Comprehensive Metabolic Panel Monitoring in Severe Preeclampsia
In a pregnant woman with severe preeclampsia (6 g proteinuria/24 hours and hypertension), obtain a comprehensive metabolic panel at least twice weekly until delivery.
Initial Laboratory Assessment
When severe preeclampsia is diagnosed, immediately obtain a complete laboratory workup including 1:
- Complete blood count – Focus on hemoglobin and platelet count to detect thrombocytopenia (<100,000/μL), which defines a severe feature 1
- Comprehensive metabolic panel – Liver transaminases (AST/ALT), serum creatinine, and uric acid 1
- Spot urine protein/creatinine ratio – Though proteinuria is already confirmed at 6 g/24 hours (massive proteinuria), baseline quantification is documented 2, 3
Frequency of CMP Monitoring
Twice-weekly laboratory surveillance is the standard monitoring interval for severe preeclampsia 1. This includes:
The rationale for this frequency is that progressively abnormal renal or liver enzyme tests are absolute indications for immediate delivery at any gestational age 1. Twice-weekly testing allows early detection of deteriorating organ function while avoiding unnecessary daily phlebotomy.
When to Increase Monitoring Frequency
Daily or continuous monitoring is warranted when 1:
- Severe hypertension (≥160/110 mmHg) persists despite treatment 1
- Any severe features develop (thrombocytopenia, renal dysfunction with creatinine >1.1 mg/dL, visual disturbances) 1
- HELLP syndrome is suspected (epigastric/right upper quadrant pain, hemolysis, elevated liver enzymes) 1
Critical Laboratory Thresholds Requiring Immediate Action
Deliver immediately regardless of gestational age if 1:
- Progressive thrombocytopenia – Declining platelet counts on serial measurements 1
- Progressively abnormal liver or renal function tests – Worsening trends, not static elevations 1
- Creatinine >1.1 mg/dL or doubling of baseline 1
- AST/ALT ≥2× upper limit of normal 1
Special Considerations for Massive Proteinuria
Your patient's 6 g/24-hour proteinuria exceeds the threshold for massive proteinuria (>5 g/24 hours), which is associated with 2, 3:
- More severe neonatal outcomes 2, 3
- Earlier delivery 2
- Increased risk of nephrotic syndrome requiring thromboprophylaxis 2
However, do not use the degree of proteinuria as an indication for delivery 1. The decision to deliver is based on gestational age, maternal stabilization, and presence of severe features—not proteinuria quantity 1.
Proteinuria Monitoring Is Not Recommended
Do not repeat proteinuria measurements during conservative management 4, 5. The amount of proteinuria does not correlate with poor maternal or neonatal outcomes beyond the initial diagnosis 4. In one study of 66 women with severe preeclampsia, 89% had increasing proteinuria during conservative management, but marked increases (≥2 g) showed no difference in rates of HELLP syndrome, abruption, cesarean delivery for fetal distress, or low Apgar scores compared to modest increases 5.
Repeated proteinuria testing may lead to unindicated preterm deliveries and related neonatal complications 4.
Clinical Monitoring at Each Visit
At every encounter (at least twice weekly), actively assess 1:
- Blood pressure – Target 110-140/85 mmHg 1
- Symptoms – Headache, visual changes, epigastric pain 1
- Physical examination – Assess for clonus 1
Common Pitfalls to Avoid
- Do not underestimate disease severity based on "mild" classification—all preeclampsia can rapidly progress 1
- Blood pressure alone is not reliable—serious organ dysfunction can develop at relatively mild hypertension levels 1
- Do not use serum uric acid or level of proteinuria as indication for delivery 1
- Do not delay delivery at ≥37 weeks based on non-reactive NST—delivery is indicated regardless of fetal testing results 1
Setting of Care
This patient requires management in a facility with 1: