Severe Preeclampsia at 33 Weeks with an Unfavourable Cervix
A 33-year-old woman, gravida 2 para 1, at 33 weeks and 4 days by a confirmed first-trimester scan, presents with a two-day frontal headache and flashing lights. Blood pressure is 168/112 mmHg and, on repeat after four hours of rest, 172/108 mmHg. Urine dipstick is 3+ protein, with a spot protein-to-creatinine ratio of 0.42 mg/mg. Platelets 96 x 10^9/L, AST 92 U/L, creatinine 0.9 mg/dL, uric acid 7.8 mg/dL, haemoglobin 11.4 g/dL, LDH 620 U/L, haptoglobin low. She has had no seizure. The cardiotocograph is reactive with no decelerations, amniotic fluid index 9 cm, and estimated fetal weight at the 12th centile with normal umbilical artery Doppler. The cervix is closed, 0 cm dilated, 2 cm long and firm, with a Bishop score of 2. She is admitted and asks whether the baby can stay inside a little longer.
1. Write your first-hour orders, including magnesium dosing, blood pressure targets, and the monitoring that goes with them.
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This is preeclampsia with severe features and a headache with visual symptoms, so treat it as an impending eclampsia. Give magnesium sulfate 4-6 g intravenously over 20-30 minutes as a loading dose, then 1-2 g/hour, and continue for 24 hours after delivery. CheckPatellar reflexes, respiratory rate and urine output hourly, and reduce or omit the infusion if the creatinine rises, since magnesium is renally cleared; keep calcium gluconate 1 g at the bedside. Lower blood pressure to below 150/100 mmHg but not below about 130/80, using intravenous labetalol 20 mg then escalating doses, or hydralazine 5-10 mg, or oral nifedipine 10 mg; avoid precipitous drops that compromise uteroplacental flow. Give betamethasone 12 mg intramuscularly, repeated in 24 hours, for fetal lung maturity. Insert a urinary catheter only if the output cannot be measured, take bloods for platelets, liver enzymes, LDH and creatinine every 6-8 hours, and keep continuous fetal monitoring plus strict fluid balance. Avoid excessive crystalloid, since pulmonary oedema is a real risk in severe preeclampsia.
2. When should she deliver, and what mode of delivery would you recommend? Justify both.
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Delivery is the definitive treatment, and she should be delivered once steroids have had 24-48 hours to act, provided her blood pressure is controlled, her platelets are stable and there is no fetal compromise. Deliver immediately without waiting for steroids if she develops eclampsia, pulmonary oedema, abruption, uncontrollable hypertension, rising liver enzymes or falling platelets, because maternal safety overrides the steroid window. Gestational age alone does not justify expectant management here: severe features at 33-34 weeks carry a high risk of progression, and observational data do not show benefit from prolonging pregnancy beyond the steroid course. Regarding mode, preeclampsia is not itself an indication for caesarean, but her Bishop score of 2 makes induction likely to be prolonged, and an unfavourable cervix in a woman with severe features and a small fetus favours caesarean delivery. A senior decision should weigh fetal presentation, estimated weight, and her preference; if the cervix were favourable, induction with continuous monitoring would be reasonable and would avoid the added risks of repeated abdominal surgery.
3. Outline postpartum and long-term management, including what she should be told before discharge.
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Continue magnesium sulfate for 24 hours after delivery, keep monitoring blood pressure for at least 72 hours and again at 7-10 days, because preeclampsia can worsen or first appear postpartum. Use antihypertensives with lactation in mind: labetalol, nifedipine or enalapril are reasonable, and methyldopa should be avoided because of depression risk. Screen for thrombocytopenia and liver enzyme recovery, and counsel about warning symptoms such as severe headache, visual change, epigastric pain or breathlessness, which should prompt immediate review. Tell her that her future pregnancies carry a substantially increased risk of preeclampsia and that low-dose aspirin from 12 weeks, together with early booking and blood pressure surveillance, reduces that risk. Arrange interval assessment of blood pressure, lipids, glucose and renal function, since preeclampsia is an independent marker of later cardiovascular disease, and encourage weight optimisation and smoking cessation. Reassure her about breastfeeding and ask about mood, because postpartum depression and anxiety are more common after a complicated pregnancy.