELLP syndrome during an 8-year period. The article states that *on admission to the hospital* 14/112 (14.5%)had *diastolic* blood pressures of <90mmHg (range 74 to 88 mmHg). Of course the first thing that strikes our eyes is the incorrect percentage: it should be 12.5% instead of 14.5%. Secondly, it states that the *diastolic* blood pressure was <90 mmHg. No mention is made of the systolic (remember that hypertension is defined as systolic > 140 OR diastolic > 90 mmHg). Thirdly, the blood pressure results cited were *at the time of admission to the hospital*. No mention is made of subsequent blood pressure readings. Undoubtedly, a small group of patients with apparent HELLP syndrome will initially have blood pressure readings that are "unimpressive". However, sooner or later (more likely the former) the blood pressure will rise above the threshold levels designated as being consistent with hypertension. Perhaps I should modify my initial statement and state that before a patient is considered cured from the HELLP syndrome, she will be noted to have hypertension. This I state because HELLP syndrome is basically severe preeclampsia and you can't have a hypertensive disorder of pregnancy without hypertension. With regard to the absence of proteinuria, I have no argument. As I stated previously, even in eclampsia 7-10% have no proteinuria. However, we must remember that the great majority of these patients had proteinuria assessed by simple dipstick methods. 24-hour urine collections were not performed. There are a couple of publications which indicate that when compared to a 24-hour urine collection, the assessment of proteinuria by disptick is far less reliable. LSanchez-Ramos
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