Twin pregnancy at 33+4 with severe preeclampsia and renal impairment

This is severe preeclampsia with maternal organ dysfunction (thrombocytopenia, transaminitis, renal impairment, oliguria), so magnesium sulfate is indicated for seizure prophylaxis. Give a 4 g IV loading dose over 20 minutes, then start maintenance at 1 g/h. Because creatinine is 1.35 mg/dL and urine output is only 25 mL/h, reduce maintenance to 0.5–1 g/h and reassess frequently; magnesium is renally cleared and accumulates in oliguria. Check serum magnesium 2 hours after loading and then 4–6 hourly, aiming for clinical effect rather than a fixed level. Monitor deep tendon reflexes, respiratory rate, oxygen saturation, urine output, and conscious level. If reflexes are absent, respiratory rate falls below 12/min, or urine output falls further, stop the infusion and give calcium gluconate 1 g IV. Do not use magnesium as an antihypertensive. For BP, give IV labetalol 20 mg, escalating to 40–80 mg every 10 minutes, or hydralazine 5–10 mg IV, or oral nifedipine 10 mg. Lower BP gradually to 140–150/90–100 mmHg; avoid abrupt falls that impair uteroplacental perfusion. Restrict fluids to about 80 mL/h including infusions unless there is hypovolemia, and insert a Foley catheter to measure hourly urine output. Alert the anaesthetic and neonatal teams early.

Delivery is indicated now, not expectant management. She has severe preeclampsia with maternal organ dysfunction at 33+4 weeks: platelets below 100 × 10^9/L, ALT more than twice the upper limit of normal, creatinine above 1.1 mg/dL, and oliguria. These features define severe disease, and progression can be abrupt. Give betamethasone 12 mg IM, repeated after 24 hours, because she is below 34 weeks and twins are at risk of respiratory morbidity; however, do not delay delivery for 48 hours if maternal or fetal status deteriorates. Magnesium sulfate for fetal neuroprotection is not routinely recommended at 33+4 weeks; it is generally used below 32 weeks, so continue magnesium for maternal seizure prophylaxis rather than for neuroprotection. Mode of delivery requires individual judgement. Both twins are cephalic, so vaginal delivery is possible if the cervix is favourable, she remains stable, and continuous fetal monitoring is available. However, severe maternal disease, an unfavourable cervix, fetal compromise, or the need for urgent delivery make caesarean section preferable. Avoid a prolonged induction. Check the platelet trend before neuraxial anaesthesia; a falling platelet count or coagulopathy may contraindicate regional block. Deliver in a unit with neonatal intensive care capability and anticipate neonatal respiratory support.

Postpartum hypertension is common and can worsen or first appear after delivery. Continue nifedipine slow-release 30–60 mg daily or switch to labetalol 100–200 mg twice daily, titrating to a target below 140/90 mmHg. Both are compatible with breastfeeding. Avoid ACE inhibitors or angiotensin receptor blockers in the immediate postpartum period in a woman with preeclampsia and renal impairment; enalapril may be considered later under specialist follow-up if needed. Monitor BP at least 4-hourly while inpatient, then daily, and arrange review at 7–10 days because postpartum preeclampsia can peak later. Continue magnesium sulfate for 24 hours postpartum, or longer if there are ongoing severe features or seizures; reassess renal function and magnesium levels. Assess VTE risk: preeclampsia, possible caesarean delivery, immobility, and any obesity increase risk. Use prophylactic low-molecular-weight heparin while an inpatient unless platelets are below the local threshold or she is bleeding, and consider extended prophylaxis for 6 weeks if multiple risk factors persist. Counsel her about the high recurrence risk of preeclampsia, the need for prepregnancy counselling, long-term cardiovascular risk, and the importance of early BP surveillance in future pregnancies.