Severe preeclampsia at 33+4 weeks in a level II hospital

Diagnosis: severe preeclampsia at 33+4 weeks - blood pressure ≥160/110 mmHg plus cerebral symptoms, proteinuria, thrombocytopenia (94 × 10⁹/L) and transaminitis. HELLP is not yet present but must be excluded by serial sampling; the uric acid of 402 µmol/L fits preeclampsia rather than chronic hypertension.

First hour

• Magnesium sulphate: loading dose 4 g IV over 15–20 minutes, then 1 g/hour by infusion pump. This is seizure prophylaxis, not antihypertensive therapy; check reflexes, respiratory rate and urine output hourly, and have calcium gluconate available.
• Antihypertensives with a target of roughly 130–140/80–90 mmHg, aiming to keep systolic below 150–160: bolus labetalol 20 mg IV, repeated every 10–15 minutes up to 200 mg total, or oral nifedipine 10 mg repeated as needed. Avoid sudden profound falls that impair uteroplacental perfusion.
• Betamethasone 12 mg IM, second dose 24 hours later. At 33+4 weeks the evidence for antenatal steroids is strong.
• Admission to an obstetric high-dependency bed, continuous CTG, hourly blood pressure, strict fluid balance with about 80 mL/hour of maintenance crystalloid to limit pulmonary oedema risk.
• Bloods every 12 hours: full count, ALT/AST, bilirubin, LDH, creatinine, uric acid, coagulation and fibrinogen; group and save; urinalysis for protein-to-creatinine ratio.

Deliberately not done: no diuretics - she is not in pulmonary oedema, and volume depletion worsens placental perfusion; no ACE inhibitors or angiotensin receptor blockers - fetotoxic. Aspirin would be pointless now.

Reasoning: at 33+4 weeks with severe features, delivery is indicated - the question is only the interval needed to complete the steroid course and to move the patient. Expectant management beyond 48 hours is not justified in severe preeclampsia, and prolongation risks abruptio placentae, eclampsia, HELLP progression and fetal death.

Plan

• Stabilise and transfer in utero to the level III perinatology centre before delivery if the 45-minute transfer can be done safely with a midwife/physician escort, magnesium infusion running and continuous monitoring. In-utero transfer gives the neonate a level III NICU and avoids a two-transfer sequence for a 1,860 g infant.
• Deliver approximately 24 hours after the first steroid dose, i.e. after completion of the course, provided maternal and fetal status remain stable.
• Mode: the cervix is closed and unripe with an estimated fetal weight of 1,860 g, so caesarean section is the realistic route; a vaginal birth attempt would only be considered with a favourable cervix, a stable mother and continuous fetal monitoring capability.

Abandon expectant management immediately if: blood pressure remains >160/110 despite two agents; platelets fall below 100 and continue to fall (especially below 70–80); ALT doubles again; creatinine rises; epigastric pain or liver capsule pain; pulmonary oedema; abruption (pain, bleeding, hypertonus, abnormal CTG); non-reassuring CTG with reduced variability or decelerations; eclamptic seizure.

Also start thromboprophylaxis with low-molecular-weight heparin once delivery has occurred and haemostasis is secure.

Postpartum surveillance

• Continue magnesium sulphate for 24 hours after delivery, because eclampsia can occur postpartum.
• Monitor blood pressure at least four times daily for the first 3–5 days and again at the 6-week check: about one third of preeclampsia-related morbidity presents or worsens after delivery. Treat hypertension persistently ≥150/100 mmHg.
• Repeat platelets, liver enzymes and creatinine; HELLP can declare itself for the first time postpartum.
• Thromboprophylaxis with low-molecular-weight heparin for 6 weeks if she has additional risk factors (BMI, caesarean, family history), otherwise at least until discharge; weigh against bleeding.
• Encourage early mobilisation, analgesia that does not mask a rising blood pressure, and lactation support; most antihypertensives used (labetalol, nifedipine, methyldopa) are compatible with breastfeeding.

Counselling

• Recurrence risk of preeclampsia is roughly 15–20%, higher (about 25–30%) after early-onset disease, and she is at increased risk of gestational hypertension, fetal growth restriction, abruption and preterm birth.
• Next pregnancy: low-dose aspirin 150 mg from 12 weeks, calcium supplementation where intake is low, booking at a perinatology centre, baseline blood pressure and renal function, and consideration of first-trimester risk assessment.
• Long term she has roughly a twofold excess risk of chronic hypertension, ischaemic heart disease and stroke, and later chronic kidney disease. Advise general-practice follow-up with annual blood pressure, weight and lipid checks, smoking avoidance, and preconception review before any further pregnancy.