Even though the initial pregnancy was termed Ã¢â‚¬Å“mild preeclampsiaÃ¢â‚¬Â and occurred near term, the rise in blood pressure was accompanied by decreases in platelet number and increments in liver enzymes. Thus, it was really not so Ã¢â‚¬Å“mildÃ¢â‚¬Â, and the current pregnancy should be considered at risk (re: previous preeclampsia has 25% risk of recurrence) and should optimally have been managed by a maternal fetal medicine subspecialist or an obstetrician, rather than a midwife.
In such high risk pregnancies we advocate baseline blood studies (called by some the preeclampsia panel) that includes in addition to the initial hemogram and platelet count, albumin, certain liver enzymes, as well as serum creatinine and uric acid level. Some would collect a timed urine collection (at least 12 and usually 24h for protein and creatinine). In addition many would start fetal heart electronic monitoring at 32 wks gestation.
In this particular case, and even though the blood pressure is not frankly hypertensive nor has qualitative proteinuria been detected fetal monitoring should be started and the Ã¢â‚¬Å“preeclampsia panelÃ¢â‚¬Â repeated to see if there have been changes (even if levels are still Ã¢â‚¬Å“normal)
To recapitulate: This pregnancy was best treated as high risk from the beginning and especially now when systolic levels have reached 130 mm Hg with an occasional 80 mm Hg diastolic. Such Ã¢â‚¬Å“high risk" pregnancies in my opinion are best monitored by maternal medicine subspecialist who have seen the many faces of preeclampsia). Also a timed urine collection for protein or a protein/creatinine level on a single voided specimen should be obtained as the single dipstick determination often misses (Ã¢â‚¬Å“false negativesÃ¢â‚¬Â) the proteinuria her caregivers seem to be awaiting before becoming more aggressive.
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