How to manage a 30-year-old pregnant woman at 36 weeks gestation with severe hypertension, headache, and blurred vision?

Management of Severe Preeclampsia at 36 Weeks Gestation

This 30-year-old pregnant woman at 36 weeks gestation with severe hypertension (BP 180/110 mmHg), severe headache, and blurred vision should be immediately hospitalized for delivery due to severe preeclampsia with neurological symptoms. 1

Immediate Management

1. Urgent hospitalization for:

   • Continuous BP monitoring
   • Neurological assessment
   • Laboratory evaluation (CBC, liver enzymes, creatinine, uric acid)
   • Fetal assessment

2. Antihypertensive therapy:

   • First-line treatment: IV labetalol for rapid BP control 1, 2
     • Initial dose: 20 mg IV (0.25 mg/kg)
     • Can be followed by 40-80 mg doses at 10-minute intervals
     • Maximum cumulative dose: 300 mg
   • Alternative options:
     • Oral nifedipine (avoid sublingual administration) 1, 3
     • Oral methyldopa 1

3. Target BP: Reduce mean BP by 15-25% with target systolic BP 140-150 mmHg and diastolic BP 90-100 mmHg 1

   • Avoid excessive rapid BP reduction which can compromise uteroplacental perfusion

4. Seizure prophylaxis:

   • Administer magnesium sulfate IV 1
   • Indicated due to severe hypertension with neurological symptoms (headache, visual disturbances)
   • Continue during labor and for at least 24 hours postpartum 4

Delivery Plan

Immediate delivery is indicated because:

• Patient is at 36 weeks gestation (term enough for delivery) 1
• Presence of severe hypertension (180/110 mmHg) 1
• Neurological symptoms (severe headache and blurred vision) indicating end-organ involvement 1

The mode of delivery should be determined based on:

• Cervical status
• Fetal presentation
• Maternal and fetal condition
• Urgency of delivery

Maternal Monitoring

• Continuous BP monitoring
• Neurological status assessment (headache, visual changes, hyperreflexia, clonus)
• Fluid balance monitoring
• Laboratory tests:
  • Complete blood count (especially platelet count)
  • Liver function tests
  • Renal function tests
  • Urine protein assessment 1

Fetal Assessment

• Continuous electronic fetal monitoring
• Ultrasound assessment of fetal growth, amniotic fluid, and umbilical artery Doppler if time permits 1

Important Considerations and Pitfalls

1. Do not delay treatment - Severe preeclampsia with neurological symptoms can rapidly progress to eclampsia and other life-threatening complications 1

2. Avoid fluid overload - Plasma volume expansion is not recommended routinely in women with preeclampsia as it can increase risk of pulmonary edema 1

3. Monitor for complications:

   • Eclampsia (seizures)
   • HELLP syndrome (hemolysis, elevated liver enzymes, low platelets)
   • Placental abruption
   • Pulmonary edema
   • Renal failure

4. Do not attempt to diagnose mild versus severe preeclampsia - All cases may become emergencies rapidly 1

5. Avoid hydralazine as first-line therapy - Associated with more perinatal adverse effects compared to other antihypertensives 1

6. Caution with magnesium sulfate and calcium channel blockers - Combination can cause excessive hypotension 1

The management of this patient requires immediate action with a focus on controlling blood pressure, preventing seizures, and proceeding with delivery to definitively treat the preeclampsia, as this is the only curative approach for this condition at 36 weeks gestation.