Is a woman at 33 weeks gestation with hypertension (High Blood Pressure) and significant proteinuria (4+ protein in urine) an indication for Cesarean Section (CS)?

From the Guidelines

A cesarean section (CS) is indicated for a patient at 33 weeks of pregnancy with high blood pressure and 4+ proteinuria, as these findings suggest severe preeclampsia requiring prompt delivery. The combination of hypertension and significant proteinuria at this gestational age represents a serious maternal condition that can rapidly progress to eclampsia, HELLP syndrome, or other life-threatening complications 1. According to the ISSHP classification, diagnosis, and management recommendations for international practice, women with preeclampsia who have proteinuria and severe hypertension, or hypertension with neurological signs or symptoms, should receive magnesium sulfate (MgSO) for convulsion prophylaxis 1.

Prior to delivery, the patient should receive magnesium sulfate for seizure prophylaxis (typically 4-6g IV loading dose followed by 1-2g/hour continuous infusion), and antenatal corticosteroids (betamethasone 12mg IM, two doses 24 hours apart or dexamethasone 6mg IM, four doses 12 hours apart) to accelerate fetal lung maturity 1. Blood pressure should be controlled with medications such as labetalol or hydralazine to keep systolic pressure below 160 mmHg and diastolic below 110 mmHg 1.

The decision for immediate delivery is based on the severity of preeclampsia and the significant risk to maternal health, which outweighs the risks of prematurity at 33 weeks, when neonatal outcomes are generally favorable with appropriate neonatal intensive care 1. Key considerations in the management of hypertensive disorders of pregnancy include:

• Maintaining BP between 110 to 140/85 mm Hg 1
• Using antihypertensive therapy and MgSO4 as appropriate 1
• Monitoring fetal growth and well-being 1
• Assessing for signs of severe preeclampsia, such as repeated episodes of severe hypertension, progressive thrombocytopenia, and abnormal renal or liver enzyme tests 1

In this case, the patient's condition meets the criteria for severe preeclampsia, and prompt delivery is necessary to prevent maternal and fetal complications 1.

From the Research

Indications for Cesarean Section (CS) in Hypertensive Disorders of Pregnancy

The decision to perform a Cesarean Section (CS) in a woman with hypertension and significant proteinuria at 33 weeks gestation depends on various factors, including the severity of the condition and the gestational age.

• According to 2, delivery is proposed for patients with preeclampsia without severe features after 37 weeks of gestation and in case of severe preeclampsia after 34 weeks of gestation.
• However, for women with non-severe hypertensive disorders at 34-37 weeks of gestation, immediate delivery might reduce the already small risk of adverse maternal outcomes, but it significantly increases the risk of neonatal respiratory distress syndrome 3.
• In the case of a woman at 33 weeks gestation with hypertension and significant proteinuria (4+ protein in urine), the decision for CS would depend on the severity of the condition and the presence of other complications.
• The study 2 suggests that maternal end-organ dysfunction and non-reassuring tests of fetal well-being are indications for delivery at any gestational age.
• Additionally, the presence of severe hypertension, thrombocytopenia, liver dysfunction, or other complications would necessitate immediate delivery, which may be via CS depending on the clinical situation 2.
• It is essential to note that each case is unique, and the decision for CS should be made on an individual basis, taking into account the specific circumstances and the risks and benefits of the procedure.

Considerations for Delivery at 33 Weeks Gestation

• At 33 weeks gestation, the fetus is still premature, and delivery would carry risks for the baby, including respiratory distress syndrome and other complications of prematurity.
• However, if the mother's condition is severe and poses a risk to her health or the fetus, delivery may be necessary, even at 33 weeks gestation 2, 3.
• The use of antenatal corticosteroids to promote fetal lung maturity may be considered in cases where delivery is anticipated before 34 weeks gestation 2.

Proteinuria and Hypertension in Pregnancy

• Significant proteinuria (4+ protein in urine) is a indicator of severe preeclampsia, and in combination with hypertension, it poses a significant risk to the mother and the fetus 4, 2.
• The presence of proteinuria and hypertension at 33 weeks gestation would require close monitoring and possibly immediate delivery, depending on the severity of the condition and the presence of other complications 2, 3.