Headache and Hypertension at 33 Weeks

Pre-eclampsia with severe features. The blood pressure alone (158/106) is below the 160/110 threshold, but severity is defined by any feature: headache with visual disturbance, thrombocytopenia (102), transaminitis (AST/ALT roughly twice the upper limit) and renal impairment. She does not yet meet HELLP criteria and has no abruption or fetal compromise - she is stable but severe.

First four hours:

• Magnesium sulfate for seizure prophylaxis: 4 g IV loading over 20 minutes, then 1 g/hour. Monitor reflexes, respiratory rate and urine output; have calcium gluconate at the bedside.
• Antihypertensives to bring blood pressure to roughly 130–150/80–100 mmHg - labetalol 200 mg orally or 20 mg IV increments, or nifedipine slow release, or hydralazine. Avoid dropping the pressure abruptly, which compromises uteroplacental perfusion.
• Corticosteroids - betamethasone 12 mg IM, two doses 24 hours apart - for fetal lung maturity.
• Strict input/output charting, urinary catheter if needed, daily weights; avoid fluid overload (risk of pulmonary oedema).
• Continuous CTG, regular observations, bloods including FBC, LFTs, creatinine, urate and coagulation repeated 12-hourly.
• Inform anaesthetics, neonatology and the senior obstetrician; site IV access and group and save.
• Strictly no ergometrine later, and document the plan clearly.

Wait for the corticosteroids, then deliver - but only if she stays stable. At 33+2 weeks with severe features, current guidance supports a short period of expectant management (typically 24–48 hours) to allow antenatal steroids to work, provided there is no maternal organ failure and no fetal compromise. Delivery is the only cure, and beyond 34 weeks there is no benefit in waiting.

Deliver sooner - within hours, regardless of steroid timing - if:

• blood pressure remains above 160/110 despite maximal treatment, or she develops chest pain or pulmonary oedema;
• platelets fall below 100 and continue to drop, transaminases double, or she develops HELLP;
• creatinine rises or urine output falls;
• she has a seizure (eclampsia), abruption, or persistent epigastric pain;
• CTG becomes non-reassuring or Doppler deteriorates;
• she goes into labour or membranes rupture.

Mode: vaginal delivery is reasonable if the cervix is favourable and fetal condition allows; caesarean for fetal compromise, unfavourable cervix with rapid deterioration, or severe maternal disease. Plan the setting so neonatal cot availability is known before you commit to delivery timing.

Eclampsia:

• Call for help, protect the airway, give oxygen, position in the left lateral position, do not force anything into the mouth.
• Magnesium sulfate 4 g IV over 5 minutes as a further bolus (she should already be loaded - check the chart; if not, load now). If the seizure recurs, give a further 2 g bolus, and consider intubation with a magnesium infusion continued.
• Control blood pressure with IV labetalol or hydralazine once the airway is secure; the commonest cause of death is aspiration and intracerebral haemorrhage, so both seizure and pressure need treating.
• Deliver once stabilised - eclampsia at 33 weeks is an indication for delivery after maternal stabilisation.
• Do not give ergometrine for the third stage; use oxytocin. Avoid Syntometrine.

Thrombocytopenia at 72:

• Repeat the count urgently and check the film and coagulation for HELLP or DIC.
• Neuraxial anaesthesia is generally avoided below 75–80 × 10⁹/L because of epidural haematoma risk - she will likely need general anaesthesia if caesarean is required.
• Platelets are not transfused routinely above 50 × 10⁹/L; reserve transfusion for counts below about 50 before surgery, or below 20, or active bleeding, and discuss with haematology and blood bank early.
• Expect the count to recover after delivery; monitor for postpartum haemorrhage and continue magnesium for 24 hours after delivery.