American Journal of Obstetrics and Gynecology (2006) 195, e10

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Dexamethasone treatment and HELLP syndrome

To the Editors: We read with great interest the article by Fonseca et al.1 This report of 132 patients diagnosed with HELLP syndrome who were randomly assigned to dexamethasone or placebo to determine the efcacy of corticosteroids for treatment of HELLP syndrome is of great clinical importance. Nevertheless, we would like to emphasize a few points to the discussion raised by Fonseca et al.1 First, I was surprised to note that an unexpected high percentage of eclampsia (13.6%) after receiving 1 to 1.5 g/h of magnesium sulphate intravenously. On rst impulse this should cause surprise, because results from large reported clinical trial as The Magpie Trial2 demonstrate clearly that magnesium sulphate is effective in considerably reducing the risk of eclampsia for women with severe preeclampsia, and second, the incidence of eclampsia after diagnosis of HELLP syndrome treated with magnesium sulphate is not very high.3 In our opinion, the high incidence of eclampsia after starting a recognized protocol (magnesium sulphate) should be discuss and this matter should be considered for explain the results of other protocol (dexamethasone). Contrary and interestingly the study by Fonseca et al1 evidence the not effectiveness of magnesium sulphate and dexamethasone in women with HELLP syndrome. Second, all patients received G4500 mL of normal saline solution every 24 hours. These large volume expansions are not recommended in women with HELLP syndrome3 and were not used in the randomized clinical trials that have been published to evaluate the effect of dexametasone therapy in women with HELLP syndrome.4 Volume expansion during pregnancy may cause an increased volume of distribution and subsequently a decrease in the peak serum concentrations of many drugs. Severe preeclampsia with or without HELLP syndrome is characterized by vasoconstriction caused by endothelial cell damage, resulting in increased cardiac afterload, decreased cardiac output, and hypovolemia. It is probably that the hypovolemia is proportional to the severity of preeclampsia, thus greater than 4000 mL per 24 hours is only necessary in women with HELLP 1. This association could explain the results by Fonseca et al.1 Third, criteria for discharge included a platelets count greater than 100,000/mm3. The platelet count at baseline was G60 000/mm3. The mean duration of hospitalization was (1.7 days) shorter among patients who received dexamethasone therapy, if we found this difference with 40,000 platelets/mm3; it is interesting to observe the results when the criteria for discharge included a platelet count greater than 150,000/mm3 (the normal platelet count in human). Paulino Vigil-De Gracia, MD, MSPOG, FACOG* *Obstetric Intensive Unit Department of Gynecology and Obstetrics Complejo Hospitalario Arnulfo Arias Madrid Caja de Seguro Social, Panama, Panama E-mail: pvigil-d@cwp.net.pa

References
1. Fonseca JE, Mendez F, Catano C, Arias F. Dexamethasone treat ment does not improve the outcome of women with HELLP syndrome: a double-blind, placebo-controlled, randomized clinical trial. Am J Obstet Gynecol 2005;193:1591-8. 2. The Magpie Trial Collaborative Group. Do women with preeclmpsia, and their babies, benet from magnesium sulphate? The Magpie Trial: a randomized placebo-controlled trial. Lancet 2002; 359:1877-90. 3. Sibai B. Diagnosis, controversies, and management of the syndrome of hemolysis, elevated liver enzymes, and low platelets count. Obstet Gynecol 2004;103:981-91. 4. Matchaba P, Moodley J. Corticosteroids for HELLP syndrome in pregnancy. Cochrane Database Syst Rev 2004;1:CD002076.

0002-9378/$ - see front matter 2006 Mosby, Inc. All rights reserved. doi:10.1016/j.ajog.2006.02.038