What is the management approach for a patient with a worrisome protein/creatinine ratio indicative of preeclampsia?

Management of Preeclampsia with Worrisome Protein/Creatinine Ratio

Patients with a worrisome protein/creatinine ratio indicating preeclampsia should be initially assessed in hospital, with subsequent management based on disease severity, gestational age, and maternal-fetal status. 1

Initial Assessment

When a patient presents with a worrisome protein/creatinine ratio:

1. Confirm the diagnosis:

   • A PCr ratio ≥30 mg/mmol (0.3 mg/mg) is considered abnormal and diagnostic of significant proteinuria 1, 2
   • Automated dipstick urinalysis followed by PCr ratio is the preferred screening method 1
   • Note that massive proteinuria (>5 g/24h) is associated with worse neonatal outcomes 1

2. Complete maternal evaluation:

   • Blood pressure measurements (severe hypertension: ≥160/110 mmHg)
   • Clinical assessment including neurological examination for clonus
   • Laboratory tests (minimum twice weekly):
     • Complete blood count (hemoglobin, platelet count)
     • Liver function tests
     • Renal function tests including uric acid 1

3. Fetal assessment:

   • Initial ultrasound to confirm fetal well-being
   • More frequent monitoring if fetal growth restriction is present 1

Management Strategy

Hospital vs. Outpatient Management

• All women with newly diagnosed preeclampsia should be initially assessed in hospital
• Outpatient management may be considered only after:
  • Condition is stable
  • Patient can reliably report problems
  • Patient can monitor blood pressure at home 1

Antihypertensive Therapy

• Initiate antihypertensive therapy for severe hypertension
• Acceptable agents include:
  • Oral methyldopa
  • Labetalol
  • Oxprenolol
  • Nifedipine
  • Second/third line: hydralazine, prazosin 1
• Reduce or cease medications if diastolic BP falls <80 mmHg 1

Seizure Prophylaxis

• Administer magnesium sulfate for:
  • Women with proteinuria AND severe hypertension
  • Women with hypertension AND neurological signs/symptoms 1, 3
• Dosing for magnesium sulfate:
  • Initial dose: 4-5g IV in 250mL of 5% Dextrose or 0.9% Sodium Chloride over 3-4 minutes
  • Maintenance: 1-2g/hour by constant IV infusion
  • Monitor for toxicity: loss of deep tendon reflexes, respiratory depression 3

Timing of Delivery

Immediate delivery is indicated if:

1. Gestational age ≥37 weeks (0 days) OR
2. Any of the following complications develop:
   • Repeated episodes of severe hypertension despite treatment with 3 classes of antihypertensives
   • Progressive thrombocytopenia
   • Progressive abnormalities in renal or liver function tests
   • Pulmonary edema
   • Neurological complications (severe headache, visual scotomata, seizures)
   • Non-reassuring fetal status 1

Monitoring Protocol

• Blood pressure: Regular monitoring (frequency based on severity)
• Laboratory tests: At least twice weekly
• Proteinuria: Repeated assessments if not already present
• Clinical assessment: Regular evaluation for signs of worsening disease 1

Special Considerations

Gestational Proteinuria

If proteinuria is present without hypertension, consider three possible outcomes:

1. Benign gestational proteinuria that resolves postpartum
2. Early preeclampsia that will manifest with hypertension later
3. Underlying renal disease 1

Monitor these women more frequently and reassess proteinuria at 3 months postpartum 1, 2

Postpartum Care

• Continue close monitoring for at least 3 days postpartum
• Continue antihypertensive medications as needed
• Avoid NSAIDs for pain relief in women with preeclampsia, especially with renal impairment 1
• Follow-up at 3 months postpartum to ensure BP, urinalysis, and laboratory abnormalities have normalized 1, 2

Long-term Considerations

Women with preeclampsia have increased long-term cardiovascular risks:

• Annual medical review is advised lifelong
• Recommend achieving pre-pregnancy weight within 12 months
• Encourage healthy lifestyle with regular exercise 1

Pitfalls to Avoid

1. Do not rely solely on the degree of proteinuria to make management decisions - the correlation between protein/creatinine ratio and 24-hour urine protein is imperfect (r²=0.41) 4

2. Do not discharge patients prematurely - eclamptic seizures can develop for the first time in the early postpartum period 1

3. Do not abruptly discontinue antihypertensive medications - taper slowly over days 1

4. Do not continue magnesium sulfate beyond 5-7 days in pregnant women as it can lead to fetal bone abnormalities 3

5. Do not use NSAIDs for postpartum analgesia in women with preeclampsia, especially those with renal impairment 1