Severe pre-eclampsia at 34 weeks with a birth-plan disagreement
Mrs B is 29 years old, para 1, at 34+2 weeks' gestation. She booked late and has had two antenatal visits. She attends the day assessment unit with a 3-day history of frontal headache, flashing lights and epigastric discomfort. BP is 162/104 mmHg on two readings 15 minutes apart, with 3+ proteinuria on dipstick. Reflexes are brisk and she has mild ankle oedema. Bloods: platelets 92 × 10⁹/L, ALT 128 U/L, creatinine 88 µmol/L, urate 420 µmol/L; haemoglobin 118 g/L. CTG is normal and the cervix is closed, long and posterior. Ultrasound shows a normally grown fetus with normal liquor and umbilical artery Dopplers. She is adamant she wants a 'natural water birth' and asks to wait until 37 weeks because she has read that babies do better at term. She declines admission initially and says she needs to get home to her toddler.
1. What is the diagnosis and immediate management? Include drugs, doses and monitoring.
Read the worked answer
Diagnosis. Severe pre-eclampsia at 34+2 weeks, with thrombocytopenia and raised transaminases; this is at least partial HELLP and she is at risk of eclampsia, abruption, stroke and renal failure.
Immediate management. Admit to obstetric HDU, continuous CTG, hourly BP, strict fluid balance and catheter.
- Magnesium sulfate: 4 g IV over 10–15 minutes, then 1 g/hour for 24 hours (or until 24 hours after birth). Monitor respiratory rate, reflexes, urine output and oxygen saturation; have calcium gluconate available.
- Antihypertensives: labetalol 200 mg orally, repeated as needed, or IV labetalol 20 mg boluses; alternative nifedipine 10 mg orally. Target <150/100 mmHg (NICE suggests 135/85). Avoid sudden profound drops.
- Betamethasone 12 mg IM, two doses 24 hours apart, for fetal lung maturity; do not delay delivery for a second dose if she deteriorates.
- Bloods including FBC, LFT, renal function, clotting, group and save; urate and urine protein quantification.
Reasoning. The key error would be to treat her as an outpatient headache or to wait for 37 weeks. Severe features at ≥34 weeks mean birth is recommended; steroids are an adjunct, not a reason to delay in an unstable mother.
2. Discuss timing and mode of birth, and how you would counsel her when she declines admission.
Read the worked answer
Timing. Birth is recommended now, after the first dose of steroids if she is stable; if she develops eclampsia, abruption, HELLP progression, pulmonary oedema or fetal compromise, deliver immediately. At 34+2 with severe disease, expectant management to 37 weeks is not appropriate.
Mode. Vaginal birth is reasonable if the cervix is favourable and mother and fetus are stable. Here the cervix is closed, long and posterior, so induction is likely to be prolonged; caesarean section is often safer, especially with thrombocytopenia (platelets 92) and for fetal indication. Discuss both and involve the consultant anaesthetist.
Counselling. She has capacity to make decisions. Explore her birth plan, correct the belief that waiting is always better for the baby, and give absolute risks: eclampsia, placental abruption, stroke, stillbirth, neonatal respiratory distress. Offer a written plan and a second senior opinion. If she declines admission, document capacity and reasoning, safety-net with clear red flags, arrange urgent follow-up and escalate to the consultant; do not simply let her leave without a plan.
3. What maternal and neonatal complications would you include in the discussion, and how would you document the consultation?
Read the worked answer
Maternal complications: eclampsia, stroke, pulmonary oedema, acute kidney injury, liver haematoma, abruption, DIC, postpartum haemorrhage, longer-term hypertension and cardiovascular risk.
Fetal/neonatal: growth restriction, hypoxia, stillbirth, prematurity, respiratory distress, jaundice, feeding difficulty, neonatal thrombocytopenia.
Documentation: record the diagnosis and observations, the MgSO4 and antihypertensive doses, the steroid consent, the discussion of timing and mode, her questions and her decision, who was present, and the safety-net advice. Use a structured note and share with the MDT. If there is disagreement, record the consultant advice and the patient's reasons. This is both good clinical care and evidence if the case is reviewed.