Headache and flashing lights at 34 weeks and 3 days

Diagnosis: preeclampsia with severe features at 34 weeks and 3 days. Severe features present: systolic ≥160 and diastolic ≥110 on repeated readings, cerebral and visual symptoms, platelets <100 × 10⁹/L, transaminases above twice the upper limit of normal, creatinine >1.1 mg/dL, and heavy proteinuria with brisk reflexes and clonus.

Timing. At 34 weeks or more with severe features, the recommendation is delivery after maternal stabilisation - do not manage expectantly. Continuing the pregnancy exposes mother and fetus to eclampsia, abruption, progression to HELLP, pulmonary oedema, renal failure, placental insufficiency and stillbirth, and the risk climbs with every day gained.

The steroid question. Antenatal corticosteroids have their clear benefit below 34 weeks, where expectant management allows the 48-hour window to be used. At 34+3, the evidence for a clinically important benefit is weak, and steroids must never delay a medically indicated delivery. The correct answer to the midwife is: stabilise with magnesium and antihypertensives, inform neonatology, and proceed to delivery - steroids may be discussed but the 48-hour wait is not acceptable here.

Mode. Vaginal delivery with induction is usually appropriate with a cephalic presentation and a normal cardiotocograph; caesarean section for obstetric indications only, remembering that caesarean in severe preeclampsia carries added bleeding and thrombotic risk.

Magnesium sulfate for prophylaxis (not a loading dose on the basis of reflexes alone - the diagnosis and severe features justify it).

• Loading dose 4 g IV over 20 minutes.
• Maintenance 1 g/h infusion.
• For a recurrent seizure: a further 2 g IV bolus over 5 minutes.
• Monitor hourly: respiratory rate (≥12–16/min), patellar reflexes present, urine output ≥30 mL/h, oxygen saturation, and conscious level. Therapeutic range is roughly 2.0–3.5 mmol/L (4.8–8.4 mg/dL).
• Signs of toxicity appear in sequence: loss of deep tendon reflexes, then respiratory depression, then cardiac arrest. The antidote is calcium gluconate 1 g IV (10 mL of 10%) given slowly.
• Reduce the infusion in renal impairment (creatinine already 1.15 mg/dL); consider halving the rate and checking levels.

Blood pressure control.

• Target 130–150/80–100 mmHg; avoid a fall of more than about 25% of mean arterial pressure, which compromises uteroplacental perfusion.
• First line: labetalol 200 mg orally, repeated at 6–8 hourly intervals, or intravenous labetalol 20 mg, then 40–80 mg every 10 minutes to a maximum of about 220 mg.
• Alternatives: hydralazine 5–10 mg IV every 20 minutes, or nifedipine 10 mg orally, repeated as needed.
• Avoid ACE inhibitors, angiotensin receptor blockers, atenolol and diuretics.
• For persistent hypertension despite these, escalate to critical care input and consider a continuous infusion.

Fluids. Restrict to about 80 mL/h of crystalloid (roughly 1 mL/kg/h). These patients are prone to pulmonary oedema from capillary leak and low oncotic pressure, and the old practice of fluid-loading oliguria causes harm. Give a bolus only for clear hypovolaemia or hypotension, and consider invasive monitoring if urine output falls with uncertain volume status.

Monitoring. Hourly input/output chart, strict urine output, daily weight, blood pressure every 1–4 hours depending on stability, oxygen saturation, respiratory examination for basal crackles, and neurological observations for headache, visual change or hyperreflexia. Continue magnesium for 24 hours postpartum. Recheck platelets, transaminases, LDH and creatinine at 6–12 hours and again at 24–48 hours.

Complications to anticipate.

• Eclampsia - can occur up to four weeks postpartum; counsel the patient to return for headache, visual disturbance or epigastric pain.
• HELLP syndrome progression, which can worsen for the first 24–48 hours after delivery; consider it with right upper quadrant pain, falling platelets and rising LDH.
• Pulmonary oedema, acute kidney injury, and posterior reversible encephalopathy syndrome (seizure, visual loss, MRI changes).
• Haemorrhage and disseminated intravascular coagulation from abruption or HELLP; thromboprophylaxis once bleeding risk is acceptable.

Analgesia. Avoid non-steroidal anti-inflammatory drugs if platelets are low, renal function is impaired or blood pressure is uncontrolled; use paracetamol with opioid sparing. Arrange a blood pressure review within 1–2 weeks and discuss future pregnancy risk and contraception before discharge.