Headache and hypertension at 34 weeks
A 34-year-old woman, gravida 2 para 1, at 34 weeks' gestation attends triage with a severe frontal headache and visual blurring for 12 hours. Blood pressure is 168/112 mmHg on two readings 15 minutes apart. Reflexes are brisk with clonus, and she has 2+ proteinuria on dipstick. Platelets are 88 × 10⁹/L, ALT is 110 U/L, and creatinine is 95 µmol/L. The fetal heart rate tracing shows a baseline of 150/min with reduced variability and no decelerations. She has no prior hypertension and no seizure activity. She is alert and oriented, and the cervix is closed.
1. What is the diagnosis and what are the immediate management priorities in the first hour?
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This is severe pre-eclampsia with features of haemolysis, elevated liver enzymes and low platelets (HELLP) syndrome: severe-range hypertension, headache and visual symptoms, hyperreflexia with clonus, proteinuria, thrombocytopenia, transaminitis and renal impairment. The immediate priorities are to prevent maternal intracranial haemorrhage and eclampsia while arranging delivery. Give antihypertensive treatment promptly, aiming to lower blood pressure to below 150/100 mmHg without abrupt falls that could compromise uteroplacental perfusion; intravenous labetalol, hydralazine or oral nifedipine are standard options, with response reassessed every 15 to 30 minutes. Give magnesium sulfate for seizure prophylaxis, with loading dose and infusion, monitoring reflexes, respiratory rate and urine output for toxicity; calcium gluconate must be available. Insert a urinary catheter, secure intravenous access, take bloods for full count, coagulation and crossmatch, and involve senior obstetrics, anaesthetics and neonatology. Delivery is the definitive treatment, and at 34 weeks with severe features it should be planned after maternal stabilisation, with steroids considered for fetal lung maturity if time allows. Avoid fluid overload and monitor for pulmonary oedema.
2. How should the abnormal fetal heart tracing influence timing of delivery, and what intrapartum monitoring is required?
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Reduced variability without decelerations in a preterm fetus may reflect maternal hypertension, medication effects or uteroplacental insufficiency, so it should prompt closer surveillance rather than immediate emergency caesarean in the absence of decelerations or bradycardia. Optimise maternal blood pressure and oxygenation, stop any agent that could depress variability, and repeat the tracing. If variability remains reduced or other abnormalities emerge, delivery should not be delayed. The mode of delivery depends on cervical favourability, fetal condition and maternal status; caesarean is often chosen when the cervix is closed and the fetus is compromised. If vaginal delivery is attempted, continuous electronic fetal monitoring is mandatory, with facilities for immediate operative delivery, and magnesium therapy continued during labour and for 24 hours postpartum. Continue close maternal observation for at least 24 to 48 hours after delivery, since eclampsia risk persists postpartum.