Severe pre-eclampsia at 33 weeks
A 34-year-old woman, gravida 2 para 1, is admitted at 33 weeks and 4 days with a blood pressure of 168/112 mmHg, 3+ proteinuria and a severe headache with visual flashes. Her platelets are 88 × 10⁹/L, ALT 120 U/L, creatinine 90 µmol/L and uric acid raised. The cardiotocograph is normal. She has no abdominal pain or vaginal bleeding, and the fetal heart rate is 140 beats/min. She had pre-eclampsia in her first pregnancy, which ended in a vaginal delivery at 37 weeks. Her body mass index is 31. She is anxious about a caesarean section and wants to know whether the baby can stay in utero longer. The neonatal unit has one available intensive care cot. The obstetric registrar is off site and asks you to make a plan.
1. What is your immediate management, including magnesium sulfate and blood pressure control? Give doses and monitoring.
Read the worked answer
- Setting: HDU, IV access, continuous CTG, hourly BP, urine output, reflexes and oxygen saturation.
- Magnesium sulfate: 4 g IV loading over 20 minutes, then 1 g/hour for 24 hours. Monitor respiratory rate >12/min, patellar reflexes and urine output >25 mL/hour. Have calcium gluconate 1 g IV ready for toxicity.
- BP control: labetalol 20 mg IV, then 40–80 mg every 10 minutes (max 300 mg) or hydralazine 5 mg IV every 20 minutes. Target 140–150/90–100 mmHg; avoid sudden hypotension.
- Fluids: restrict to about 80 mL/hour unless hypovolaemic.
- Steroids: betamethasone 12 mg IM, second dose in 24 hours, because she is <34 weeks.
- Avoid: ACE inhibitors, diuretics and ergometrine.
2. How would you decide on timing and mode of delivery, and what is the role of antenatal corticosteroids?
Read the worked answer
- Delivery is the only cure. At 33+4 with severe features but no deterioration, give steroids and deliver after 24–48 hours if maternal and fetal status remain stable.
- Deliver immediately for eclampsia, abruption, fetal distress, HELLP syndrome, pulmonary oedema or uncontrollable BP.
- Mode: vaginal delivery if cephalic, cervix favourable and no fetal compromise; caesarean section for unfavourable cervix, malpresentation or fetal compromise.
- The available neonatal cot supports delivery here; if the mother deteriorates before steroids are complete, do not delay delivery for the second dose.
- Explain that expectant management beyond 48 hours increases risk of eclampsia and abruption.
3. What postpartum monitoring is required, and what would you tell the patient about recurrence risk?
Read the worked answer
- Continue magnesium sulfate for 24 hours postpartum; monitor BP, platelets, LFTs, creatinine and urine output.
- Postpartum hypertension can worsen or appear de novo; monitor BP for at least 6 weeks and treat if ≥140/90 mmHg. Labetalol and nifedipine are compatible with breastfeeding.
- Warn about headache, visual changes, epigastric pain, shortness of breath and reduced urine output.
- Recurrence risk is about 15–20%, higher with early onset. In future pregnancy, start aspirin from 12 weeks, ensure calcium intake and arrange early specialist review.
- Discuss contraception and preconception planning.