HOMEPAGE Resources for SBM

1999 Spring Year2 Case2 - Toxemia of Pregnancy

Case History
Learning Objectives
Web References
Literature References


January 28, 1999
The patient is a 22 year old white female. She lives with her husband and their 11- month-old son. She is a pre med. student. She feels good today.

Her history goes back to July of 1997 when she started to develop intermittent severe headaches as well as some nausea. At the time, her father had been diagnosed with lung cancer and she was worried that she might have brain cancer. She went to the hospital and had a CT scan of her head done which was negative. However they also did a urine test which showed that she was pregnant. They told her that the headaches and nausea was probably related to her pregnancy. Following this she went to an obstetrician for evaluation. A sonogram was done and showed that she was 7 weeks pregnant.

The patient has a history of kidney disease dating back to age 11. At that time when she had a respiratory infection she noticed some blood in her urine. For many years she was evaluated for the possibility of bladder infection and it was not until the age of 16 that a diagnosis was made. Her urine showed a slight increase in the level of protein and a kidney biopsy established a diagnosis of IgA nephropathy. Her kidney function was normal when the diagnosis was made and remains normal. When she gets colds or infections she sometimes will have an increase in the amount of blood in the urine (usually microscopic) and protein level. At baseline, her protein in her urine is slightly increased above normal but her kidney function is normal. Her obstetrician had some concern that her kidney function might worsen during pregnancy. In fact, it improved. Her protein levels in her urine decreased to a normal range and her kidney function responded normally to her pregnancy. After the pregnancy, she again started to have a slightly increased amount of protein in the urine.

She did fairly well during the pregnancy but had a good deal of nausea and vomiting during the first trimester. In fact, she lost 15 lbs. She continued to do well until about the seventh month when her blood pressure began to increase. During the eight month her blood pressure increased further and she started to gain weight. She became very bloated and developed pitting edema of her lower extremities. She gained 80 pounds during the pregnancy. Her headaches, which had disappeared earlier in the pregnancy, returned and she also had some visual symptoms, seeing spots appear. She was told that she had developed pre-eclampsia. The physicians were worried about her kidney function as well as her liver function and did frequent blood tests. Both her kidney and liver did very well. She was followed very closely by her physician and later in her pregnancy by visiting nurses at home. Finally, two days before her due date, because of her blood pressure, weight gain, change in her reflexes and visual symptoms it was felt that they needed to induce her labor.

She was given magnesium sulfate as well as pitocin to induce her labor. She was in labor for 53 hours. Her cervix only dilated to 4 cm. Finally they decided to do a cesarean section. She had no further complications from her pre-eclampsia and her blood pressure declined to its baseline value, which is slightly low. She was in the hospital for 3 days after her cesarean section. Her son was normal and had no difficulties because of the pregnancy. By six months after delivery, she had lost 50 pounds.

During her pregnancy she had a good deal of family support from her husband, as well as her father, who was dying of lung cancer, even though he was very sick. He came to the hospital with her. At the time she became pregnant her mother had left her father and was living in Chicago. This also made the time of her pregnancy very stressful for her. Her father died 3 months ago of his lung cancer.

At the current time she feels well. She is now pregnant for a second time and is 5 ˝ months pregnant. She was told that the pre-eclampsia is unlikely to develop a second time and is more common with first pregnancies. Her kidney function has again improved with this pregnancy and her urine protein is not at a normal level. She is followed very closely by her gynecologist as well as an internist who specializes in medical problems during pregnancies (Dr. Richard Lee). Her obstetrician thinks she might be able to have a vaginal delivery this time rather than another cesarean section. She states that her mother had mild toxemia during the time when she was pregnant with her. This was also her mother's first pregnancy and she did not have problems with other pregnancies. Melissa has good health insurance through her husband, who works as a manager at Home Depot.

BP 126/80
Creatinine 0.7 mg/dl (normal range 0.7-1.4)
Uric Acid 4.0 mg/dl (normal range 2.5-7.5)
Urinalysis - no blood, no protein
Urinary total protein 101 mg/24 hr (normal range < 150)
Creatine Clearance 143 mg/min (normal range 75-115)
Creatinine Clearance 155 mg/min
BP 128/70
Creatinine 0.6 mg/dl
Uric acid 4.9 mg/dl
BP 164/104
Admitted for induction of labor
Cesarean section
BP 132/64


Review anatomy, histology and physiology of the placenta.

Pathogenesis: A number of inter-related factors are involved.
Placental implantation is defective (shallow) – genetic?
Placental ischemia, release of vasoactive substances (angiotensin, thromboxane, etc.)
Arteriolar spasm
Pre-eclampsia: Incidence 7-10% of pregnancies, usually in last trimester
Risk factors – primipara, mole, hypertension, kidney disease
Criteria for diagnosis – hypertension, proteinuria, coagulation abnormalities
HELLP – hemolysis, elevated LFTs, low platelets
Eclampsia: Above with CNS involvement including seizures, headache, hyper-reflexia, etc.

Kidney: Fibrin thrombi in glomeruli; cortical necrosis
Liver: Fibrin deposits, infarcts, hemorrhage (focal or subcapsular)
Pituitary: Ischemia, Sheehan’s syndrome


Anesthetic Management of Pre-eclampsia
DESCRIPTION:Includes literature references
URL: http://groucho.med.yale.edu/gta/Pre-eclampsia.html

Etiology of Preeclampsia
DESCRIPTION:A variety of abnormalities are apparent early in pregnancy in women destined to develop preeclampsia .
URL: http://pc101186.med.cornell.edu/wwwpreg/lit/ETIOLOGY.HTM

URL: HTTP://www.healthanswers.com/database/ami/converted/000890.html


G. Chamberlain et al.
The Changing Body in Pregnancy
Brit. Med J., 302: 719 (1991)

E. Dafnis et al.
The Effect of Pregnancy on Renal Function: Physiology and Pathophysiology
Am. J. of the Medical Sciences, 303: 184 (1992)

M. Zamorski et al.
Preeclampsia and Hypertensive Disorders of Pregnancy
American Family Physician, 53: 1596 (1996)

R. B. Ness et al.
Heterogeneous Causes Constituting the Single Syndrome of Preeclampsia: A Hyposthesis and its implications
Am. J. Obstetrics & Gynecology, 175: 1365 (1996)

B. M. Sibai et al.
Risk Factors Associated With Preeclampsia in Healthy Multiparous Women
Am. J. Obstetrics & Gynecology, 177: 1003 (1997)

K.-H. Lim et al.
The Clinical Utility of Serum Uric Acid Measurements in Hypertensive Diseases of Pregnancy
Am. J. Obstetrics & Gynecology, 178: 1067 (1998)

N. Sattar et al.
Potential Pathogenic Roles of Aberrant Lipoprotein and Fatty Acid Metabolism in Pre-eclampsia
Br. J. Obstetrics & Gynecology, 103: 614 (1996)

A. C. C. van Oppen et al.
Cardiac Output in Normal Pregnancy: A Critical Review
Obstetrics & Gynecology, 87: 310 (1996)

I. M. Bernstein et al.
Intolerance to Volume Expansion: A Theorized Mechanism for the Development of Preeclampsia
Obstetrics & Gynecology, 92: 306 (1998)

Magnesium Sulphate: A Review of Cliical Pharmacology Applied to Obstetrics
Br. J. Obstetrics & Gynecology, 105: 206 (1998)

B. Sibai
Treatment of Hypertension in Pregnant Women
Drug Therapy, 335: 257 (1996)

C. W. G. Redman
Management of Pre-Eclampsia
The Lancet, 341: 1451 (1993)