Donna Lorne

Donna is a 34 year-old woman who is being followed by you in the prenatal clinic. She is 33 weeks gestation with her second pregnancy. The first ended with a healthy term infant born by normal vaginal delivery.

During her routine visit, she mentions she has a bit of a headache that has been present for one week. You assess her blood pressure, which is 158/96 (and is similar when you repeat it). She has never had high blood pressure before.

You dip her urine, which is 2+ for protein.

You are concerned about Donna and symptoms and findings.

Ask Donna about symptoms of organ damage:

• neurological: headache, visual disturbances, tremulousness, decreased level of consciousness
• liver: RUQ or epigastric pain, nausea and vomiting
• cardiovascular: chest pain, shortness of breath, distended jugular veins
• renal: decreased urine output
• blood: bleeding, petechiae

It would be appropriate to have Donna attend the hospital for further assessment. Evaluate the following (abnormal findings in brackets)

• hemoglobin (decreased)
• WBC and differential (increased)
• platelets (decreased)
• INR, PTT, fibrinogen, LDH (increased)
• creatinine, urine protein (increased)
• liver enzymes (increased)
• uric acid (increased)

A non-stress test or biophysical profile would be appropriate to monitor fetal well-being.

Monitor symptoms and urine output.

Obstetric referral, and transport as necessary, should be carried out.

As her fetus is <34 weeks gestational age, corticosteroids should be given to increase lung maturity. Delivery is normally induced after fetal lung maturity is facilitated by the corticosteroids.

Her blood pressure should be acutely treated, using labetalol or nifedipine as first line, or hydralazine as second line. However, avoid decreasing the blood pressure too sharply.

Fluids should be gently given to avoid pulmonary edema.

Seizure prophylaxis should be given in the form of IV magnesium sulfate, if symptoms are worsening or if there is evidence of organ dysfunction in the labwork. Monitor closely for magnesium toxicity.

Magnesium toxicity can cause:

• weakness, paralysis (decreased/absent reflexes)
• decreased respirations
• cardiac toxicity
• decreased level of consciousness

Treatment is with calcium gluconate IV.

Donna is admitted to hospital and treated with labetalol and corticosteroids. Two days later her headache remains, as does her proteinuria, but her blood pressure is improved at 128/84 and her bloodwork is normal.

She is induced and she gives birth to a healthy girl, with no complications for mother or baby.

She has a few questions for you.

Approximately 25% of seizures occur after labour; seizure prophylaxis should be given for 24 hours, and blood pressure, urine output, and blood indicators of end-organ dysfunction should be monitored.

Patients should be advised to report any symptoms suggestive of organ damage (as above, eg headache, vision disturbance, tremulousness, abdominal pain, petechiae).

Prevention of coagulopathy with prophylaxis (medications, stockings, increased activity) should be considered if the mother has been bed-bound for a number of days, is obese, or has had a Caesarean section. Use caution with medications if platelets are decreased, ie in HELLP syndrome.

Blood pressure control may be necessary prior to, and following, discharge.

Low-risk women should be given calcium supplementation.

High-risk women (which of course would describe Donna) should be treated with calcium and aspirin.

It also appears to be helpful to avoid weight gain between pregnancies, and to rest during the third trimester.