Severe pre-eclampsia at 34 weeks with a previous caesarean

Diagnosis

She has pre-eclampsia with severe features at 34+2 weeks, complicated by a partial HELLP syndrome. Severe features are present on several counts: BP of 172/114 (at or above 160/110), persistent headache and visual disturbance, and platelets under 100 with transaminases more than twice the upper limit of normal. The low haptoglobin, raised LDH and red cell fragments confirm microangiopathic haemolysis, giving the H (haemolysis), EL (elevated liver enzymes) and LP (low platelets) triad. She is not eclamptic - there has been no seizure - but she is at high risk of one.

First hour

• Move to a high-dependency room with continuous CTG, IV access and strict hourly fluid balance with a urine output chart.
• Magnesium sulfate for seizure prophylaxis: 4 g IV loading dose over about 20 minutes, then 1 g/hour. Monitor respiratory rate, reflexes, urine output and magnesium levels; keep calcium gluconate at the bedside. Continue for 24 hours after delivery.
• Antihypertensives for BP at or above 160/110: labetalol 200 mg orally or 20-50 mg IV in increments, or hydralazine 5-10 mg IV every 20-30 minutes, or nifedipine 10-20 mg orally. Aim for 130-150/80-100 and avoid a precipitous drop, which compromises uteroplacental perfusion.
• Never give an ACE inhibitor or ARB.
• Bloods and crossmatch: repeat FBC, film, LFTs, U&E, coagulation, group and hold, and send a catheter specimen of urine.
• Corticosteroids if a 24-48 hour window can safely be gained.
• Escalate to the consultant obstetrician, anaesthetist and neonatologist, and involve a tertiary unit if this hospital lacks neonatal intensive care.

When

Delivery is the only definitive treatment and it is indicated because she has severe features at 34 weeks. The question is not whether, but how much time to buy. If her platelets, liver enzymes and blood pressure are stable, the CTG remains normal and she has no epigastric pain, a 24-48 hour window to complete antenatal corticosteroids is reasonable and improves neonatal respiratory outcomes. However, do not delay delivery for steroids if there is progressive thrombocytopenia, rising transaminases, DIC, abruption, pulmonary oedema, renal deterioration, uncontrollable blood pressure or a non-reassuring CTG. With a platelet count of 86 and falling, the window may close quickly - repeat the count every 6-12 hours and agree a trigger for delivery in advance.

How

The previous caesarean does not mandate a repeat caesarean, but it raises the stakes on induction. Vaginal birth is reasonable if the cervix is favourable, the fetus is cephalic with a normal CTG, and she wants a VBAC - a prostaglandin or balloon induction with continuous monitoring and a low threshold for caesarean. In practice, with an unfavourable cervix at 34 weeks, severe pre-eclampsia, HELLP and a scar, caesarean section is usually the safer and faster option, and the decision should be made jointly with her and documented.

Practical points

• Check platelets and coagulation before neuraxial anaesthesia; a platelet count above about 75-80 is generally needed for a spinal, otherwise plan a general anaesthetic.
• Anticipate postpartum haemorrhage, and have blood products available.
• Give corticosteroids and arrange the neonatal team to attend; expect a preterm baby requiring respiratory support.
• Continue magnesium intra-operatively - pre-eclampsia does not disappear when the baby is born.

Assessment

Postpartum pre-eclampsia commonly worsens between days two and five as fluid mobilises, so this is expected but not benign. Work through the dangerous causes of a severe headache in this setting:

• Eclampsia - ask about visual disturbance, twitching, and check reflexes; ensure magnesium has been continued for 24 hours after delivery.
• Cerebral venous sinus thrombosis, which is more common in the puerperium, especially after caesarean section and with dehydration.
• Post-dural puncture headache if she had a spinal - positional, worse upright.
• Intracerebral haemorrhage or posterior reversible encephalopathy syndrome - check for focal signs and papilloedema.
• Common and reversible causes: pain, sleep deprivation, missed antihypertensive doses, a full bladder, infection, and retained products of conception.

Management

• Recheck FBC, film, LFTs, U&E, urate and urine protein; repeat BP four-hourly or more often.
• Treat the blood pressure: labetalol or nifedipine, both compatible with breastfeeding. Avoid methyldopa because of depression risk, and avoid ACE inhibitors in the early postnatal period.
• Give regular analgesia and ensure thromboprophylaxis with LMWH, which she qualifies for on multiple counts.
• If the headache is sudden, severe, focal or persistent despite BP control, arrange urgent CT or MRI and discuss with neurology.

Future pregnancies

Explain that recurrence is roughly 20% overall and higher after early, severe disease, so she should have pre-pregnancy counselling. In a future pregnancy: low-dose aspirin from 12 weeks, calcium supplementation, early booking, home BP monitoring, and delivery in a unit with neonatal intensive care. Also explain that pre-eclampsia is a marker of long-term cardiovascular risk - she needs annual BP and weight checks and risk factor management with her GP for life, not just until the six-week check.