Toxemia: Early Warning Signs
The earliest clinical sign of preeclampsia is often a stable or rising hemoglobin/hematocrit (and possibly red blood cell count) which occurs as the blood volume begins to contract. Early on, this will be accompanied by a minor degree of small for dates fetal growth. At this point, usually between 22 to 29 weeks, the mother may still feel fairly well. This is one good reason to begin careful abdominal palpation from the onset of care and to become good at estimating early fetal growth with your hands. The liver is not severely compromised at this point, but it is inadequately supplied with nutrients. If you do a liver profile now, liver enzymes will likely be normal. After a few weeks, subclinical liver compromise will often be evident in a liver profile test, reflected in either rising enzymes levels or falling blood protein levels or both. Kidney function tests will not become abnormal until other lab work has been abnormal for a while, since kidney compromise usually commences after the blood volume contraction is well under way. If you have any doubt, always run a liver profile test and check the hemoglobin. If problems are identified at this stage and diligent attention is paid to increasing protein and other nutrients, the hemoglobin will start to drop rapidly and fetal growth will improve, reflecting that the blood volume is beginning to expand. If you do not catch it at this point, symptoms will worsen, but may not necessarily include high blood pressure or proteinuria. You must be alert, keeping in mind the underlying physiology of toxemia, not just the secondary symptom picture.

If you feel some degree of true toxemia exists, the most important thing is to provide the system with enough fluid and nutrients to try to make up for lost time. Focus on protein, nutrient rich calories, fluids (drink to a healthy thirst, but don't overdo it), and adequate salt. Have the mother eat a high protein item every waking hour. Initially recommend an increase to 150 to 200 grams of protein daily (250 to 350 grams or more with multiple gestations), with 3,000 to 4,000 calories and 500 mg of choline daily. Increase calcium and magnesium if indicated. What you actually recommend will depend upon lab results, whether it is a multiple gestation, and the symptom picture when you detect the problem; the worse the picture, the more protein and calories you should recommend. You want to give the liver enough raw materials to make up for a longstanding lack as rapidly as possible. An inadequate increase may allow the liver to maintain things so that symptoms do not worsen, but not offer sufficient amino acids to turn the situation around. If the woman has a history of liver disorders, recommend less protein (120-150 grams for a single fetus); her liver may be overwhelmed otherwise, and monitor her lab work closely for changes.

Recheck lab tests 4 to 7 days later. Often, women feel an immediate and profoundly increased sense of well being. If the second lab report shows some improvement, keep up the high protein intake until all values are where they should be for her gestation. Recheck again 4 to 6 days later, if the third lab result shows no change, increase the protein. Once liver enzymes and blood proteins have normalized, the hemoglobin has dropped appropriately, the fetus is an appropriate size for dates and secondary symptoms have subsided, the woman can cut back to 100 grams of protein daily (150 grams with multiples).
-Anne Frye workshop, from Pre-eclampsia Society Newsletter, No. 36, 1998

Reprinted from Midwifery Today E-News (Vol 1 Issue 37, Sep 17, 1999)
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