A 27-year-old G2P1 at 29 weeks’ gestation who is being followed for Rh isoimmunization presents for her OB visit. The fundal height is noted to be 33 cm. An ultrasound reveals fetal ascites and a pericardial effusion.
Which of the following can be another finding in fetal hydrops?
Characteristics of fetal hydrops include abnormal fluid in two or more sites such as the thorax, abdomen, and skin. Fetal hydrops occurs as a result of excessive and prolonged hemolysis which causes anemia. This stimulates erythroid hyperplasia of the bone marrow and extramedullary hematopoiesis in the liver and spleen. The placenta is also markedly erythematous, enlarged, and boggy. Hydrothorax may be so severe that it may restrict lung development and cause pulmonary compromise after delivery. Ascites, hepatomegaly, and splenomegaly may lead to severe dystocia. Hydropic changes are easily seen on fetal ultrasound.
A 39-year-old G2P1001 at 39 weeks’ gestational age is sent to labor and delivery from her obstetrician’s office because of a blood pressure reading of 150/100 mm Hg obtained during a routine OB visit. Her baseline blood pressures during the pregnancy were 100 to 120/60 mm Hg to 70 mm Hg. On arrival to labor and delivery, the patient reports no headache, visual changes, nausea, vomiting, or abdominal pain. The heart rate strip is reactive and the tocodynamometer shows irregular uterine contractions. The patient’s cervix is 3 cm dilated. Her repeat blood pressure is 160/90 mm Hg. Hematocrit is 34.0%, platelets are 90,000 mL, SGOT is 22 units per liter, SGPT is 15 units per liter, and urinalysis is negative for protein.
Which of the following is the most correct diagnosis?
In 2013, and the ACOG task force published new evidence based recommendations about hypertension in pregnancy. They recognize four categories of hypertension in pregnancy. These are as follows: (i) preeclampsia-eclampsia, (ii) chronic hypertension, (iii) chronic hypertension with superimposed preeclampsia, and (iv) gestational hypertension. Preeclampsia is defined as blood pressure of 140/90 mm Hg or greater on at least two separate occasions that are 6 hours or more apart after 20 weeks’ gestation, in conjunction with proteinuria greater than 300 mg per 24-hour urine collection (or a dipstick reading of +1 if other quantitative methods are not available). In recognition of the syndromic nature of preeclampsia, the task force removed the dependence of the diagnosis on the presence of proteinuria. In the absence of proteinuria, preeclampsia is diagnosed as hypertension in association with thrombocytopenia, impaired liver function, new renal insufficiency, pulmonary edema, or new-onset cerebral or visual disturbances. Gestational hypertension is blood pressure elevation after 20 weeks’ gestation without proteinuria or the aforementioned systemic findings. Chronic hypertension is hypertension that predates pregnancy. Superimposed preeclampsia is chronic hypertension in association with preeclampsia. Eclampsia is present when women with preeclampsia develop seizures.
While being evaluated in triage, she is noted to have tonic-clonic seizure.
Which of the following is the next step in the management of this patient?
Women who have suffered an eclamptic seizure need to be immediately started on magnesium sulfate as a loading dose and then as a continuous infusion to prevent further seizures. This is the most appropriate next step. These women also need to have their blood pressure controlled with antihypertensive medications if the diastolic is increased above 105 mm Hg to 110 mm Hg. The purpose of antihypertensive therapy is to avoid a maternal stroke. Hydralazine, nifedipine, and labetalol are commonly used in acute hypertensive crises. Phenytoin is not indicated for seizure prophylaxis, as magnesium sulfate has been shown to be safer and more effective for prevention of recurrent seizures. Low dose aspirin does not have a role. Eclampsia in a term patient is typically managed with prompt delivery, but does not necessarily require cesarean.
The decision is made to deliver the patient promptly.
Which factors will help you determine the best mode of delivery?
The treatment for eclampsia in most situations is prompt delivery; however, this does not preclude a trial of labor. The maternal and fetal status must be considered when determining route of delivery. After the patient is stabilized after her seizure, factors to consider include gestational age, parity, cervical examination, prior delivery history, fetal position, fetal status, and maternal status. Maternal age and a platelet status of 90,000 do not typically contribute to this decision.
The patient is successfully inducted and undergoes vaginal delivery. Postpartum, she is on magnesium sulfate for seizure prophylaxis. Her vital signs are—blood pressure 154/98 mm Hg, pulse 93 beats per minute, respiratory rate 24 breaths per minute, and temperature 37.3°C. She has adequate urine output at greater than 40 cc/h. On examination, she is oriented to time and place, but she is somnolent and her speech is slurred. She has good movement and strength of her extremities, but her deep tendon reflexes are absent.
Which of the following is the most likely cause of her symptoms?
Magnesium therapy is typically continued for 24 hours postpartum in order to decrease the risk of seizures. This patient is showing signs of magnesium toxicity. The therapeutic range of serum magnesium to prevent seizures is 4 to 7 mg/dL. At levels between 8 mg/dL and 12 mg/dL, patellar reflexes are lost. At 10 mg/dL to 12 mg/dL, somnolence and slurred speech commonly occur. Muscle paralysis and respiratory difficulty occur at 15 mg/dL to 17 mg/dL, and cardiac arrest occurs at levels greater than 30 mg/dL.
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