What are the clinical manifestations and management of a pregnant woman with preeclampsia, characterized by hypertension and impaired renal function?

From the Guidelines

A 30-year-old primigravida at 32 weeks gestation presents to the emergency department with complaints of severe headache and blurred vision for the past 6 hours. Her blood pressure on arrival is 160/100 mmHg. She has gained 3 kg in the past week and shows 2+ proteinuria on dipstick. On examination, she has significant bilateral lower extremity edema and hyperreflexia. Laboratory results reveal elevated liver enzymes (AST 60 U/L, ALT 65 U/L), low platelets (80,000/μL), and a 24-hour urine protein of 3.5 g. The patient has no prior history of hypertension or renal disease. Fetal assessment shows appropriate growth with normal amniotic fluid and reassuring heart rate patterns. Questions:

1. What is the most likely diagnosis for this patient?
2. What immediate management steps should be taken?
3. What medication should be administered to prevent eclamptic seizures, and at what dosage?
4. What are the indications for delivery in this case?
5. What maternal and fetal complications might develop if this condition is not properly managed?
6. What postpartum monitoring would you recommend for this patient? According to the guidelines from the ISSHP 1, the management of hypertensive disorders of pregnancy should prioritize the control of blood pressure and the prevention of eclamptic seizures. The use of magnesium sulfate for convulsion prophylaxis is recommended for women with preeclampsia who have proteinuria and severe hypertension, or hypertension with neurological signs or symptoms 1. The indications for delivery in this case would include repeated episodes of severe hypertension despite maintenance treatment with 3 classes of antihypertensive agents, progressive thrombocytopenia, progressively abnormal renal or liver enzyme tests, pulmonary edema, abnormal neurological features, or nonreassuring fetal status 1. The maternal and fetal complications that might develop if this condition is not properly managed include placental abruption, fetal growth restriction, and maternal stroke or renal failure 1. Postpartum monitoring should include blood pressure monitoring, repeated assessments for proteinuria, and clinical assessment including clonus, as well as twice weekly blood tests for hemoglobin, platelet count, liver transaminases, creatinine, and uric acid 1. The guidelines from the ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA also recommend the use of antihypertensive agents such as labetalol, nifedipine, and methyldopa for the management of hypertension in pregnancy 1. The prevention of preeclampsia relies on the identification of high-risk women and close clinical and laboratory monitoring aimed at its early recognition, and institution of intensive monitoring or delivery when indicated 1. The treatment of chronic hypertension during pregnancy includes lifestyle modification and the use of antihypertensive agents, with the goal of preventing severe hypertension and prolonging gestation to allow the fetus more time to mature before delivery 1. The management of severe hypertension in pregnancy requires urgent treatment to prevent maternal and fetal complications, and the use of antihypertensive agents such as hydralazine, labetalol, and nifedipine is recommended 1.

From the Research

Clinical Case: Preeclampsia

A 30-year-old woman, 32 weeks pregnant, presents to the emergency department with a blood pressure of 160/100 mmHg and proteinuria. She has a history of chronic hypertension and is currently taking labetalol 200mg twice daily. Her symptoms include headache and visual disturbances.

Patient Information

• Age: 30 years
• Gestational age: 32 weeks
• Blood pressure: 160/100 mmHg
• Proteinuria: present
• Medical history: chronic hypertension
• Current medication: labetalol 200mg twice daily

Questions

• What are the potential risks and benefits of continuing labetalol versus switching to nifedipine or hydralazine for blood pressure management in this patient, as discussed in studies 2, 3, 4?
• How do the different dosage regimens of nifedipine, labetalol, and hydralazine affect the treatment of severe hypertension during pregnancy, according to the network meta-analysis 4?
• What are the potential consequences of not continuing the patient's home antihypertensive medication regimen during hospitalization, as noted in study 5?
• How do the safety and efficacy of intravenous hydralazine and labetalol compare for the treatment of asymptomatic hypertension in hospitalized patients, as evaluated in the systematic review 6?
• What are the implications of the patient's proteinuria and visual disturbances on her diagnosis and treatment plan, in the context of preeclampsia?