Re: Cigdem Arkuran's Reference
From: Efrain Ramirez (eramirez@icepr.com)
Tue Jul 31 21:00:19 2001
Luis - thanks for your comments -
Having said it all - explaining everything - in the end it was a
judgement call - with sound clinical acumen and in good faith - with
good outcome - and IMHO - neither lucky nor irrelevant.
At Tue, 31 Jul 2001, Luis Sanchez-Ramos, MD wrote:
>
>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
--
"Life is neither the notes nor the silence between the notes, but the music that
arises out of sound and silence felt as a living whole. Stop choosing...between
chaos and order, and live at the boundary between them, where rest and action
move together..." David Whyte
