A 38-year-old woman, gravida 1 para 0, at 32 weeks gestation comes to the office due to a progressively worsening headache. The patient also reports increased leg swelling and a 4.54-kg (10-lb) weight gain since her last visit 2 weeks ago. She has no chronic medical conditions, and her pregnancy has been uncomplicated. Review of medical records shows that blood pressure was 130/80 mm Hg at 30 weeks gestation. Today, blood pressure is 165/100 mm Hg. There is 2+ pitting edema to the knees. Serum creatinine is 0.9 mg/dL. Which of the following findings would most likely be present in this patient's urinalysis?

Question

Quizplus · Accepted Answer

11ec160b_3a00_4440_9249_2fda0529d36b_MD0001_00 This patient with a worsening headache and new-onset hypertension (ie, systolic ≥140 or diastolic ≥90 mm Hg) after 20 weeks gestation has preeclampsia. Preeclampsia is most likely caused by narrowed uteroplacental spiral artery formation and abnormal placentation, which lead to placental hypoperfusion and ischemia. These changes trigger the release of antiangiogenic factors that cause widespread maternal vasoconstriction (eg, hypertension), endothelial cell damage (eg, third spacing with edema and weight gain), and end-organ damage (eg, headache). The kidneys are commonly affected by preeclampsia, and urinalysis can support the diagnosis: Third spacing (ie, intravascular volume depletion) and vasoconstriction of the renal vessels result in decreased urine production (ie, oliguria) and concentrated urine (ie, increased specific gravity) because the kidneys attempt to retain sodium and water. Damage to the renal endothelium increases glomerular permeability and allows for leakage of large molecules, as evidenced by proteinuria, which is classic for preeclampsia. Renal vasoconstriction causes a decreased glomerular filtration rate (GFR) and an increased serum creatinine level (above baseline). Healthy pregnant patients have decreased baseline serum creatinine levels due to blood volume expansion and increased GFR; therefore, a normal-appearing creatinine level (0.7-0.9 mg/dL) during pregnancy, as seen in this patient, typically indicates renal compromise. Definitive management of preeclampsia is with delivery, and renal function typically recovers postpartum. (Choices A and B) Decreased urine specific gravity (ie, decreased concentration of urine solutes) is associated with excessive fluid intake (eg, primary polydipsia) or diabetes insipidus. It is not associated with hypertension in pregnancy. (Choices C, E, and F) Microscopic hematuria (ie, red blood cells on urinalysis) is typically associated with urinary tract disease, such as infection, kidney or bladder cancer, and renal calculus. Hematuria is not associated with hypertension in pregnancy. Educational objective: Preeclampsia is new-onset hypertension after 20 weeks gestation with signs of end-organ damage (eg, headache). Renal effects of preeclampsia include oliguria with increased specific gravity, proteinuria, and serum creatinine levels. __________ References: Hypertension in pregnancy: taking cues from pathophysiology for clinical practice. (http://www.ncbi.nlm.nih.gov/pubmed/29485737) The changing landscape of acute kidney injury in pregnancy from an obstetrics perspective. (http://www.ncbi.nlm.nih.gov/pubmed/31500091)

A 38-Year-Old Woman, Gravida 1 Para 0, at 32 Weeks