In a 34-year-old primigravida at 35 weeks gestation, which one of the following supports a diagnosis of mild preeclampsia rather than severe preeclampsia?
Correct Answer A:
The criteria for severe preeclampsia specify a blood pressure of 160/110 mm Hg or above on two occasions, 6 hours apart. Other criteria include proteinuria above 5 g/24 hr, thrombocytopenia with a platelet count < 100 x 109/L, liver enzyme abnormalities, epigastric or right upper quadrant pain, alteration of mental status.
A 25-year-old female at 30 weeks gestation has a blood pressure of 140/90 mm Hg (baseline 135/85 mm Hg) and urine positive for 1+ protein.
This patient should be evaluated with a:
Correct Answer B:
This patient may have preeclampsia. The current diagnostic criteria require a blood pressure ≥140/90 on repeated measurements and proteinuria > 300 mg/24 hr, which usually corresponds to a urine protein of 1+ or greater on a urine dipstick test. A 24-hour urine collection is the preferred means of making the diagnosis, along with serial blood pressure measurements. Previous guidelines include edema in the diagnostic criteria, and the elevated blood pressure criteria could be met with an elevation of 30 mm Hg systolic or 15 mm Hg diastolic above the baseline prepregnancy blood pressure. Elevated serum uric acid is commonly seen in preeclampsia but lacks sensitivity and specificity in making this diagnosis. Calcium levels and magnesium levels are not diagnostic. Once the diagnosis of preeclampsia is made there are several laboratory tests that are recommended weekly: hemoglobin, hematocrit, platelets, serum creatinine, serum transaminases, serum lactic dehydrogenase, serum albumin, coagulation profiles, and peripheral blood smears. In addition, repeat 24-hour urine collections are advised, since rising 24-hour urine protein levels are worrisome. Urine protein excretion > 5000 mg/24 hr is by itself diagnostic of severe preeclampsia.
A 20-year-old female is seen for follow-up 6 weeks after delivery. Her pregnancy was complicated by preeclampsia. Her examination is unremarkable.
This patient will be at increased risk for which one of the following in midlife?
Correct Answer E: Preeclampsia affects as many as 5% of first pregnancies and is manifested as hypertension, proteinuria, edema, and rapid weight gain after 20 weeks gestation. Very young mothers and those over age 35 have a higher risk. Patients who have had preeclampsia have a fourfold increased risk of hypertension and a twofold increased risk of ischemic heart disease, stroke, and venous thromboembolism. There does not appear to be an association between preeclampsia and cancer, breast cancer in particular.
A 23-year-old gravida 1 para 0 at 36 weeks gestation presents to the office complaining of ankle swelling and occasional headache for the past 2 days. She denies any abdominal pain or visual disturbances. On examination you note a fundal height of 35 cm, a fetal heart rate of 140 beats/min, 2+ lower extremity edema, and a blood pressure of 144/92 mm Hg. A urine dipstick shows 1+ proteinuria.
Which one of the following is the most appropriate next step in the management of this patient?
This patient most likely has preeclampsia, which is defined as an elevated blood pressure and proteinuria after 20 weeks gestation. The patient needs further evaluation, including a 24-hour urine for quantitative measurement of protein, blood pressure monitoring, and laboratory evaluation that includes hemoglobin, hematocrit, a platelet count, and serum levels of transaminase, creatinine, albumin, LDH, and uric acid. A peripheral smear and coagulation profiles also may be obtained. Antepartum fetal testing, such as a nonstress test to assess fetal well-being, would also be appropriate. Ultrasonography should be done to assess for fetal intrauterine growth restriction, but only after an initial laboratory and fetal evaluation.
Delivery is the definitive treatment for preeclampsia. The timing of delivery is determined by the gestational age of the fetus and the severity of preeclampsia in the mother. Vaginal delivery is preferred over cesarean delivery, if possible, in patients with preeclampsia. It is not necessary to start this patient on antihypertensive therapy at this point. An obstetric consultation should be considered for patients with preeclampsia.
Your patient is in the second stage of labor, and you determine that the fetus is in face presentation, mentum anterior.
Progress has been rapid and fetal heart tones are normal. You would now:
Correct Answer C: Most infants with face presentation, mentum anterior, can be delivered vaginally, either spontaneously or with low forceps. Cesarean section is indicated for fetal distress and failure to progress. Midforceps delivery is not indicated. If fetal electrodes are attached, the chin is the preferred location.
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