Severe preeclampsia at 36 weeks in a district hospital
A 34-year-old woman, G2P1, at 36 weeks and 2 days by dating ultrasound presents to a district hospital with a two-day history of frontal headache and right upper quadrant pain. Blood pressure is 172/110 mmHg on two readings 15 minutes apart; urine protein is 3+ on dipstick. She is alert, with brisk reflexes and 1+ ankle oedema. Platelets 92 × 10⁹/L, AST 96 U/L, ALT 88 U/L, creatinine 1.0 mg/dL, haemoglobin 11.2 g/dL, LDH 480 U/L and uric acid 7.8 mg/dL. The fetal heart tracing is category I with a reactive non-stress test. The hospital has no neonatal intensive care unit and the nearest tertiary centre is a two-hour road transfer; an ambulance is available and the weather is clear.
1. What is the diagnosis and what features determine severity? How does this change your management?
Read the worked answer
The diagnosis is preeclampsia with severe features, with partial HELLP syndrome. Severe features are present because of systolic BP of at least 160 mmHg, platelets below 100 × 10⁹/L, AST/ALT more than twice the upper limit of normal, and symptoms of headache and right upper quadrant pain. The RUQ pain and raised LDH reflect hepatic involvement. At 36+2 weeks, delivery is indicated; there is no role for expectant management once severe features are present, because the risks of abruption, DIC, pulmonary oedema, stroke and fetal compromise rise.
The differential includes acute fatty liver of pregnancy (more hypoglycaemia, coagulopathy and encephalopathy), TTP (more neurological and renal involvement, ADAMTS13 deficiency), HUS, viral hepatitis and gallbladder disease. Do not wait for all HELLP criteria to be met before acting. The category I fetal tracing is reassuring but does not change the maternal indication for delivery.
2. Outline the medications and monitoring you would start now, including doses and targets.
Read the worked answer
Start magnesium sulfate for seizure prophylaxis: 4–6 g IV loading dose over 20 minutes, then 1–2 g/hour. Monitor deep tendon reflexes, respiratory rate, urine output and oxygen saturation hourly; check serum magnesium if there is renal impairment. Keep calcium gluconate 10% 10 mL at the bedside for toxicity.
Lower the blood pressure with labetalol 20 mg IV, then 40–80 mg every 10 minutes up to a total of 300 mg, or hydralazine 5–10 mg IV every 20 minutes, or oral nifedipine 10 mg. Aim for 140–150/90–100 mmHg rather than a normal blood pressure, because a rapid fall can impair uteroplacental perfusion. Insert an indwelling catheter, monitor fluid balance strictly, and check platelets, liver enzymes, creatinine and coagulation serially.
Corticosteroids for fetal lung maturity are not indicated at 36+2 weeks because there is no evidence of benefit after 34–36 weeks; give them only if gestational age is uncertain and the fetus is likely to be preterm.
3. Where should she deliver, and what would you do about transfer? Include postpartum and future counselling.
Read the worked answer
Delivery is the definitive treatment. If the mother is stable after magnesium and antihypertensive treatment and delivery is not imminent, transfer in utero to the tertiary centre with a neonatal unit is preferred, because a 36-week infant may need respiratory support and maternal complications such as abruption or DIC are better managed there. Stabilise before transfer and send a midwife or doctor with the magnesium infusion and antihypertensives. If she deteriorates, has a non-reassuring fetal tracing, or transfer would cause unacceptable delay, deliver locally with neonatal support available.
Mode of delivery is vaginal unless there is an obstetric indication for caesarean. Continue magnesium for 24 hours postpartum and monitor blood pressure for at least 72 hours and again at 7–10 days, because eclampsia can occur after delivery. Counsel her that recurrence in a future pregnancy is around 15–25%, that low-dose aspirin from 12 weeks reduces risk, and that she has a lifelong increased cardiovascular risk requiring blood pressure and lipid follow-up.