A 25 year old nulliparous woman at 35 weeks’ gestation comes to the labor and delivery ward complaining of contractions, a headache, and flashes of light in front of her eyes. Her pregnancy has been uncomplicated except for an episode of first trimester bleeding that completely resolved. She has no medical problems. Her temperature is 37 C (98.6 F), blood pressure is 160/110 mm Hg, pulse is 88/minute, and respirations are 12/minute. Examination shows that her cervix is 2 centimeters dilated and 75% effaced, and that she is contracting every 2 minutes. The fetal hea tracing is in the 140s and reactive. Urinalysis shows 3+ proteinuria. Laboratory values are as follows: leukocytes 9,400/mm3, hematocrit 35%, platelets 101,000/mm3. Aspaate aminotransferase (AST) is 200 U/L, and ALT 300 U/L. Which of the following is the most appropriate next step in management?
Correct Answer: Sta magnesium sulfate
Description: This patient has severe preeclampsia. Preeclampsia is diagnosed on the basis of hypeension, edema, and proteinuria. Severe preeclampsia may be diagnosed when the patient has one of the following: a headache that does not respond to analgesics, visual changes, seizure, very elevated blood pressures, pulmonary edema, elevated liver function tests, severe proteinuria, oliguria, an elevated creatinine, thrombocytopenia, hemolysis, intrauterine growth restriction, or oligohydramnios. The management of severe preeclampsia after 32 weeks is with delivery. Prior to 32 weeks, consideration may be given to expectant management of the patient depending on the clinical circumstances. This patient is at 35 weeks' with headache, visual changes, elevated blood pressures, thrombocytopenia, and elevated liver function tests. She, therefore, needs to be delivered. She appears to already be in labor as she is contracting every two minutes and her cervix is dilated and effaced. At this point, magnesium sulfate should be staed. Magnesium sulfate has consistently been demonstrated to be the most effective medication for seizure prophylaxis in women with preeclampsia. To administer oxytocin would not be necessary for this patient. She appears to already be in labor with contractions every two minutes. To discharge the patient would absolutely be incorrect. Severe preeclampsia need to be delivered or, at the very least, admitted to the hospital. There is no role for discharging a patient home in the management of severe preeclampsia. To encourage ambulation would also be incorrect. Severe preeclampsia should be kept on bed rest. Ref: Cunningham F.G., Leveno K.J., Bloom S.L., Hauth J.C., Rouse D.J., Spong C.Y. (2010). Chapter 34. Pregnancy Hypeension. In F.G. Cunningham, K.J. Leveno, S.L. Bloom, J.C. Hauth, D.J. Rouse, C.Y. Spong (Eds), Williams Obstetrics, 23e.
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Gynaecology & Obstetrics
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