New hypertension at 30 weeks: pre-eclampsia with borderline features
A 29-year-old woman, gravida 2 para 1, attends an antenatal clinic at 30 weeks and 3 days with a blood pressure of 154/102 mmHg on two readings four hours apart. Urine dipstick shows 2+ protein; a 24-hour collection is not available. She reports mild frontal headache but no visual disturbance, epigastric pain, or vomiting. Reflexes are normal and there is no clonus. Platelets 138 × 10⁹/L, ALT 42 U/L, creatinine 78 µmol/L, uric acid 0.42 mmol/L. Fetal heart rate is 142 beats/min, cardiotocography is category I, and estimated fetal weight is on the 25th centile. She lives 90 minutes from the referral hospital and has no car. Her first delivery was by caesarean section for fetal distress at 38 weeks. She is not on any antihypertensive and has no history of hypertension before 20 weeks.
1. Classify her hypertensive disorder and decide whether to admit or manage as an outpatient. Justify your decision.
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She has new hypertension after 20 weeks with proteinuria, so this is a pregnancy hypertensive disorder, most consistent with pre-eclampsia. The platelet count is 138 × 10⁹/L, just below the usual 150 threshold, ALT is mildly raised at 42 U/L, and uric acid is elevated; these suggest early end-organ involvement even without severe features. She has a headache but no visual symptoms, epigastric pain, clonus, or severe hypertension (≥160/110).
The key decision is admission for observation, not outpatient management. Reasons: proteinuria, borderline platelets and liver enzymes, a headache, a fetus on the 25th centile, previous caesarean, and a 90-minute journey with no car. A 24-hour urine collection is not available, so use the spot protein:creatinine ratio if possible. Admit for blood pressure monitoring, daily pre-eclampsia bloods, fetal monitoring, and antenatal corticosteroids. If she refuses, document and arrange daily review, but the distance makes safe outpatient care difficult.
2. What antihypertensive would you start, what target would you aim for, and is magnesium sulphate indicated?
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Target blood pressure is usually 135–145/85–90 mmHg, avoiding abrupt falls that could impair placental perfusion. Labetalol is a reasonable first-line oral agent (for example 100 mg twice daily, titrated), with nifedipine as an alternative. Methyldopa is also used but causes sedation and dry mouth; it is not wrong but is less preferred in many protocols. Do not use ACE inhibitors, ARBs, or diuretics.
Magnesium sulphate is indicated for seizure prophylaxis in severe pre-eclampsia, defined by severe hypertension, symptoms such as headache or visual disturbance, clonus, or significant biochemical or haematological abnormalities. She has a headache and borderline platelets, so the threshold is arguable; many protocols would not start magnesium without severe hypertension or other severe features, but would reassess frequently. If she develops BP ≥160/110, symptoms, clonus, or falling platelets, start magnesium sulphate with loading and maintenance doses and monitor reflexes, respiratory rate, and urine output.
3. Discuss corticosteroid use and timing of delivery. What findings would change your plan?
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At 30 weeks, antenatal corticosteroids (dexamethasone or betamethasone) are recommended if there is a risk of delivery within 7 days, because they reduce neonatal respiratory distress, intraventricular haemorrhage, and mortality. Give them now while arranging transfer or admission; do not delay for a 24-hour urine collection.
Delivery is indicated for severe features that are not controlled, fetal compromise, or worsening maternal organ dysfunction. With mild features, expectant management with close monitoring may allow steroids to work and gain gestational age, but only in a facility with maternal and neonatal capability. What would change the plan: BP ≥160/110, platelets below 100, ALT double the upper limit, creatinine rising, pulmonary oedema, headache with visual changes, clonus, fetal growth restriction with abnormal Doppler, or a non-reassuring CTG. Those findings would prompt delivery rather than expectant management, and magnesium sulphate would be started.